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[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n\n\n\n\nHere is the query:\nWhat was Mr. Nilsson's body weight at discharge in 02/02/05?\n\nChoose the correct answer from the following options:\nA. 4830 g\nB. 4765 g\nC. 5060 g\nD. 12.4 kg\nE. 6050 g\n\n\nYour response:\n", "role": "user" }, { "content": "5060 g", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n\n\n### text_5\n**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n\n\n\n\nHere is the query:\nWhat was the liver fibrosis stage in Mr. Wells as per the report on 08/24/2019?\n\nChoose the correct answer from the following options:\nA. Stage 1\nB. Stage 2\nC. Stage 3\nD. Stage 4\nE. Not specified\n\n\nYour response:\n", "role": "user" }, { "content": "Not specified", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n\n\n\n\nHere is the query:\nWhich medication was added to Mr. Hurley's treatment in 02/2021?\n\nChoose the correct answer from the following options:\nA. Azacitidine\nB. Levofloxacin\nC. Rifampicin\nD. Ethambutol\nE. Pyrazinamide\n\n\nYour response:\n", "role": "user" }, { "content": "Azacitidine", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n\n\n### text_3\n**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n\n\n### text_7\n**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n\n\n### text_8\n**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n\n\n### text_9\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n\n\n### text_10\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n\n\n### text_11\n**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n\n\n### text_12\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n\n\n\n\nHere is the query:\nAccording to the GI Tumor Board Review on January 9th, 2022, which of the following statements is true for Mrs. Anderson?\n\nChoose the correct answer from the following options:\nA. The CT scan showed signs of liver metastases.\nB. The CT scan indicated remission of her tumor.\nC. The CT scan showed progression of her tumor.\nD. Distant metastases were identified.\nE. The patient had no history of FOLFIRINOX therapy.\n\n\nYour response:\n", "role": "user" }, { "content": "The CT scan showed progression of her tumor.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n", "title": "text_9" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n", "title": "text_10" }, { "content": "**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n", "title": "text_11" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n", "title": "text_12" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n\n\n\n\nHere is the query:\nWhen did Mr. Rudolph undergo atrial fibrillation ablation?\n\nChoose the correct answer from the following options:\nA. 2010\nB. 2012\nC. 2013\nD. 2019\nE. 2020\n\n\nYour response:\n", "role": "user" }, { "content": "2013", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n\n\n\n\nHere is the query:\nCould you please specify the chronological sequence of the radiology imaging examinations that Mr. Rudolph underwent?\n\nChoose the correct answer from the following options:\nA. Chest CT < Chest CT < CT-guided liver biopsy < Abdominal CT\nB. Chest CT < Abdominal CT < Chest CT < CT-guided liver biopsy\nC. Chest CT < CT-guided liver biopsy < Chest CT < Abdominal CT\nD. Chest CT < Abdominal CT < Chest CT\nE. CT-guided liver biopsy < Chest CT < Abdominal CT\n\n\nYour response:\n", "role": "user" }, { "content": "Chest CT < CT-guided liver biopsy < Chest CT < Abdominal CT", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on Mr. Ben Harder, born on 08/02/1940, who was admitted\nto our hospital from 12/17/2015 to 12/27/2015.\n\n**Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Status post excision on the nose with suspicion of basal cell\n carcinoma\n\n- Status post laparoscopic cholecystectomy\n\n- Retropubic radical prostatectomy without nerve preservation and with\n bilateral pelvic lymphadenectomy was performed on 12/17/2015.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------- ---------------------------------------------------\n Valsartan (Diovan) 160 mg 1-0-1\n Aspirin 100 mg 1-0-1\n Simvastatin (Zocor) 15 mg 0-0-1\n Doxazosin (Cardura) 1 mg 0-0-1\n Enoxaparin (Lovenox) 0.6 mL s.c. Administer subcutaneously for a total of 4 weeks.\n Acetaminophen (Tylenol) 500 mg 1-1-1 (for 4 days)\n\n**Histopathology:**\n\n1. 2 adenocarcinoma metastases in 2 out of 4 lymph nodes, left external\n iliac region.\n\n2. 3 adenocarcinoma metastases in 3 out of 6 lymph nodes, right pelvic\n region.\n\n3. 7 adenocarcinoma metastases in 7 out of 7 lymph nodes, right lumbar\n para-aortic region.\n\n4. Acinar adenocarcinoma of the prostate is observed bilaterally, with\n a Gleason score of 4 (70%) + 5 (25%) = 9 and a tertiary Gleason\n grade of 3 (5%) according to the modified Gleason grading of the\n ISUP 2005. The tumor is multifocal and encompasses the entire\n prostate with a maximum extrapolated tumor extension of 60 mm. There\n is extracapsular tumor growth, with focal involvement at the dorsal\n right base. Vascular invasion is not noted, but perineural invasion\n is extensive. Both seminal vesicles are heavily infiltrated, and the\n resection margin of the left seminal vesicle is involved. Before\n tissue embedding, the margins of the specimen show focal\n infiltration by the tumor, in the right anterior region near the\n base (section 7) with a total contact area of 2 mm wide, and the\n primary Gleason grade at the positive margin is 4. In addition to\n the carcinoma, other prostatic tissue shows features of myoglandular\n hyperplasia and high-grade prostatic intraepithelial neoplasia\n (HGPIN). The prostatic urethra is free of tumors or dysplasia.\n\n5. **Tumor classification:** pT3bpN1(12/17), R1L0V0, Gleason: 4 + 5 = 9\n\n**Medical History:** Mr. Harder was admitted for open prostatectomy due\nto biopsy-confirmed prostate carcinoma.\n\nInitial PSA value: 5.42 ng/ml. Gleason score of biopsy: 4+5=9 in 11 out\nof 12 biopsy samples. Clinical tumor stage: cT2c PSMA PET-CT + MRI from\n12/23/2015: Left capsular penetration without rectal infiltration.\nSeminal vesicles are infiltrated on both sides. Evidence of multiple\nlymph nodes; intrapelvic locoregional and two lymph nodes on the right\nparailiacal and lumbar interaortocaval region.\n\nTRUS: 88 cc Digital Rectal Examination: Abnormal findings on the left\nside\n\n**Physical Examination:** The patient is in good general condition, has\na lean nutritional status, and reports feeling well. The abdomen is\nsoft, with no tenderness, masses, resistance, or guarding, and the\nexternal genitalia are unremarkable.\n\n**Ultrasound upon admission:** Both kidneys are not dilated and show no\nspace-occupying lesions. The bladder is minimally filled and appears\nunremarkable to the extent assessable.\n\n**Pretherapeutic Tumor Conference:** The findings were discussed\ninterdisciplinary, and the possible treatment options were explained.\nThe patient opted for radical prostatectomy.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complications. The postoperative course was uneventful. Blood\ntransfusions were not required. Unfortunately, a cystogram on revealed\nextravasation, requiring the indwelling catheter to be retained. The\nwound drain was lifted once with serum-identical creatinine values and\nretained with persistent output (approximately 400 ml daily). Both\nkidneys were not dilated, and there were no signs of lymphocele or\nhematoma in the pelvic region on ultrasound. A follow-up rehabilitation\ntreatment has been organized through our social services. We discharged\nthe patient with absorbable intracutaneous sutures for further\noutpatient care.\n\n**Current Recommendations:** The patient was discharged with a permanent\ncatheter and will present on 01/03/2016 for cystogram and possibly\ncatheter removal. If catheter removal is indicated, we recommend\nconsidering a trial of voiding with subsequent admission if the\ncystogram is normal. The wound drain was also retained, and we request\ndocumentation of output. If output regresses and remains persistently \\<\n30-40 ml, and there is no ultrasound evidence of lymphocele, it could be\nremoved on an outpatient basis or during the follow-up appointment.\n\nWe recommend the first PSA check 6 -- 8 weeks postoperatively, followed\nby quarterly intervals. If the PSA level does not reach the zero range\nor rises again from the zero range, the patient can be offered\nradiotherapy of the prostatic bed and lymphatic drainage pathways in\ncombination with a 2-year hormonal ablative therapy as an individual\ntherapeutic trial. Alternatively, primary hormonal ablative therapy is\nan option. If the PSA level reaches the zero range, the patient may be\noffered adjuvant hormonal ablative therapy for 2 years, possibly\ncombined with radiotherapy. Additional findings will be discussed in our\npost-therapeutic conference. In case of changes in the recommended\nprocedure mentioned above, we will inform you again.\n\n**Course of the lab results:**\n\n **Parameter** **12/18/15** **12/19/15** **12/20/15** **12/23/15** **Reference Range**\n --------------------------- --------------- ---------------- --------------- -------------- ---------------------\n Sodium 135 mEq/L 138 mEq/L 136-145 mEq/L\n Potassium 5.1 mEq/L 4.4 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffe method) 0.93 mg/dL 1.05 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 83 65 \n Hemoglobin 11.4 g/dL 12.4 g/dL 12.5-17.2 g/dL\n Hematocrit 0.323 L/L 0.361 L/L 0.370-0.490 L/L\n Red Blood Cells 3.8 x10\\^12/L 4.3 x10\\^12/L 4.2 x10\\^12/L 4.0-5.7 x10\\^12/L\n White Blood Cells 9.57 x10\\^9/L 11.51 x10\\^9/L 9.65 x10\\^9/L 3.90-10.50 x10\\^9/L\n Platelets 216 x10\\^9/L 239 x10\\^9/L 285 x10\\^9/L 150-370 x10\\^9/L\n MCV 88.1 fL 86.0 fL 88.3 fL 80.0-101.0 fL\n MCH 30.2 pg 30.1 pg 29.5 pg 27.0-34.0 pg\n MCHC 34.5 g/dL 35.3 g/dL 33.8 g/dL 31.5-36.0 g/dL\n MPV 10.2 fL 10.4 fL 10.3 fL 7.0-12.0 fL\n RDW-CV 12.1% 12.2% 12.8% 11.6-14.4%\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about Mr. Ben Harder, born on 08/02/1940 who received\ninpatient treatment from 01/13/2016 to 01/19/2016.\n\n**Diagnosis:** Urinary Tract Infection in Patient with indwelling\ncatheter\n\n**Other Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n- Arterial hypertension\n\n- History of excision on the nose with suspicion of basal cell\n carcinoma\n\n- History of laparoscopic cholecystectomy\n\n**Medication upon Admission: **\n\n **Medication (Brand)** **Dosage** **Frequency**\n ------------------------------ ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan (Atacand) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multivitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Selenium 999 mcg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Thiamine 200 mg 1x/Week\n Pyridoxine 25 mg 2-3x/Week\n\n**Current presentation:** Mr. Harder returned to our clinic on\n01/13/2016, complaining of new-onset symptoms including increased\nurgency and frequency of urination, discomfort, lower abdominal pain,\nand fever. Given his recent surgery and indwelling catheter, concerns\nwere raised about a possible urinary tract infection.\n\n**Clinical Examination:** On physical examination, Mr. Harder appeared\nunwell. He had a temperature of 38.8°C, elevated heart rate\n(tachycardia), and mild lower abdominal tenderness on palpation. The\nindwelling urinary catheter was in situ, and no signs of catheter\ndislodgment or leakage were observed.\n\n**Ultrasound of the Abdomen upon admission:** Bilateral, no urinary\ntransport obstruction, approximately 4x2 cm-sized fluid collection noted\nin the right inguinal area, suggestive of possible lymphocele.\n\n**CT Scan Abdomen/Pelvic from 01/13/2016:** The liver displays a smooth\ncontour, with homogeneous parenchymal contrast enhancement, and no\nevidence of focal intrahepatic lesions. There is no indication of\nintrahepatic or extrahepatic cholestasis. History of previous\ncholecystectomy with an accentuated common hepatic duct. Spleen,\npancreas, and adrenal glands appear unremarkable. Both orthotopically\nlocated kidneys exhibit simultaneous and equal contrast enhancement. No\nintrarenal structural abnormalities or signs of urinary obstruction are\nobserved. The colonic frame and small intestine show adequate perfusion,\nwithout focal wall thickening. The stomach is distended. The urinary\nbladder contains a catheter. Two intraluminal air pockets are seen.\nKnown circumferential, uniform bladder wall thickening from previous\nexaminations. No free intrabdominal air is detected. No evidence of\nascites. Bilateral iliac and inguinal operative clips from prior\nlymphadenectomy. Right iliac region shows a serous fluid collection\nmeasuring approximately 3 x 2 cm. Para-aortic lymph nodes, up to 14 mm\nin size, are consistent with findings from previous evaluations. No\nsuspicious malignancy-related bone destruction is noted. A drainage tube\nhas been placed through the right lower abdominal wall, with its tip\nlocated in the left pelvic area.\n\n**Assessment:** No evidence of abscess formation. A lymphocele measuring\napproximately 3 x 2 cm is noted in the right iliac region, without signs\nof acute inflammation.\n\n**Microbiological Examination**\n\n**Material**: Catheter Urine Examination Request: Identification of\nPathogens and Resistance Results: Organism 1: Growth of 100,000 CFU/mL\nEnterococcus faecalis Possible ICD-10 Coding Suggestion: Enterococci as\nPathogen.\n\n- Acute Cystitis\n\n- Pyelonephritis\n\n- Urinary Tract Infection related to Catheter/Implant\n\n- Urinary Tract Infection, Unspecified Location\n\n**Antibiogram**\n\n- Gentamicin HL: S\n\n- Levofloxacin: R 1\n\n- Teicoplanin: S \\<=0.5\n\n- Ampicillin: S \\<=2\n\n- Piperacillin: S\n\n- Ampicillin/Sulbactam: S \\<=2\n\n- Piperacillin/Tazobactam: S\n\n- Imipenem: S \\<=1\n\n- Cefuroxim: R \\>=64\n\n- Gentamicin: R\n\n- Cotrimoxazole: R \\<=10\n\n- Ciprofloxacin: R \\<=0.5\n\n- Vancomycin: S 2\n\n- Linezolid: S 2\n\n- Tigecyclin: S \\<=0.12\n\n**Therapy and Progression:** After CT morphological exclusion of an\nabscess formation or retention, the wound drainage was removed under\nantibiotic coverage. Initially, empirical antibiotic therapy with\nCefuroxim was administered, followed by targeted treatment with oral\nUnacid based on resistance testing. The drainage insertion site healed\nprimarily. The bladder catheter was removed, after which urination was\nfree of residual urine. The patient has primary continence. We\ndischarged the patient to further outpatient treatment, with the patient\nreporting subjective well-being.\n\nMr. Harder showed gradual clinical improvement after initiating\nantibiotic therapy. His fever subsided, and lower abdominal tenderness\ndiminished. The IV fluids were discontinued, and he remained on oral\nantibiotics.\n\n**Urine Culture Results:** The urine culture results returned positive\nfor Escherichia coli (E. coli), a common uropathogen. The sensitivity\nprofile indicated susceptibility to ciprofloxacin.\n\n**Follow-Up:** Mr. Harder was closely monitored for the duration of his\nantibiotic course. He was advised to complete the full course of\nantibiotics and maintain adequate hydration. The urinary catheter was\nremoved on the fifth day of hospitalization after demonstrating improved\nurine output and resolution of symptoms. No further complications\nrelated to the catheter removal were observed.\n\n**Current Recommendations:**\n\n1. Please refer to the previous discharge letter for the procedure\n regarding prostate cancer.\n\n2. He was educated on the signs and symptoms of UTIs and instructed to\n seek prompt medical attention if symptoms recurred.\n\n**\\\n**\n\n\n\n### text_2\n**Dear colleague, **\n\nThank you for assigning Mr. Ben Harder, born on 08/02/1940 to the PET/CT\ncombination scanner examination on 12/11/2022.\n\n**Diagnoses:**\n\n- Initial diagnosis of prostate cancer in December 2015, confirmed by\n prostate biopsy.\n\n- Tumor detected in 11 out of 12 biopsy samples\n\n- Maximum Gleason score of 9\n\n- Preoperative PSA level: 5.42 ng/ml\n\n- In the initial PET/CT examination (preoperative) on 12/23/2015\n evidence of prostate cancer extending beyond the capsule in both\n prostatic lobes was found.\n\n- Infiltration of the left seminal vesicles and beginning infiltration\n of the right seminal vesicles\n\n- Multiple retroperitoneal lymph node metastases and bilateral pelvic\n lymph nodes.\n\n- Radical prostatectomy\n\n- Current PSA level: 1.23 ng/ml\n\n- Radiation therapy planned at our facility\n\n**Technique**: To expedite renal-urinary activity elimination, the\npatient was adequately hydrated. The examination was conducted using the\nPET/CT combination scanner BIOGRAPH 64 with CT parameters set at 120 kV\nand 1 mm slice thickness. PET emission data were acquired with 5 bed\npositions on a radiation therapy-compatible table for whole-body\nexamination in the caudocranial direction with transverse slices at 3.0\nmm intervals over the same axial range as the CT scan. Iterative\nreconstruction was performed. A whole-body scan was conducted 90 minutes\nafter the administration of 278 MBq Ga-68-PSMA (prostate-specific\nmembrane antigen). Transmissions-corrected and non-corrected PET scans,\nCT scans, fusion images, and the determination of the SUV value\n(standard uptake value, a measure of activity uptake per volume) were\nused for evaluation.\n\n**PET Findings:** The 3D whole-body images documented in 3 planes using\nPET and PET/CT technology showed the following changes compared to the\nprior examination on 12/23/2015:\n\n- Post-radical prostatectomy, there is diffuse activity accumulation\n in the region dorsal to the bladder, on the left side.\n\n- Regarding the known retroperitoneal lymph node metastases, the\n following changes were observed: New retrocrural nodule on the\n right. SUV 6.6, diameter: 6 mm.\n\n- Known interaortocaval lymph node, dorsally at the level of L3/4,\n showed increased metabolic activity from SUV 4.7 to 11.5. Slightly\n increased in size, measuring 7 to 8 mm. Additionally, two new\n metabolically active nodules cranially, up to the level of L2/3.\n\n- Slightly increased metabolic activity in the known right iliaca\n communis lymph node, located between the fifth lumbar vertebra and\n the psoas muscle, from 4.0 to 4.6, with the same size of 5 mm.\n\n- Progressive enlargement of the known confluent lymph nodes on the\n right parailiacal externa proximal side, now having a combined size\n of 10 x 26 mm (width x height), previously individual nodules of 10\n and 12 mm. SUV 18.2, previously max 11.5.\n\n- New paraaortic lymph nodes on the left, mostly small, SUV 11.2.\n\n- Newly added lymph nodes in both biiliac communal areas. Maximum size\n on the left is 15 mm, SUV 17.2.\n\n- New retrocrural lymph node on the right, measuring 6 mm, SUV 6.6.\n\n- Known lymph node on the right perirectal, slightly progressive from\n 8 to 10 mm. SUV 6.9, previously 6.4.\n\n- Known lymph node on the left iliaca externa not currently\n verifiable, possibly postoperative scarring.\n\n- Newly added focus in the bone at the level of the spinous\n process/dorsal arch of the fifth lumbar vertebra. In CT, a 7 mm\n focal sclerosis is noted. Normal activity accumulation in the soft\n tissues of the neck, axillae, and chest. Physiological accumulation\n in the parenchymal upper abdominal organs. Kidneys and urinary tract\n appear functionally normal. Whole-body CT following bolus-like\n peripheral venous machine injection of 100 ml of Optiray 350: No\n suspicious lymph nodes in the cervical, axillary, or mediastinal\n regions. Normal-sized thyroid gland. No pleuropulmonary infiltrates\n or round lesions. Scarred changes in the left lower lobe.\n Normal-sized liver without focal lesions. Spleen, pancreas, adrenal\n glands, and kidneys appear regular. No urinary obstruction..\n\n**Results**: In the postoperative PET/CT compared to the preoperative\nexamination on, there is now malignancy-typical PSMA receptor binding in\nthe former prostate lodge, indicating a local recurrence. Progression of\nretroperitoneal lymph node metastases, with further extension cranially,\nextending to the interaortocaval region up to the level of L2/3. Newly\nadded metastases on the left paraaortic and biiliac communal areas.\nProgression of known right iliaca externa lymph node metastases. The\nleft iliaca externa nodule is not verifiable, likely removed. New small\nretrocrural nodule on the right. New osteosclerotic metastasis in the\ndorsal arch of LWK 5. Minimal activity accumulation in the 8th rib on\nthe right lateral aspect. A developing metastasis cannot be conclusively\nruled out here. We kindly request information on the patient\\'s further\nclinical course (submission of medical reports, etc.).\n\n**Lab results**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Glucose (Plasma) 91 mg/dL 55-100 mg/dL\n Alkaline Phosphatase 93 U/L \\< 130 U/L\n Total Cholesterol 152 mg/dL \\< 200 mg/dL\n LDL-Cholesterol 89 mg/dL \\< 130 mg/dL\n HDL-Cholesterol 50 mg/dL 40-60 mg/dL\n Non-HDL Cholesterol 101.8 mg/dL \\< 200 mg/dL\n Triglycerides 64 mg/dL \\< 150 mg/dL\n White Blood Cells 4.1 K/uL 4.5-11 K/uL\n Red Blood Cells 4.68 M/uL 4.0-5.5 M/uL\n Hemoglobin 13.6 g/dL 12.5-17.2 g/dL\n Hematocrit 39.5% 37.0-49.0%\n MCH 29.1 pg 27.0-34.0 pg\n MCHC 34.4 g/dL 31.5-36.0 g/dL\n MCV 84.4 fL 80.0-101.0 fL\n RDW 13.0% 11.6-14.4%\n Platelets 238 K/uL 150-370 K/uL\n\n**\\\n**\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to provide an update on Mr. Ben Harder, born on\n08/02/1940, who received inpatient treatment at our facility from\n06/23/2023 to 06/26/2023.\n\n**Diagnosis:**\n\nProstate Cancer pT3b pN1 R1 L0 V0 Gleason Score: 4 + 5 = 9 (Initial\ndiagnosis in December 2015)\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015. Currently, lymph node and bone metastasis\n\n**Other Diagnoses:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015.\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n (thora 11 and 12) with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT in 06/2023 scan indicated new extensive metastasis in\n the sacrum and diffuse lung metastases, accompanied by a PSA level\n of 1.35 ng/ml.\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n**Medications on Admission:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Candesartan (Atacand) 16 mg 1-0-1-0\n Aspirin 100 mg 1-0-0-0\n Chlorthalidone (Thalitone) 25 mg 1-0-0-0\n\n**Physical Examination:** The patient was in good general condition and\nhad normal orientation to all qualities. There were no edemas, dyspnea,\nfever, or cough.\n\n**Medical History:** Mr. Hader presents himself for the 1st cycle of RLT\nwith Ac-225-PSMA/Lu-177-I&T-PSMA for lymph node and bone metastatic\nprostate cancer on an inpatient basis. In the presence of progressive\nimaging findings under guideline-compliant therapy, the indication for\nRLT tandem therapy was confirmed according to the tumor conference on.\nUpon admission, the patient reports feeling well, denies any B-symptoms.\nThere is no fever or nausea, and the weight is currently stable. There\nhas been a tendency to fall for some time. The rest of the medical\nhistory is assumed to be known.\n\n**Neurological Consultation on 06/25/2023: **\n\nClinically neurological examination revealed a polyneuropathy syndrome\nof the lower extremities, predominantly on the right side, as well as a\nknown right-sided foot drop. In summary, we consider the falls to be\nmultifactorial due to foot weakness as well as polyneuropathy syndrome\nwith impaired proprioception as the cause of the balance disorder.\nRecommended further procedure: In the presence of a known PNP syndrome\nthat has occurred during chemotherapy, consider outpatient neurological\nevaluation and objectification by means of Electromyography and\npolyneuropathy laboratory tests.\n\n**Salivary Gland Scintigraphy on 06/26/2023**\n\n**Assessment**: Normal function of the submandibular and parotid glands\nbilaterally.\n\nPost-therapeutic imaging with Lu-177-PSMA imaging using\nSPECT/low-dose-CT\n\n**Assessment:** Consistent with the PET-CT, there is no tracer uptake in\nthe area of the prostate. Intensive accumulation of the therapeutic\nagent in the area of lymph node metastases, especially mediastinal.\nCorresponding to the PET/CT, there are clear focal tracer accumulations\nin the left upper lobe of the lung in the area of nodular or diffuse\ntissue condensations, possibly metastases or, secondarily,\npost-inflammatory. Intensive tracer uptake in the area of known bone\nmetastases from the previous examination. No newly appearing\ntracer-enhancing lesions. In addition, physiological accumulation in the\norgan systems involved in tracer metabolism and excretion. NB: Small\npleural effusions on both sides. Known pronounced peribronchial cuffs in\nthe upper lobes on both sides, possibly scarred, or indicative of\npulmonary venous congestion. Known atrophic kidney on the right.\n\n**Current Recommendations:**\n\n- Blood count checks and determination of kidney and liver parameters\n 1, 2, 4, and 8 weeks after therapy\n\n- Outpatient neurologic assessment for the evaluation of\n polyneuropathy\n\n- PSA determination 6-8 weeks after therapy\n\n- Appointment for a 2nd cycle of radioligand therapy\n (Ac-225-/Lu-177-PSMA)\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Neutrophils (%) 72.2 % 42.0-77.0 %\n Lymphocytes (%) 8.6 % 20.0-44.0 %\n Monocytes (%) 11.6 % 2.0-9.5 %\n Basophils (%) 1.4 % 0.0-1.8 %\n Eosinophils (%) 6.0 % 0.5-5.5 %\n Immature Granulocytes (%) 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 2.31 mEq/L 2.20-2.55 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n C-reactive Protein 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 µg/L \\< 4.40 µg/L\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 µg/L 1.32-8.92 µg/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 0.285 L/L 0.370-0.490 L/L\n RBC 3.3 /pL 4.0-5.6 /pL\n WBC 4.98 /nL 3.90-10.50 /nL\n Platelets 281 /nL 150-370 /nL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Neutrophils (Absolute) 3.59 /nL 1.50-7.70 /nL\n Immature Granulocytes (Absolute) 0.010 /nL \\< 0.050 /nL\n Lymphocytes (Absolute) 0.43 /nL 1.10-4.50 /nL\n Monocytes (Absolute) 0.58 /nL 0.10-0.90 /nL\n Eosinophils (Absolute) 0.30 /nL 0.02-0.50 /nL\n Basophils (Absolute) 0.07 /nL 0.00-0.20 /nL\n Reticulocytes 31.3 /nL 25.0-105.0 /nL\n Reticulocyte (%) 0.94 % 0.50-2.00 %\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to report on our mutual patient, Mr. Ben Harder, born on\n08/02/1940, who presented himself to our outpatient clinic on 1/8/2023.\n\n**Diagnoses:**\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9 (initial\n diagnosis in 11/2015)\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally on\n 11/16/2015\n\n- Currently, there are lymph node and bone metastases\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Initial PSA level was 4.8 ng/ml\n\n- History of Docetaxel therapy\n\n- History of Cabazitaxel therapy\n\n- History of 4 cycles of Lutetium-Radioligand therapy\n\n- Subsequently, radiation therapy was initiated for the lymph node\n metastasis but discontinued after 11 sessions due to dyspnea and G3\n esophagitis.\n\n- Arterial hypertension\n\n- Chronic renal insufficiency\n\n- Type 2 diabetes mellitus\n\n**Treatment and Progression:** The patient presents for a second opinion\non his prostate cancer, which has metastasized to the bones and lymph\nnodes and has become castration-resistant. He recently received\nLutetium-Radioligand therapy. Genetic sequencing from the tissue biopsy\ndid not reveal any significant gene mutations. The patient wishes to\nundergo further evaluation for the diagnosis of relevant genetic\nmutations. A previously punctured subdiaphragmatic lymph node metastasis\nhas not yet undergone genetic testing, which may be justified based on\nthe available data and publications in specific cases. A chemotherapy\nsession with Cabazitaxel is planned for the end of January in the\ntreating urological practice. In cases of DNA repair gene alterations, a\nplatinum combination could also be considered. Further possible\ndiagnostic and therapeutic steps were discussed with the patient. An\napplication for a repeat genetic sequencing will be submitted by our\ncolleagues from the genetics department.\n\n**Current Recommendations:**\n\n- Application for genetic sequencing for the punctured lymph node\n metastasis through the genetics department and DNA-med\n\n- Subsequent re-genetic sequencing of the subdiaphragmatic lymph node\n metastasis for relevant mutations\n\n- After receiving the results, a follow-up appointment can be\n scheduled in our uro-oncology outpatient clinic.\n\n.\n\n**\\\n**\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting to you regarding the inpatient stay of our patient Mr.\nBen Harder, born on 08/02/1940. He was under our care from 09/16/2023 to\n09/23/2023.\n\n**Diagnosis**: Prostate Cancer pT3b pN1 R1 L0 V0\n\n- Gleason Score: 4 + 5 = 9\n\n- Postoperative status following retropubic radical prostatectomy\n without nerve preservation and with pelvic lymphadenectomy.\n\n- Currently presenting with lymph node and bone metastases, mCRPC\n (metastatic castration-resistant prostate cancer)\n\n- Initial PSA level: 4.8 ng/ml\n\n**Previous Treatment and Course:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects in 01/2023.\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT scan indicated new extensive metastasis in the sacrum\n and diffuse lung metastases, accompanied by a PSA level of 1.35\n ng/ml.\n\n- Current PET-CT not available. Recommendations for further treatment\n options are as follows, based on externally described\n image-morphological progression in the recent CT:\n\n 1. Actinium-225-PSMA Therapy (Lu-177 Tandem Therapy), provided that\n all vital metastases are PSMA-positive (mandatory exclusion of\n post-renal urinary flow obstruction)\n\n 2. Alternatively, consider initiating therapy with Abiraterone +\n Prednisolone or a Cabazitaxel re-challenge (if there was a\n favorable response to the last 2 cycles of Cabazitaxel\n\n 3. Evaluation of pre-screening for CAR-T cell studies in oncology\n at CBF (contact will be made)\n\n**Other Diagnoses:**\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n- Type 2 Diabetes Mellitus\n\n**Current Presentation:** Mr. Ben Harder is presenting for his 2nd cycle\nof Radioligand Therapy (RLT) with Ac-225-PSMA/Lu-177-I&T-PSMA for lymph\nnode and bone metastatic prostate cancer. In light of progressive\nimage-morphological findings despite guideline-compliant treatment, the\nindication for RLT tandem therapy was determined in the tumor\nconference.\n\n**Medical History:** Mr. Harder reports that after the last treatment\ncycle, he experienced pronounced fatigue symptoms. He particularly\nstruggled with climbing stairs and walking longer distances. However, he\nmanaged to fully recover from these symptoms through targeted training.\nAdditionally, he developed pain in the area of the right ribcage\nfollowing the last treatment cycle. The pain occurs intermittently and\nis accompanied by increased salivation and nausea, sometimes leading to\nvomiting. Mr. Ben Harder also reports newly developed swallowing\ndifficulties. He feels that food gets stuck in his throat after\nswallowing.\n\n**Therapy and Progression:**\n\nIn the case of Mr. Ben Harder, due to metastatic prostate cancer with\nradiographic progression despite previous guideline-recommended therapy,\naccording to the recommendations, there was an indication for the 2nd\nradioligand therapy with Ac-225-PSMA/Lu-177-I&T-PSMA. The\npost-therapeutic imaging showed targeted accumulation of the therapeutic\nagent within the tumor. The therapy was administered due to elevated\nrenal retention parameters with reduced activity of Lu-177-PSMA. The\ncourse of therapy and the entire hospital stay were uncomplicated, so we\ncan now transition the patient to your outpatient care. We recommend\nclose laboratory monitoring (blood count, liver and kidney parameters)\nat 1, 2, 4, and 8 weeks, as well as a PSA determination 6-8 weeks after\ntherapy.\n\nIn the case of significant fatigue symptoms after the 1st cycle of\ntandem RLT, if there are blood count changes indicating a decrease in\nhemoglobin levels and recurrent fatigue symptoms, the administration of\nerythropoietin or the indication for blood product transfusion should be\nconsidered. Depending on the PSA value 6 weeks post-therapy and the\nfindings of the PSMA-PET/CT, the further course of action will be\ndetermined in the interdisciplinary Tumor Conference.\n\nIf the patient desires, they can seek a second opinion on further\ntherapeutic procedures in the specialized clinic of the Uro-Oncology\ncolleagues. In case of pronounced rib pain, if requested by the patient,\nthe possibility of undergoing radiation therapy can be evaluated. To do\nso, Mr. Harder can schedule an appointment at the Radio-Oncology clinic.\nPsycho-oncological counseling has been offered to the patient.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan Cilexetil (Atacan) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multi-Vitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Sodium Selenite 999 µg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B Complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Vitamin B1 200 mg 1x/Week\n Vitamin B6 25 mg 2-3x/Week\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------------- ---------------------\n Neutrophils % 80.3 % 42.0-77.0 %\n Lymphocytes % 6.7 % 20.0-44.0 %\n Monocytes % 8.9 % 2.0-9.5 %\n Basophils % 1.3 % 0.0-1.8 %\n Eosinophils % 2.4 % 0.5-5.5 %\n Immature Granulocytes % 0.4 % 0.0-1.0 %\n I:T Ratio 0.005 \n HFLC Absolute 0.0 /µL \n Sodium 140 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Calcium 9.36 mg/dL 8.8-10.2 mg/dL\n Chloride 102 mEq/L 98-107 mEq/L\n Creatinine 1.25 P+ mg/dL 0.70-1.20 mg/dL\n Estimated GFR 52 mL/min/1.73m\\^2 \n BUN (Urea) 44 mg/dL 17-48 mg/dL\n Uric Acid 3.8 mg/dL 3.6-8.2 mg/dL\n CRP 1.3 mg/L \\< 5.0 mg/L\n PSA 2.98 ng/mL \\< 4.4 ng/mL\n ALT (GPT) 22 U/L \\< 41 U/L\n AST (GOT) 49 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 19 U/L 8-61 U/L\n LDH 404 P+ U/L 135-250 U/L\n Testosterone \\<0.03 P- ng/mL 1.32-8.92 ng/mL\n TSH 1.14 mIU/L 0.27-4.20 mIU/L\n Complete Blood Count \n Differential Count \n Hemoglobin 10.6 g/dL 12.5-17.2 g/dL\n Hematocrit 30.5 % 37.0-49.0 %\n RBC 3.4 M/µL 4.0-5.6 M/µL\n WBC 5.49 K/µL 3.90-10.50 K/µL\n Platelets 279 K/µL 150-370 K/µL\n MCV 88.7 fL 80.0-101.0 fL\n MCH 30.8 pg 27.0-34.0 pg\n MCHC 34.8 g/dL 31.5-36.0 g/dL\n MPV 10.1 fL 7.0-12.0 fL\n RDW-CV 14.1 % 11.5-15.0 %\n Absolute Neutrophils 4.41 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.020 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.37 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.49 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.13 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 37.8 K/µL 25.0-105.0 K/µL\n Reticulocyte Percentage 1.10 % 0.50-2.00 %\n Reticulocyte Production Index 0.4 \n Ret-Hb 35.0 pg 28.5-34.5 pg\n Prothrombin Time 117 % \\> 78 %\n INR 0.94 \\< 1.25\n aPTT 30.2 sec 25.0-38.0 sec\n\n\n\n\nHere is the query:\nWhat significant change in Mr. Harder's bone metastasis was reported in the PSMA-PET-CT scan in July 2023 compared to earlier scans?\n\nChoose the correct answer from the following options:\nA. Decrease in metabolic activity\nB. New extensive metastasis in the sacrum\nC. New small metastasis in the sacrum\nD. Remission of iliac metastases\nE. Increase in the size of known iliac metastases\n\n\nYour response:\n", "role": "user" }, { "content": "New extensive metastasis in the sacrum", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Ben Harder, born on 08/02/1940, who was admitted\nto our hospital from 12/17/2015 to 12/27/2015.\n\n**Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Status post excision on the nose with suspicion of basal cell\n carcinoma\n\n- Status post laparoscopic cholecystectomy\n\n- Retropubic radical prostatectomy without nerve preservation and with\n bilateral pelvic lymphadenectomy was performed on 12/17/2015.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------- ---------------------------------------------------\n Valsartan (Diovan) 160 mg 1-0-1\n Aspirin 100 mg 1-0-1\n Simvastatin (Zocor) 15 mg 0-0-1\n Doxazosin (Cardura) 1 mg 0-0-1\n Enoxaparin (Lovenox) 0.6 mL s.c. Administer subcutaneously for a total of 4 weeks.\n Acetaminophen (Tylenol) 500 mg 1-1-1 (for 4 days)\n\n**Histopathology:**\n\n1. 2 adenocarcinoma metastases in 2 out of 4 lymph nodes, left external\n iliac region.\n\n2. 3 adenocarcinoma metastases in 3 out of 6 lymph nodes, right pelvic\n region.\n\n3. 7 adenocarcinoma metastases in 7 out of 7 lymph nodes, right lumbar\n para-aortic region.\n\n4. Acinar adenocarcinoma of the prostate is observed bilaterally, with\n a Gleason score of 4 (70%) + 5 (25%) = 9 and a tertiary Gleason\n grade of 3 (5%) according to the modified Gleason grading of the\n ISUP 2005. The tumor is multifocal and encompasses the entire\n prostate with a maximum extrapolated tumor extension of 60 mm. There\n is extracapsular tumor growth, with focal involvement at the dorsal\n right base. Vascular invasion is not noted, but perineural invasion\n is extensive. Both seminal vesicles are heavily infiltrated, and the\n resection margin of the left seminal vesicle is involved. Before\n tissue embedding, the margins of the specimen show focal\n infiltration by the tumor, in the right anterior region near the\n base (section 7) with a total contact area of 2 mm wide, and the\n primary Gleason grade at the positive margin is 4. In addition to\n the carcinoma, other prostatic tissue shows features of myoglandular\n hyperplasia and high-grade prostatic intraepithelial neoplasia\n (HGPIN). The prostatic urethra is free of tumors or dysplasia.\n\n5. **Tumor classification:** pT3bpN1(12/17), R1L0V0, Gleason: 4 + 5 = 9\n\n**Medical History:** Mr. Harder was admitted for open prostatectomy due\nto biopsy-confirmed prostate carcinoma.\n\nInitial PSA value: 5.42 ng/ml. Gleason score of biopsy: 4+5=9 in 11 out\nof 12 biopsy samples. Clinical tumor stage: cT2c PSMA PET-CT + MRI from\n12/23/2015: Left capsular penetration without rectal infiltration.\nSeminal vesicles are infiltrated on both sides. Evidence of multiple\nlymph nodes; intrapelvic locoregional and two lymph nodes on the right\nparailiacal and lumbar interaortocaval region.\n\nTRUS: 88 cc Digital Rectal Examination: Abnormal findings on the left\nside\n\n**Physical Examination:** The patient is in good general condition, has\na lean nutritional status, and reports feeling well. The abdomen is\nsoft, with no tenderness, masses, resistance, or guarding, and the\nexternal genitalia are unremarkable.\n\n**Ultrasound upon admission:** Both kidneys are not dilated and show no\nspace-occupying lesions. The bladder is minimally filled and appears\nunremarkable to the extent assessable.\n\n**Pretherapeutic Tumor Conference:** The findings were discussed\ninterdisciplinary, and the possible treatment options were explained.\nThe patient opted for radical prostatectomy.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complications. The postoperative course was uneventful. Blood\ntransfusions were not required. Unfortunately, a cystogram on revealed\nextravasation, requiring the indwelling catheter to be retained. The\nwound drain was lifted once with serum-identical creatinine values and\nretained with persistent output (approximately 400 ml daily). Both\nkidneys were not dilated, and there were no signs of lymphocele or\nhematoma in the pelvic region on ultrasound. A follow-up rehabilitation\ntreatment has been organized through our social services. We discharged\nthe patient with absorbable intracutaneous sutures for further\noutpatient care.\n\n**Current Recommendations:** The patient was discharged with a permanent\ncatheter and will present on 01/03/2016 for cystogram and possibly\ncatheter removal. If catheter removal is indicated, we recommend\nconsidering a trial of voiding with subsequent admission if the\ncystogram is normal. The wound drain was also retained, and we request\ndocumentation of output. If output regresses and remains persistently \\<\n30-40 ml, and there is no ultrasound evidence of lymphocele, it could be\nremoved on an outpatient basis or during the follow-up appointment.\n\nWe recommend the first PSA check 6 -- 8 weeks postoperatively, followed\nby quarterly intervals. If the PSA level does not reach the zero range\nor rises again from the zero range, the patient can be offered\nradiotherapy of the prostatic bed and lymphatic drainage pathways in\ncombination with a 2-year hormonal ablative therapy as an individual\ntherapeutic trial. Alternatively, primary hormonal ablative therapy is\nan option. If the PSA level reaches the zero range, the patient may be\noffered adjuvant hormonal ablative therapy for 2 years, possibly\ncombined with radiotherapy. Additional findings will be discussed in our\npost-therapeutic conference. In case of changes in the recommended\nprocedure mentioned above, we will inform you again.\n\n**Course of the lab results:**\n\n **Parameter** **12/18/15** **12/19/15** **12/20/15** **12/23/15** **Reference Range**\n --------------------------- --------------- ---------------- --------------- -------------- ---------------------\n Sodium 135 mEq/L 138 mEq/L 136-145 mEq/L\n Potassium 5.1 mEq/L 4.4 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffe method) 0.93 mg/dL 1.05 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 83 65 \n Hemoglobin 11.4 g/dL 12.4 g/dL 12.5-17.2 g/dL\n Hematocrit 0.323 L/L 0.361 L/L 0.370-0.490 L/L\n Red Blood Cells 3.8 x10\\^12/L 4.3 x10\\^12/L 4.2 x10\\^12/L 4.0-5.7 x10\\^12/L\n White Blood Cells 9.57 x10\\^9/L 11.51 x10\\^9/L 9.65 x10\\^9/L 3.90-10.50 x10\\^9/L\n Platelets 216 x10\\^9/L 239 x10\\^9/L 285 x10\\^9/L 150-370 x10\\^9/L\n MCV 88.1 fL 86.0 fL 88.3 fL 80.0-101.0 fL\n MCH 30.2 pg 30.1 pg 29.5 pg 27.0-34.0 pg\n MCHC 34.5 g/dL 35.3 g/dL 33.8 g/dL 31.5-36.0 g/dL\n MPV 10.2 fL 10.4 fL 10.3 fL 7.0-12.0 fL\n RDW-CV 12.1% 12.2% 12.8% 11.6-14.4%\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Ben Harder, born on 08/02/1940 who received\ninpatient treatment from 01/13/2016 to 01/19/2016.\n\n**Diagnosis:** Urinary Tract Infection in Patient with indwelling\ncatheter\n\n**Other Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n- Arterial hypertension\n\n- History of excision on the nose with suspicion of basal cell\n carcinoma\n\n- History of laparoscopic cholecystectomy\n\n**Medication upon Admission: **\n\n **Medication (Brand)** **Dosage** **Frequency**\n ------------------------------ ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan (Atacand) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multivitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Selenium 999 mcg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Thiamine 200 mg 1x/Week\n Pyridoxine 25 mg 2-3x/Week\n\n**Current presentation:** Mr. Harder returned to our clinic on\n01/13/2016, complaining of new-onset symptoms including increased\nurgency and frequency of urination, discomfort, lower abdominal pain,\nand fever. Given his recent surgery and indwelling catheter, concerns\nwere raised about a possible urinary tract infection.\n\n**Clinical Examination:** On physical examination, Mr. Harder appeared\nunwell. He had a temperature of 38.8°C, elevated heart rate\n(tachycardia), and mild lower abdominal tenderness on palpation. The\nindwelling urinary catheter was in situ, and no signs of catheter\ndislodgment or leakage were observed.\n\n**Ultrasound of the Abdomen upon admission:** Bilateral, no urinary\ntransport obstruction, approximately 4x2 cm-sized fluid collection noted\nin the right inguinal area, suggestive of possible lymphocele.\n\n**CT Scan Abdomen/Pelvic from 01/13/2016:** The liver displays a smooth\ncontour, with homogeneous parenchymal contrast enhancement, and no\nevidence of focal intrahepatic lesions. There is no indication of\nintrahepatic or extrahepatic cholestasis. History of previous\ncholecystectomy with an accentuated common hepatic duct. Spleen,\npancreas, and adrenal glands appear unremarkable. Both orthotopically\nlocated kidneys exhibit simultaneous and equal contrast enhancement. No\nintrarenal structural abnormalities or signs of urinary obstruction are\nobserved. The colonic frame and small intestine show adequate perfusion,\nwithout focal wall thickening. The stomach is distended. The urinary\nbladder contains a catheter. Two intraluminal air pockets are seen.\nKnown circumferential, uniform bladder wall thickening from previous\nexaminations. No free intrabdominal air is detected. No evidence of\nascites. Bilateral iliac and inguinal operative clips from prior\nlymphadenectomy. Right iliac region shows a serous fluid collection\nmeasuring approximately 3 x 2 cm. Para-aortic lymph nodes, up to 14 mm\nin size, are consistent with findings from previous evaluations. No\nsuspicious malignancy-related bone destruction is noted. A drainage tube\nhas been placed through the right lower abdominal wall, with its tip\nlocated in the left pelvic area.\n\n**Assessment:** No evidence of abscess formation. A lymphocele measuring\napproximately 3 x 2 cm is noted in the right iliac region, without signs\nof acute inflammation.\n\n**Microbiological Examination**\n\n**Material**: Catheter Urine Examination Request: Identification of\nPathogens and Resistance Results: Organism 1: Growth of 100,000 CFU/mL\nEnterococcus faecalis Possible ICD-10 Coding Suggestion: Enterococci as\nPathogen.\n\n- Acute Cystitis\n\n- Pyelonephritis\n\n- Urinary Tract Infection related to Catheter/Implant\n\n- Urinary Tract Infection, Unspecified Location\n\n**Antibiogram**\n\n- Gentamicin HL: S\n\n- Levofloxacin: R 1\n\n- Teicoplanin: S \\<=0.5\n\n- Ampicillin: S \\<=2\n\n- Piperacillin: S\n\n- Ampicillin/Sulbactam: S \\<=2\n\n- Piperacillin/Tazobactam: S\n\n- Imipenem: S \\<=1\n\n- Cefuroxim: R \\>=64\n\n- Gentamicin: R\n\n- Cotrimoxazole: R \\<=10\n\n- Ciprofloxacin: R \\<=0.5\n\n- Vancomycin: S 2\n\n- Linezolid: S 2\n\n- Tigecyclin: S \\<=0.12\n\n**Therapy and Progression:** After CT morphological exclusion of an\nabscess formation or retention, the wound drainage was removed under\nantibiotic coverage. Initially, empirical antibiotic therapy with\nCefuroxim was administered, followed by targeted treatment with oral\nUnacid based on resistance testing. The drainage insertion site healed\nprimarily. The bladder catheter was removed, after which urination was\nfree of residual urine. The patient has primary continence. We\ndischarged the patient to further outpatient treatment, with the patient\nreporting subjective well-being.\n\nMr. Harder showed gradual clinical improvement after initiating\nantibiotic therapy. His fever subsided, and lower abdominal tenderness\ndiminished. The IV fluids were discontinued, and he remained on oral\nantibiotics.\n\n**Urine Culture Results:** The urine culture results returned positive\nfor Escherichia coli (E. coli), a common uropathogen. The sensitivity\nprofile indicated susceptibility to ciprofloxacin.\n\n**Follow-Up:** Mr. Harder was closely monitored for the duration of his\nantibiotic course. He was advised to complete the full course of\nantibiotics and maintain adequate hydration. The urinary catheter was\nremoved on the fifth day of hospitalization after demonstrating improved\nurine output and resolution of symptoms. No further complications\nrelated to the catheter removal were observed.\n\n**Current Recommendations:**\n\n1. Please refer to the previous discharge letter for the procedure\n regarding prostate cancer.\n\n2. He was educated on the signs and symptoms of UTIs and instructed to\n seek prompt medical attention if symptoms recurred.\n\n**\\\n**\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nThank you for assigning Mr. Ben Harder, born on 08/02/1940 to the PET/CT\ncombination scanner examination on 12/11/2022.\n\n**Diagnoses:**\n\n- Initial diagnosis of prostate cancer in December 2015, confirmed by\n prostate biopsy.\n\n- Tumor detected in 11 out of 12 biopsy samples\n\n- Maximum Gleason score of 9\n\n- Preoperative PSA level: 5.42 ng/ml\n\n- In the initial PET/CT examination (preoperative) on 12/23/2015\n evidence of prostate cancer extending beyond the capsule in both\n prostatic lobes was found.\n\n- Infiltration of the left seminal vesicles and beginning infiltration\n of the right seminal vesicles\n\n- Multiple retroperitoneal lymph node metastases and bilateral pelvic\n lymph nodes.\n\n- Radical prostatectomy\n\n- Current PSA level: 1.23 ng/ml\n\n- Radiation therapy planned at our facility\n\n**Technique**: To expedite renal-urinary activity elimination, the\npatient was adequately hydrated. The examination was conducted using the\nPET/CT combination scanner BIOGRAPH 64 with CT parameters set at 120 kV\nand 1 mm slice thickness. PET emission data were acquired with 5 bed\npositions on a radiation therapy-compatible table for whole-body\nexamination in the caudocranial direction with transverse slices at 3.0\nmm intervals over the same axial range as the CT scan. Iterative\nreconstruction was performed. A whole-body scan was conducted 90 minutes\nafter the administration of 278 MBq Ga-68-PSMA (prostate-specific\nmembrane antigen). Transmissions-corrected and non-corrected PET scans,\nCT scans, fusion images, and the determination of the SUV value\n(standard uptake value, a measure of activity uptake per volume) were\nused for evaluation.\n\n**PET Findings:** The 3D whole-body images documented in 3 planes using\nPET and PET/CT technology showed the following changes compared to the\nprior examination on 12/23/2015:\n\n- Post-radical prostatectomy, there is diffuse activity accumulation\n in the region dorsal to the bladder, on the left side.\n\n- Regarding the known retroperitoneal lymph node metastases, the\n following changes were observed: New retrocrural nodule on the\n right. SUV 6.6, diameter: 6 mm.\n\n- Known interaortocaval lymph node, dorsally at the level of L3/4,\n showed increased metabolic activity from SUV 4.7 to 11.5. Slightly\n increased in size, measuring 7 to 8 mm. Additionally, two new\n metabolically active nodules cranially, up to the level of L2/3.\n\n- Slightly increased metabolic activity in the known right iliaca\n communis lymph node, located between the fifth lumbar vertebra and\n the psoas muscle, from 4.0 to 4.6, with the same size of 5 mm.\n\n- Progressive enlargement of the known confluent lymph nodes on the\n right parailiacal externa proximal side, now having a combined size\n of 10 x 26 mm (width x height), previously individual nodules of 10\n and 12 mm. SUV 18.2, previously max 11.5.\n\n- New paraaortic lymph nodes on the left, mostly small, SUV 11.2.\n\n- Newly added lymph nodes in both biiliac communal areas. Maximum size\n on the left is 15 mm, SUV 17.2.\n\n- New retrocrural lymph node on the right, measuring 6 mm, SUV 6.6.\n\n- Known lymph node on the right perirectal, slightly progressive from\n 8 to 10 mm. SUV 6.9, previously 6.4.\n\n- Known lymph node on the left iliaca externa not currently\n verifiable, possibly postoperative scarring.\n\n- Newly added focus in the bone at the level of the spinous\n process/dorsal arch of the fifth lumbar vertebra. In CT, a 7 mm\n focal sclerosis is noted. Normal activity accumulation in the soft\n tissues of the neck, axillae, and chest. Physiological accumulation\n in the parenchymal upper abdominal organs. Kidneys and urinary tract\n appear functionally normal. Whole-body CT following bolus-like\n peripheral venous machine injection of 100 ml of Optiray 350: No\n suspicious lymph nodes in the cervical, axillary, or mediastinal\n regions. Normal-sized thyroid gland. No pleuropulmonary infiltrates\n or round lesions. Scarred changes in the left lower lobe.\n Normal-sized liver without focal lesions. Spleen, pancreas, adrenal\n glands, and kidneys appear regular. No urinary obstruction..\n\n**Results**: In the postoperative PET/CT compared to the preoperative\nexamination on, there is now malignancy-typical PSMA receptor binding in\nthe former prostate lodge, indicating a local recurrence. Progression of\nretroperitoneal lymph node metastases, with further extension cranially,\nextending to the interaortocaval region up to the level of L2/3. Newly\nadded metastases on the left paraaortic and biiliac communal areas.\nProgression of known right iliaca externa lymph node metastases. The\nleft iliaca externa nodule is not verifiable, likely removed. New small\nretrocrural nodule on the right. New osteosclerotic metastasis in the\ndorsal arch of LWK 5. Minimal activity accumulation in the 8th rib on\nthe right lateral aspect. A developing metastasis cannot be conclusively\nruled out here. We kindly request information on the patient\\'s further\nclinical course (submission of medical reports, etc.).\n\n**Lab results**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Glucose (Plasma) 91 mg/dL 55-100 mg/dL\n Alkaline Phosphatase 93 U/L \\< 130 U/L\n Total Cholesterol 152 mg/dL \\< 200 mg/dL\n LDL-Cholesterol 89 mg/dL \\< 130 mg/dL\n HDL-Cholesterol 50 mg/dL 40-60 mg/dL\n Non-HDL Cholesterol 101.8 mg/dL \\< 200 mg/dL\n Triglycerides 64 mg/dL \\< 150 mg/dL\n White Blood Cells 4.1 K/uL 4.5-11 K/uL\n Red Blood Cells 4.68 M/uL 4.0-5.5 M/uL\n Hemoglobin 13.6 g/dL 12.5-17.2 g/dL\n Hematocrit 39.5% 37.0-49.0%\n MCH 29.1 pg 27.0-34.0 pg\n MCHC 34.4 g/dL 31.5-36.0 g/dL\n MCV 84.4 fL 80.0-101.0 fL\n RDW 13.0% 11.6-14.4%\n Platelets 238 K/uL 150-370 K/uL\n\n**\\\n**\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mr. Ben Harder, born on\n08/02/1940, who received inpatient treatment at our facility from\n06/23/2023 to 06/26/2023.\n\n**Diagnosis:**\n\nProstate Cancer pT3b pN1 R1 L0 V0 Gleason Score: 4 + 5 = 9 (Initial\ndiagnosis in December 2015)\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015. Currently, lymph node and bone metastasis\n\n**Other Diagnoses:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015.\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n (thora 11 and 12) with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT in 06/2023 scan indicated new extensive metastasis in\n the sacrum and diffuse lung metastases, accompanied by a PSA level\n of 1.35 ng/ml.\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n**Medications on Admission:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Candesartan (Atacand) 16 mg 1-0-1-0\n Aspirin 100 mg 1-0-0-0\n Chlorthalidone (Thalitone) 25 mg 1-0-0-0\n\n**Physical Examination:** The patient was in good general condition and\nhad normal orientation to all qualities. There were no edemas, dyspnea,\nfever, or cough.\n\n**Medical History:** Mr. Hader presents himself for the 1st cycle of RLT\nwith Ac-225-PSMA/Lu-177-I&T-PSMA for lymph node and bone metastatic\nprostate cancer on an inpatient basis. In the presence of progressive\nimaging findings under guideline-compliant therapy, the indication for\nRLT tandem therapy was confirmed according to the tumor conference on.\nUpon admission, the patient reports feeling well, denies any B-symptoms.\nThere is no fever or nausea, and the weight is currently stable. There\nhas been a tendency to fall for some time. The rest of the medical\nhistory is assumed to be known.\n\n**Neurological Consultation on 06/25/2023: **\n\nClinically neurological examination revealed a polyneuropathy syndrome\nof the lower extremities, predominantly on the right side, as well as a\nknown right-sided foot drop. In summary, we consider the falls to be\nmultifactorial due to foot weakness as well as polyneuropathy syndrome\nwith impaired proprioception as the cause of the balance disorder.\nRecommended further procedure: In the presence of a known PNP syndrome\nthat has occurred during chemotherapy, consider outpatient neurological\nevaluation and objectification by means of Electromyography and\npolyneuropathy laboratory tests.\n\n**Salivary Gland Scintigraphy on 06/26/2023**\n\n**Assessment**: Normal function of the submandibular and parotid glands\nbilaterally.\n\nPost-therapeutic imaging with Lu-177-PSMA imaging using\nSPECT/low-dose-CT\n\n**Assessment:** Consistent with the PET-CT, there is no tracer uptake in\nthe area of the prostate. Intensive accumulation of the therapeutic\nagent in the area of lymph node metastases, especially mediastinal.\nCorresponding to the PET/CT, there are clear focal tracer accumulations\nin the left upper lobe of the lung in the area of nodular or diffuse\ntissue condensations, possibly metastases or, secondarily,\npost-inflammatory. Intensive tracer uptake in the area of known bone\nmetastases from the previous examination. No newly appearing\ntracer-enhancing lesions. In addition, physiological accumulation in the\norgan systems involved in tracer metabolism and excretion. NB: Small\npleural effusions on both sides. Known pronounced peribronchial cuffs in\nthe upper lobes on both sides, possibly scarred, or indicative of\npulmonary venous congestion. Known atrophic kidney on the right.\n\n**Current Recommendations:**\n\n- Blood count checks and determination of kidney and liver parameters\n 1, 2, 4, and 8 weeks after therapy\n\n- Outpatient neurologic assessment for the evaluation of\n polyneuropathy\n\n- PSA determination 6-8 weeks after therapy\n\n- Appointment for a 2nd cycle of radioligand therapy\n (Ac-225-/Lu-177-PSMA)\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Neutrophils (%) 72.2 % 42.0-77.0 %\n Lymphocytes (%) 8.6 % 20.0-44.0 %\n Monocytes (%) 11.6 % 2.0-9.5 %\n Basophils (%) 1.4 % 0.0-1.8 %\n Eosinophils (%) 6.0 % 0.5-5.5 %\n Immature Granulocytes (%) 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 2.31 mEq/L 2.20-2.55 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n C-reactive Protein 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 µg/L \\< 4.40 µg/L\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 µg/L 1.32-8.92 µg/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 0.285 L/L 0.370-0.490 L/L\n RBC 3.3 /pL 4.0-5.6 /pL\n WBC 4.98 /nL 3.90-10.50 /nL\n Platelets 281 /nL 150-370 /nL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Neutrophils (Absolute) 3.59 /nL 1.50-7.70 /nL\n Immature Granulocytes (Absolute) 0.010 /nL \\< 0.050 /nL\n Lymphocytes (Absolute) 0.43 /nL 1.10-4.50 /nL\n Monocytes (Absolute) 0.58 /nL 0.10-0.90 /nL\n Eosinophils (Absolute) 0.30 /nL 0.02-0.50 /nL\n Basophils (Absolute) 0.07 /nL 0.00-0.20 /nL\n Reticulocytes 31.3 /nL 25.0-105.0 /nL\n Reticulocyte (%) 0.94 % 0.50-2.00 %\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to report on our mutual patient, Mr. Ben Harder, born on\n08/02/1940, who presented himself to our outpatient clinic on 1/8/2023.\n\n**Diagnoses:**\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9 (initial\n diagnosis in 11/2015)\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally on\n 11/16/2015\n\n- Currently, there are lymph node and bone metastases\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Initial PSA level was 4.8 ng/ml\n\n- History of Docetaxel therapy\n\n- History of Cabazitaxel therapy\n\n- History of 4 cycles of Lutetium-Radioligand therapy\n\n- Subsequently, radiation therapy was initiated for the lymph node\n metastasis but discontinued after 11 sessions due to dyspnea and G3\n esophagitis.\n\n- Arterial hypertension\n\n- Chronic renal insufficiency\n\n- Type 2 diabetes mellitus\n\n**Treatment and Progression:** The patient presents for a second opinion\non his prostate cancer, which has metastasized to the bones and lymph\nnodes and has become castration-resistant. He recently received\nLutetium-Radioligand therapy. Genetic sequencing from the tissue biopsy\ndid not reveal any significant gene mutations. The patient wishes to\nundergo further evaluation for the diagnosis of relevant genetic\nmutations. A previously punctured subdiaphragmatic lymph node metastasis\nhas not yet undergone genetic testing, which may be justified based on\nthe available data and publications in specific cases. A chemotherapy\nsession with Cabazitaxel is planned for the end of January in the\ntreating urological practice. In cases of DNA repair gene alterations, a\nplatinum combination could also be considered. Further possible\ndiagnostic and therapeutic steps were discussed with the patient. An\napplication for a repeat genetic sequencing will be submitted by our\ncolleagues from the genetics department.\n\n**Current Recommendations:**\n\n- Application for genetic sequencing for the punctured lymph node\n metastasis through the genetics department and DNA-med\n\n- Subsequent re-genetic sequencing of the subdiaphragmatic lymph node\n metastasis for relevant mutations\n\n- After receiving the results, a follow-up appointment can be\n scheduled in our uro-oncology outpatient clinic.\n\n.\n\n**\\\n**\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting to you regarding the inpatient stay of our patient Mr.\nBen Harder, born on 08/02/1940. He was under our care from 09/16/2023 to\n09/23/2023.\n\n**Diagnosis**: Prostate Cancer pT3b pN1 R1 L0 V0\n\n- Gleason Score: 4 + 5 = 9\n\n- Postoperative status following retropubic radical prostatectomy\n without nerve preservation and with pelvic lymphadenectomy.\n\n- Currently presenting with lymph node and bone metastases, mCRPC\n (metastatic castration-resistant prostate cancer)\n\n- Initial PSA level: 4.8 ng/ml\n\n**Previous Treatment and Course:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects in 01/2023.\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT scan indicated new extensive metastasis in the sacrum\n and diffuse lung metastases, accompanied by a PSA level of 1.35\n ng/ml.\n\n- Current PET-CT not available. Recommendations for further treatment\n options are as follows, based on externally described\n image-morphological progression in the recent CT:\n\n 1. Actinium-225-PSMA Therapy (Lu-177 Tandem Therapy), provided that\n all vital metastases are PSMA-positive (mandatory exclusion of\n post-renal urinary flow obstruction)\n\n 2. Alternatively, consider initiating therapy with Abiraterone +\n Prednisolone or a Cabazitaxel re-challenge (if there was a\n favorable response to the last 2 cycles of Cabazitaxel\n\n 3. Evaluation of pre-screening for CAR-T cell studies in oncology\n at CBF (contact will be made)\n\n**Other Diagnoses:**\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n- Type 2 Diabetes Mellitus\n\n**Current Presentation:** Mr. Ben Harder is presenting for his 2nd cycle\nof Radioligand Therapy (RLT) with Ac-225-PSMA/Lu-177-I&T-PSMA for lymph\nnode and bone metastatic prostate cancer. In light of progressive\nimage-morphological findings despite guideline-compliant treatment, the\nindication for RLT tandem therapy was determined in the tumor\nconference.\n\n**Medical History:** Mr. Harder reports that after the last treatment\ncycle, he experienced pronounced fatigue symptoms. He particularly\nstruggled with climbing stairs and walking longer distances. However, he\nmanaged to fully recover from these symptoms through targeted training.\nAdditionally, he developed pain in the area of the right ribcage\nfollowing the last treatment cycle. The pain occurs intermittently and\nis accompanied by increased salivation and nausea, sometimes leading to\nvomiting. Mr. Ben Harder also reports newly developed swallowing\ndifficulties. He feels that food gets stuck in his throat after\nswallowing.\n\n**Therapy and Progression:**\n\nIn the case of Mr. Ben Harder, due to metastatic prostate cancer with\nradiographic progression despite previous guideline-recommended therapy,\naccording to the recommendations, there was an indication for the 2nd\nradioligand therapy with Ac-225-PSMA/Lu-177-I&T-PSMA. The\npost-therapeutic imaging showed targeted accumulation of the therapeutic\nagent within the tumor. The therapy was administered due to elevated\nrenal retention parameters with reduced activity of Lu-177-PSMA. The\ncourse of therapy and the entire hospital stay were uncomplicated, so we\ncan now transition the patient to your outpatient care. We recommend\nclose laboratory monitoring (blood count, liver and kidney parameters)\nat 1, 2, 4, and 8 weeks, as well as a PSA determination 6-8 weeks after\ntherapy.\n\nIn the case of significant fatigue symptoms after the 1st cycle of\ntandem RLT, if there are blood count changes indicating a decrease in\nhemoglobin levels and recurrent fatigue symptoms, the administration of\nerythropoietin or the indication for blood product transfusion should be\nconsidered. Depending on the PSA value 6 weeks post-therapy and the\nfindings of the PSMA-PET/CT, the further course of action will be\ndetermined in the interdisciplinary Tumor Conference.\n\nIf the patient desires, they can seek a second opinion on further\ntherapeutic procedures in the specialized clinic of the Uro-Oncology\ncolleagues. In case of pronounced rib pain, if requested by the patient,\nthe possibility of undergoing radiation therapy can be evaluated. To do\nso, Mr. Harder can schedule an appointment at the Radio-Oncology clinic.\nPsycho-oncological counseling has been offered to the patient.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan Cilexetil (Atacan) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multi-Vitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Sodium Selenite 999 µg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B Complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Vitamin B1 200 mg 1x/Week\n Vitamin B6 25 mg 2-3x/Week\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------------- ---------------------\n Neutrophils % 80.3 % 42.0-77.0 %\n Lymphocytes % 6.7 % 20.0-44.0 %\n Monocytes % 8.9 % 2.0-9.5 %\n Basophils % 1.3 % 0.0-1.8 %\n Eosinophils % 2.4 % 0.5-5.5 %\n Immature Granulocytes % 0.4 % 0.0-1.0 %\n I:T Ratio 0.005 \n HFLC Absolute 0.0 /µL \n Sodium 140 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Calcium 9.36 mg/dL 8.8-10.2 mg/dL\n Chloride 102 mEq/L 98-107 mEq/L\n Creatinine 1.25 P+ mg/dL 0.70-1.20 mg/dL\n Estimated GFR 52 mL/min/1.73m\\^2 \n BUN (Urea) 44 mg/dL 17-48 mg/dL\n Uric Acid 3.8 mg/dL 3.6-8.2 mg/dL\n CRP 1.3 mg/L \\< 5.0 mg/L\n PSA 2.98 ng/mL \\< 4.4 ng/mL\n ALT (GPT) 22 U/L \\< 41 U/L\n AST (GOT) 49 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 19 U/L 8-61 U/L\n LDH 404 P+ U/L 135-250 U/L\n Testosterone \\<0.03 P- ng/mL 1.32-8.92 ng/mL\n TSH 1.14 mIU/L 0.27-4.20 mIU/L\n Complete Blood Count \n Differential Count \n Hemoglobin 10.6 g/dL 12.5-17.2 g/dL\n Hematocrit 30.5 % 37.0-49.0 %\n RBC 3.4 M/µL 4.0-5.6 M/µL\n WBC 5.49 K/µL 3.90-10.50 K/µL\n Platelets 279 K/µL 150-370 K/µL\n MCV 88.7 fL 80.0-101.0 fL\n MCH 30.8 pg 27.0-34.0 pg\n MCHC 34.8 g/dL 31.5-36.0 g/dL\n MPV 10.1 fL 7.0-12.0 fL\n RDW-CV 14.1 % 11.5-15.0 %\n Absolute Neutrophils 4.41 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.020 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.37 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.49 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.13 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 37.8 K/µL 25.0-105.0 K/µL\n Reticulocyte Percentage 1.10 % 0.50-2.00 %\n Reticulocyte Production Index 0.4 \n Ret-Hb 35.0 pg 28.5-34.5 pg\n Prothrombin Time 117 % \\> 78 %\n INR 0.94 \\< 1.25\n aPTT 30.2 sec 25.0-38.0 sec\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n\n\n\n\nHere is the query:\nWhich of the following procedures was NOT performed on Mr. Rudolph on 01/16/2019?\n\nChoose the correct answer from the following options:\nA. Diagnostic ureterorenoscopy on the left\nB. Biopsy of the left ureter\nC. Retrograde urography on the left\nD. DJ catheter placement on the left\nE. Laparoscopic cholecystectomy\n\n\nYour response:\n", "role": "user" }, { "content": "Laparoscopic cholecystectomy", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nPatient: Miller, John, born 04/07/1961\n\nWe report to you about our common patient, Mr. John Miller, who is in\nour inpatient treatment since 07/30/2019.\n\n**Diagnoses:**\n\n\\- Suspected right cerebral glioblastoma (first diagnosis)\n\n\\- Symptoms: Aphasia, passive confusion\n\n**Patient history: **\n\nMr. Miller was admitted as an emergency. He was on the phone with a\nfriend when he suddenly began to exhibit speech difficulties and\nstruggled to find the right words. Consequently, his friend called 911.\n\nUpon the ambulance\\'s arrival, Mr. Miller was disoriented and exhibited\naggressive behavior. There was evidence of a torn door. He had blood on\nhis right forearm and around his mouth, but there were no indications of\na tongue bite or urinary incontinence.\n\nUpon admission, Mr. Miller was coherent and showed no speech issues. He\nattributed a mild weakness in his right arm to pre-existing pain in the\nupper arm. An immediate CT scan revealed a mass suggestive of a\nglioblastoma in the right cerebral hemisphere, leading to a\nneurosurgical consultation.\n\nGiven the possibility of an epileptic seizure, Mr. Miller was\nhospitalized and started on Levetiracetam. He is currently unaware of\nhis regular medications but takes antihypertensives and diabetes\nmedications, among others. His friend and brother have been notified and\nare ensuring that a detailed medication list is provided.\n\nAfter a brief stay in ward ABC, Mr. Miller was transferred to the\nneurosurgery team for further evaluation and treatment. We appreciate\nthe prompt transfer and are available for any further inquiries.\n\nPlanned Procedures:\n\n-Schedule EEG\n\n-Clarify routine medications\n\n**Surgery Report**\n\n**Diagnosis:** Suspected HGG (high-grade glioma) of the right hemisphere\n\n**Procedure:** Microsurgical navigation-guided resection of the tumor\nwith intraoperative neuromonitoring (stable MEPs) and intraoperative MRI\nusing 5-ALA. Pathology samples taken (Preliminary: HGG; Final to be\nconfirmed). Resection was followed by duragen placement, watertight\ndural closure, and multilayer wound closure, with skin sutures.\n\n**Time:**\n\n-Start: 11:12 am\n\n-Finish: 3:54 pm\n\n-Duration: 4 hours 42 minutes\n\n**Assessment:**\n\nMr. Miller presented with a seizure characterized by speech disturbance\nand disorientation. Imaging revealed a significant right hemispheral\nmass, likely representing a high-grade brain tumor. The need for\nsurgical resection was determined following discussions at our\ninterdisciplinary tumor board. After being informed about the procedure,\nalternative treatments, the operation\\'s urgency, benefits, and\npotential risks, Mr. Miller provided written consent following ample\ntime for consideration and the opportunity to ask further questions.\n\n**Procedure Details:**\n\nThe patient was positioned supine with his head secured in a Nova clamp.\nNavigation data were read, followed by skin preparation, and the\nsurgical field was sterilized and draped. An arch-shaped incision was\nmade, followed by hemostasis, deep tissue dissection, placement of a\nburr hole, and the creation of a large bone flap over the lesion. The\nbone flap was then elevated. Multiple washings were performed, followed\nby dural opening under microscopic visualization. A corticotomy was\ncarried out with bipolar forceps, CUSA, and suction to progressively\nreduce the tumor, utilizing 5-ALA fluorescence and continuous\nneurophysiological monitoring. An intraoperative MRI showed residual\ntumor, prompting further resection. Hemostasis was achieved, and the\nwound was closed using tabotamp, followed by duragen placement and dural\nsuturing. The bone flap was refixed using Dogbone plates. The wound area\nwas irrigated extensively once more, followed by subcutaneous and skin\nsutures.\n\n**Date:** 10/01/2019\n\n**Clinical Indication:**Suspected recurrence of GBM in the right\nhemisphere\n\n**Requested Imaging:**cMRI with or without contrast + DTI.\n\n**Findings:***Imaging Modality (GE 3.0T):* 3D FLAIR, DTI, SWI, T2\\*\nperfusion, 3D T1 with and without contrast, 3D T2,\nsubtraction.Following resection of a right hemispheric glioblastoma in\n08/19, and compared to the last two scans (external: 07/19, internal:\n08/19), there is a notable expansion of the prior detected flair\nhyperintense regions. These now span from the right parietal-subcortical\narea across the right basal ganglia to the right temporo-occipital/right\ntemporal pole. Specifically, at the dorsocranial edge of the resection\ncavity, the hyperintense regions appear to have grown since 08/19. These\ncoincide with hyperperfused regions in the T2\\* perfusion. Linear SWI\nsignal changes are suggestive of mild post-surgical bleeding. No\nsignificant postoperative hemorrhage or territorial ischemia is\ndetected. A normal venous sinus drainage is observed. Right temporal\nhorn appears congested, possibly due to CSF trapping.\n\n**Assessment:**\n\nFollowing the resection of the right hemispheric glioblastoma in 08/19:\n\n-Markedly progressive flair edema and evolving barrier disturbance.\nRegions especially towards the dorsal side of the resection cavity show\nthis alongside associated hyperperfusion. With the recent PET imaging\nfrom 10/19, there is an indication of progressive disease as per RANO\ncriteria.\n\n-Long-term progressive congestion of the right temporal horn, likely CSF\ntrapping.\n\n**Surgery Report****Diagnosis:**Tumor recurrence after resection of a\nglioblastoma (IDH wild type, WHO CNS grade 4) of the right hemisphere in\n08/2019. The patient underwent combined radiochemotherapy at the local\nclinical center.\n\n**Procedure:**Navigated, microsurgical resection supported by 5-ALA,\nwith stable MEPs through the previous right temporal access. iMRI\nconducted between 11:10 and 11:50. Used Duragen/TachoSil, dog bones for\nclosure, followed by layered wound closure and skin sutures.\n\n**Timing:**\n\n-Incision: 09:23 am on 10/12/19\n\n-Suture: 12:32 pm on 10/12/19\n\n**Assessment:**The patient had previously undergone surgery for a\nglioblastoma and a recurrence was detected on imaging. The tumor board\nhad already deliberated on the surgery. The patient was informed about\nthe surgical procedure, particularly about conducting an extensive\nresection caudally without impacting function post-mapping. The patient\nconsented, understanding the potential for longer progression-free\nsurvival.\n\n**Procedure Details:**The patient was placed in a supine position with\nthe head turned to the side and fixed using the Noras clamp. The right\nshoulder was padded. The surgical area was prepared by trimming hair\naround the previous scar, followed by sterilization and draping. After a\nteam time-out, prophylactic antibiotics were administered. The previous\nscar was reopened and old plates were removed. The microscope was then\nswung into position and the dura was opened. Navigation proceeded\nbeneath the labbé vein, with tumor resection as guided by ALA\nfluorescence. Post-tumor removal, extensive hemostasis was achieved\nusing absorbent cotton and TABOTAMP. Intraoperative MRI confirmed a\ncomplete resection of the tumor. The dura was sealed using DuraGen,\nensuring a watertight closure. The bone flap was reinserted, followed by\nsubcutaneous suturing, skin suturing, and sterile dressing of the wound.\n\n\n\n\n### text_1\n**Dear colleague, **\n\nWe write to update you regarding our shared patient, Mr. John Miller,\nborn on 07/04/1961, who visited us on 12/02/2019.\n\n**Diagnosis:**Glioblastoma recurrence, IDH 1 wild type.\n\n**Tumor Location:**Right hemisphere including temporal regions.\n\n**Clinical History & Treatment:**\n\n-07/2019: Mr. Miller experienced speech disturbances and confusion.\n\n-08/01/2019: Brain PET-MRI revealed a suspected malignancy in the right\nhemisphere, including temporal areas.\n\n-08/11/2019: Glioblastoma was resected at our facility.\n\n-08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy\nwith a boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local\nclinical center.\n\n-10/01/2019: cMRI with suspected recurrence.\n\n-10/12/2019: A recurrent resection was performed at our facility.\n\n-11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n**Recent Evaluation (12/01/2019):**Mr. Miller visited our facility with\nhis brother. Our assessment, based on CTCAE criteria, indicated that he\nis in a fair but stable general and nutritional health (KPS 70-80%,\nweight undisclosed, height 175 cm). Neurological and general evaluations\nrevealed a degree of aphasia, mainly with word-finding difficulty, and\nshort-term memory impairment. However, he remains fully oriented and\nindependent in daily life.\n\n**Additional Observations:**\n\nHis surgical wound has healed well.\n\n**Pre-existing Conditions:** Arterial hypertension, Diabetes Mellitus\nType II\n\n**Allergies:** None\n\n**Current Medications:** Antihypertensive drugs and insulin.\n\nPostoperatively, Mr. Miller remains in good health. A recent brain MRI\nnoted that the suspected recurring GBM lesion near the superior border\nof the surgical site was entirely resected. Furthermore, CT scans at the\nanterior medial and lateral edges suggest that a complete resection was\nmost likely achieved.\n\nGiven the presumed complete resection of the glioblastoma recurrence, we\nhave recommended Mr. Miller for a neuro-oncology review and a follow-up\nwith PET-MRI in three months.\n\n**Next Steps:**\n\n-He has a scheduled appointment in neuro-oncology on 01/23/2020 at 10:00\nAM.\n\n-A follow-up PET-MRI is set for 01/29/2020 at 12:45 PM. We have advised\nMr. Miller to fast for 4 hours prior and to bring a referral from his\nprimary care physician, along with a recent creatinine test result.\n\n-A review of these findings will be held in our outpatient department on\n01/30/2020 at 2:00 PM.\n\nThank you for your continued care and collaboration. Please do not\nhesitate to reach out for any additional information.\n\nWarm regards,\n\n\n\n### text_2\n**Dear colleague, **\n\nRegarding our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nGlioblastoma recurrence, IDH 1 wild type\n\n**Tumor Location**:\n\nRight hemisphere/temporal.\n\n**Medical History**:\n\n07/2019: Onset of speech arrest and confusion.\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\nMr. Miller came in on 12/01/2019 with his brother. Clinical examination\nfindings are as follows:\n\n-General health: Stable with reduced vitality.\n\n-Nutritional status: Stable (KPS 70-80%, weight in kg, height 169 cm).\n\n-No evident motor, sensory, visual, or cranial nerve deficits.\n\n-Neurocognitive deficits: Short-term memory issues.\n\n-Aphasia: Grade II (mainly word-finding disorders). The patient is fully\noriented and independent in daily life.\n\n-No evidence of recurrence in PET-MRI. Next imaging scheduled in\n03/2020.\n\n**Past Medical Conditions**:\n\n-Hypertension\n\n-Type II Diabetes Mellitus\n\n**Allergies**: None.\n\n**Medications**:\n\n-Antihypertensive medications\n\n-Insulin\n\nBest Regards,\n\n\n\n\n### text_3\n**Dear colleague, **\n\nUpdating you on our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nRecurrent Glioblastoma, IDH 1 wild type (ICD-10: 71.8).\n\n**Molecular Pathology**:\n\nNo p.R132H mutation in IDH.\n\nNo combined 1p/19q loss.\n\nSuspected CDKN2A/B deletion.\n\n**Medical History**:\n\nNo pain or B symptoms.\n\nIntermittent dizziness and headaches since the last check-up.\n\n**Neurological Findings**:\n\nPatient is alert and oriented.\n\nWeight: 80 kg (total loss: 15 kg), Height: 175 cm.\n\nKarnofsky Performance Score: 80%.\n\nMotor function and sensory assessments were unremarkable.\n\n**Allergies**: None.\n\n**Medications**:\n\nLisinopril 10mg once daily in the morning\n\nBisoprolol 2.5mg once daily at bedtime\n\nJanuvia 50mg twice daily\n\nAllopurinol 100mg once daily in the morning\n\nEzetimibe 10mg once daily at bedtime\n\nLevetiracetam 1000mg once daily in the morning Insulin as per regimen\n\n**Secondary Diagnoses**:\n\nHypertension\n\nType II Diabetes Mellitus\n\n**Medical Course**:\n\nDetails from 07/2019 through 03/2020 provided, including surgeries,\nradiochemotherapies, and diagnostics.\n\nIn summary, Mr. Miller\\'s glioblastoma diagnosis in 07/2019 led to\nvarious treatments, including radiochemotherapy and surgeries. His\nrecent PET/MRI on 01/2020 indicates potential recurrent areas.\n\nBest regards,\n\n**Patient:** John Miller\n\n**DOB:** 04/07/1961\n\n**Admission Date:** 04/11/2020\n\n**Discharge Date:** 04/18/2020\n\n**Admission Diagnosis:**\n\nRecurrent tumor in the hippocampal region and along the prior resection\ncavity.\n\nHistory of glioblastoma (IDH wild type, WHO CNS grade 4) in the right\nhemisphere, resected on 08/2019.\n\nHistory of combined radiochemotherapy with Temodar (Temozolomide) from\nAugust to September 2019 at the local clinical center.\n\nSubsequent first re-resection in 10/2019.\n\n**Presenting Complaint:**\n\nMr. Miller presented to the neurosurgical outpatient department\naccompanied by his wife. Recent imaging indicated a potential recurrence\nof the glioblastoma. The neuro-oncological board on 04/12/2020\nrecommended a re-resection.\n\n**Physical eon Admission:**\n\nAlert, oriented x4, cooperative.\n\nNon-fluent aphasia.\n\nCranial nerves intact.\n\nNo sensory or motor deficits in the extremities.\n\nSurgical scar clean and dry.\n\nNo signs of neurogenic bladder or rectal dysfunction.\n\nKPSS 70%.\n\n**Medications on Admission:**\n\n-Lisinopril 10mg daily\n\n-Bisoprolol 2.5mg nightly\n\n-Januvia 50mg twice daily\n\n-Allopurinol 100mg daily\n\n-Atorvastatin 40mg nightly\n\n-Ezetimibe 10mg nightly\n\n-Levetiracetam 1000mg twice daily\n\n-Actraphane insulin as prescribed\n\n**Surgical Intervention (04/12/2020):**\n\nNavigated microsurgical resection of tumor spots assisted with 5-ALA.\nStable MEPs were maintained. An intraoperative MRI (iMRI) was utilized.\nPost-resection, the surgical area was managed using Tabotamp, Duragen,\nTachoSil, and dog-bone plates, concluding with layered wound closure.\n\n**Postoperative Course:**\n\nUncomplicated recovery.\n\nPost-op MRI showed no residual tumor.\n\nSurgical site remained clean, dry, and showed no signs of infection or\nirritation.\n\n**Discharge Diagnosis:**\n\nRecurrence of known glioblastoma, WHO CNS grade 4.\n\n**Interdisciplinary Neuro-oncological Tumor Board Recommendation\n(04/20/2020):**\n\nMolecular tumor board review.\n\nOffer reinitiation of Temozolomide chemotherapy.\n\n**Physical Examination on Discharge:**\n\nSimilar to admission, with suture in place and wound site in good\ncondition.\n\nKPSS 70%.\n\n**Medications on Discharge:**\n\n-Allopurinol 100mg daily (morning)\n\n-Atorvastatin 40mg nightly (evening)\n\n-Bisoprolol 2.5mg nightly (evening)\n\n-Ezetimibe 10mg nightly (evening)\n\n-Sitagliptin (Januvia) 50mg twice daily (morning and evening)\n\n-Levetiracetam (Keppra) 1000mg twice daily (morning and evening)\n\n-Lisinopril 10mg daily (morning)\n\n-Acetaminophen 500mg as needed for pain or fever\n\n-Actraphane insulin as prescribed\n\n**Surgery Report **\n\n**Diagnosis**:\n\nTumor recurrence in the right hippocampal region and along the resection\ncavity post glioblastoma resection on 8/11/2019.\n\nPrevious treatments include radiochemotherapy at our clinic. Local\ntherapy center (from August to September 2019) and re-resection on\n10/12/2019.\n\n**Surgery Type**:\n\nRe-opening of the temporal region with navigation, microsurgery using\n5-ALA assistance, iMRI, and re-resection, among other procedures.\n\n**Procedure Details**:\n\nStart: 11:50 pm on 04/12/2020\n\nEnd: 4:00 pm on 04/12/2020\n\nDuration: 4 hours 10 minutes.\n\n**Assessment**:\n\nEvidence of recurrent glioblastoma areas warranted another biopsy and\nresection. After informing Mr. Miller about the procedure\\'s risks and\nbenefits, he provided written consent.\n\n**Operation**:\n\nDetails on the positioning, pre-operative preparations, resection, and\npost-operative procedures are provided.\n\nBest regards,\n\nMEDICAL HISTORY:\n\nMr. Miller underwent surgery because of tumor recurrence in the right\nhemisphere last November to treat a right temporal glioblastoma. He\npresented to our private outpatient clinic due to a wound complication,\nspecifically a wound dehiscence measuring about 1 cm. On closer\nexamination, pus was noted. Despite being symptom-free otherwise, a\nconsultation with Dr. Doe was scheduled. After discussion, it was\ndecided to clean the wound, trim the deteriorated wound edges, and clean\nthe bone flap with an antibiotic solution before reinserting it. The\npatient was thoroughly educated about the nature and risks of the\nprocedure and gave consent.\n\nOPERATION:\n\nThe patient was placed in a supine position. The hair surrounding the\nsurgical site was trimmed, followed by skin disinfection and sterile\ndraping. The bicoronal skin incision was reopened. Deteriorated wound\nedges were excised and the wound was extensively cleaned with\nirrigation. The bone flap was removed and immersed in a Refobacin\nsolution. The epidural pannus tissue was removed. The dura was\ncompletely sutured. Multiple samples were collected both subgaleally and\nepidurally. A sponge was applied, followed by the reinsertion of the\nbone flap using a dog bone miniplate fixation and local application of\nvancomycin powder. A subgaleal drain was placed, and the skin was closed\nusing Donati continuous sutures. A sterile staple dressing was applied,\nand the patient was transferred to recovery.\n\nCLINICAL NOTES:\n\nEpidural pannus suggestive of infection. Past surgical history includes\nglioblastoma removal in 8/11/2019 and subsequent surgeries because of\nrecurrence, the last of these in 04/12/2020. Nature and type of growth?\n\nMACROSCOPIC EXAMINATION:\n\nFixed tissue samples measuring 1.2 x 1.0 x 0.4 cm were entirely\nembedded.\n\nSTAINING: 1 block, Hematoxylin & Eosin (HE), Periodic Acid Schiff (PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology shows entirely necrotic tissue and some bony fragments. No\nmicroorganisms were detected in the PAS stain.\n\nFINDINGS:\n\nFully necrotic tissue. No signs of inflammation or malignancy in the\navailable samples.\n\nOPERATIVE REPORT:\n\nDiagnosis: Wound healing disruption high on the forehead, following a\nresection of recurrent gioblastoma in the right hemisphere in\n04/12/2020.\n\nProcedure: Wound revision, thorough wound cleaning, reinsertion of the\nautologous bone flap.\n\nTime of incision: 3:30 PM, 06/01/2020\n\nTime of suture completion: 4:35, 06/01/2020\n\nDuration: 65 minutes\n\nPATIENT HISTORY:\n\nThe patient had two prior surgeries with our team. The most recent was a\nrevision due to a wound healing complication. The patient was informed\nabout the procedure\\'s nature, extent, risks, and potential outcomes,\nand was given ample opportunity to ask questions. After thoughtful\nconsideration, written consent was obtained.\n\nOPERATION:\n\nThe patient was positioned supine with the head in a neutral position.\nThe surgical area was sterilized and draped. Antibiotic prophylaxis was\nadministered, and a timeout procedure was conducted. The old wound was\nreopened and slightly extended by about 1 cm in both directions. The\nbone flap was removed, inspected, and cleaned. It was then reinserted\nafter refreshing the bone edges. The wound edges were refreshed, and the\nwound was irrigated again before closure.\n\nSUMMARY:\n\nSuccessful wound revision without complications for a wound healing\ncomplication post-glioblastoma surgery.\n\nCLINICAL NOTES:\n\nComplication in wound healing after glioblastoma removal and radiation\ntherapy. Possible inflammation? Evaluate for pus. Nature and type of\ngrowth?\n\nMACROSCOPIC EXAMINATION:\n\nSubcutaneous tissue samples, 1.2 x 1.0 x 0.4 cm, were completely\nembedded after being cut into two.\n\nEpidural tissue samples, 5.6 x 5.3 x 1.0 cm, were partially embedded.\n\nSTAINING: 2 blocks, Hematoxylin & Eosin (HE), Periodic Acid Schiff\n(PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology displays connective tissue surrounded by a pronounced\ninflammatory infiltrate, comprised of neutrophils, lymphocytes, and\nnumerous eosinophils. Additionally, budding capillaries were seen. No\nspecific findings in the PAS stain.\n\nHistologically, connective tissue infiltrated by predominantly\nlymphocytic inflammation was observed. Eosinophils and abundant necrotic\ntissue were also seen. Additionally, polarizable material was noted,\noccasionally engulfed by multinucleated giant cells. Hemorrhagic signs\nwere indicated by hemosiderin deposits. No specific findings in the PAS\nstain.\n\nFINDINGS:\n\n1 & 2. Soft tissue displays acute phlegmonous inflammation and chronic\ngranulating inflammation.\n\n**Brief report (07/15/2020): **\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 06/01/2020.\n\nWound healing disorder right parietal at the site of previous right-side\nglioblastoma, last revision 04/12/2020.\n\n-Single right body focal seizure 04/20/2020, single generalized seizure\n05/12/2020\n\n-Previous resection on 10/12/2019\n\n-Wound healing disorder with subsequent wound revision (06/2020)\n\n-Last cMRI on 05/03/2020: no recurrence observed.\n\nSecondary diagnoses:\n\nHypothyroidism\n\nSurgery type: injection of Ropivacaine, smear for microbiology,\nreadaptation of three small wound dehiscence, tobacco bag suture,\noverlay polyhexanide gel, plaster application\n\nInstructions: Return next Tuesday for wound check. Sutures to remain in\nplace for 10 days. Check microbiology results on Thursday. Clinically,\nno signs of infection observed.\n\nSurgical report:\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 04/20/2020.\n\nASSESSMENT:\n\nThe patient was presented at the emergency unit after observing a small\nwound dehiscence after the aforementioned surgery for a wound healing\ndisorder. The treating surgeon recommended a second local wound revision\nattempting to readapt the wound with a minor surgery. The patient\nprovided written consent for the procedure. The intervention was\nconducted with standard coagulation parameters.\n\nSURGERY:\n\nSterile preparation and draping of the surgical area. Initial injection\nof Ropivacaine. This was followed by swab collection for microbiology.\nThe wound edges were excised and the wound dehiscence was readapted\nusing a tobacco bag suture. Afterward, polyhexanide gel was applied,\nfollowed by a sterile plaster dressing.\n\nSurgery report:\n\nDiagnosis: significant scalp wound healing disorder in the prior\nsurgical access area post-resection and irradiation of a glioblastoma\nmultiforme.\n\nOperating time: 49 minutes\n\n\n\n### text_4\n**Dear colleague, **\n\nwe report on Mr. Miller, John, born 04/07/1961, who was in our inpatient\ntreatment from 09/12/2020 to 10/07/2020.\n\nDischarge diagnosis: Recurrence of the pre-described glioblastoma right\ninsular, WHO CNS grade 4 (IDH wild type, MGMT methylated).\n\nPhysical examination on admission:\n\nPatient awake, fully oriented, cooperative. Non-fluent aphasia. Speech\nclear and fluent. Latent left hemisymptomatic with strength grades 4+/5,\nstance and gait unsteady. Cranial nerve status regular. Scar conditions\nnon-irritant except for frontal superficial erosion at frontal wound\npole of pterional approach. Karnofsky 70%.\n\nMedication on Admission:\n\nLevothyroxine sodium 50 μg/1 pc (Synthroid® 50 micrograms, tablets)\n1-0-0-0\n\nLorazepam 0.5 mg/1 pc (Ativan® 0.5 mg, tablets) 1-1-1-1\n\nLacosamide 100 mg/1 pc (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\n**Imaging: **\n\ncMRI +/- contrast agent dated 09/15/2020: There is a contrast enhancing\nformation on the right temporo-mesial with approach to the insular\ncistern with suspected tumor recurrence.\n\nPET dated 09/10/2020 (external): Significant tracer multinodulation with\nactive areas in the islet region is seen.\n\n**Surgery of 09/18/2020: **\n\nReopening of existing skin incision and extension of craniotomy\ncranially, microsurgical navigated tumor resection right insular (IONM:\nMEP waste lower extremity with incomplete recovery) CUSA; extensive\nhemostasis, intraoperative MRI, sutures, reimplantation of bone flap\nwith multilayer wound closure. Skin suture.\n\nHistopathological report:\n\nRecurrence of pre-described glioblastoma, WHO CNS grade 4 (IDH wild\ntype, MGMT methylated).\n\nCourse:\n\nThe patient initially presented postoperatively with left hemiplegia in\nthe sense of SMA. This regressed significantly during the inpatient\nstay. Postoperative imaging revealed a regular resection finding. In\ncase of a possible adjustment disorder, the patient was treated with\nsertraline and lorazepam. The wound was dry and non-irritant during the\ninpatient stay. The patient received regular physiotherapeutic exercise.\nThe patient\\'s case was discussed in our neuro-oncological tumor board\non 09/29/2020, where the decision was made for adjuvant definitive\nradiochemotherapy. An inpatient transfer was offered by the colleagues\nof radiotherapy.\n\nProcedure:\n\nWe transfer Mr. Miller today in good clinical general condition to your\nfurther treatment and thank you for the kind takeover. We ask for\nregular wound controls as well as regular ECG controls to exclude a\nQTc-time prolongation under sertraline. Furthermore, the medication with\nlorazepam should be further phased out in the course of time. In case of\nacute neurological deterioration, a re-presentation in our neurosurgical\noutpatient clinic or surgical emergency room is possible at any time.\n\nClinical examination findings at discharge:\n\nPatient awake, fully oriented, cooperative. Speech clear and fluent.\nCranial nerve status without pathological findings. Hemiparesis\nleft-sided strength grade 4/5, right-sided no sensorimotor deficit.\nStance and gait unsteady. Non-fluent aphasia. Wound dry, without\nirritation. Karnofsky 70%.\n\n**Medication at Discharge:**\n\nLevothyroxine sodium 50 μg (Synthroid® 50 micrograms, tablets) 1-0-0-0\n\nLorazepam 0.5 mg (Ativan® 0.5 mg, tablets) as needed\n\nLacosamide 100 mg (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\nAcetaminophen 500 mg (Tylenol® 500 mg tablets) 1-1-1-1\n\nSertraline 50 mg (Zoloft® 50 mg film-coated tablets) by regimen\n\n**Magnetic Resonance Imaging (MRI) Report**\n\nDate of Examination: 02/02/2021\n\nClinical Indication: Multifocal glioblastoma WHO grade IV, IDH wild\ntype, MGMT methylated.\n\nClinical Query: Hemiparesis on the right side. Is there a structural\ncorrelate? Tumor progression?\n\n**Previous Imaging**: Multiple prior studies. The most recent contrasted\nMRI was on 09/15/2020.\n\n**Findings**:\n\n**Imaging Device**: GE 3T; Protocol: 3D FLAIR, 3D T1 Mprage with and\nwithout contrast, SWI, DWI, 3D T2, axial T2\\*, perfusion, DTI.\n\n1. **Report: **\n\n Known multimodal pretreated GBM since 2019, recently post-surgical\n resection for tumor progression in the frontotemporal region on\n 09/18/2020. Also noted is a post-surgical resection of additional\n foci in the right insular region. The resection cavity in the right\n frontal, insular, and temporal regions appears unchanged in size and\n configuration. Residual blood products are noted within.\n\n There are increased areas of contrast enhancement compared to the\n immediate post-operative images. There is a minor growth in a\n nodular enhancement posterior to the right middle cerebral artery.\n Adjacent to this, there\\'s a new nodular enhancement, which could be\n a postoperative reactive change or a new tumor lesion.\n\n Ongoing diffusion abnormalities are observed in the right caput\n nuclei caudatus, putamen, and globus pallidus, especially pronounced\n in posterior sections.\n\n Persistent FLAIR-hyperintense peritumoral edema in the right\n hemisphere remains unchanged. The midline shift is approximately 9mm\n to the left, which remains unchanged.\n\n Post-operative swelling and fluid accumulation are noted at the\n surgical entry point. The bone flap is in place. The width of both\n the internal and external CSF spaces remains constant, with no\n evidence of obstruction.\n\n The orbital contents are symmetrical. Paranasal sinuses and mastoid\n air cells are aerated appropriately.\n\n**Impression**:\n\nResidual tumor segments along the right middle cerebral artery showing\ngrowth. Adjacent to it, a new nodular area of contrast enhancement\nsuggests either a postoperative change or a new tumor lesion.\n\nPreviously identified ischemic changes in the right caput nuclei\ncaudatus, putamen, and globus pallidus. Persistent brain edema with a\nleftward midline shift of approximately 9mm remains unchanged.\n\n\n\n### text_5\n**Dear colleague, **\n\nHerewith we report on our common patient Mr. John Miller, born\n04/07/1961, who was at our clinic between 02/04/2021 to 04/22/2021.\n\n-Recurrent manifestation of a glioblastoma\n\n-Stage: WHO CNS grade 4\n\n**Histology:**\n\nRecurrence of the pre-described glioblastoma, WHO CNS grade 4.\n\nMolecular pathological findings:\n\nIDH status: no p.R132H mutation (immunohistochemical).\n\nATRX: preservation of nuclear expression (immunohistochemical).\n\np53: technically not evaluable (immunohistochemical).\n\n1p/19q status: no combined loss (850k methylation analysis).\n\nCDKN2A/B: Deleted (850k methylation analysis).\n\nMGMT promoter: Methylated (850k methylation analysis).\n\nTumor localization: Islet/frontal right\n\nSecondary diagnoses:\n\nSymptomatic epilepsy\n\nHypothyroidism\n\nNausea\n\nLeukopenia I° (CTCAE)\n\nAnemia II° (CTCAE)\n\nPrevious course / therapies:\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n03/2020: Suspected recurrence\n\n04/2020: Revision surgery\n\n06-07/2020 Wound revisions and flap plasty for atrophic wound healing\ndisorder\n\n02/2021: Suspected recurrence with new FLAIR-positive tumor\nmanifestation insular on the right side. Stereotactic biopsy with\nevidence of glioblastoma.\n\nPathology: Renewed manifestation of a glioblastoma.\n\nRecommended radiochemotherapy.\n\nAccording to the interdisciplinary neuro-oncology board of 01/26/2021,\nwe gave the indication for adjuvant radiochemotherapy for the recurrence\nof glioblastoma.\n\n**Radiochemotherapy: **\n\nTechnique:\n\n1\\) Percutaneous intensity-modulated radiotherapy was administered to the\nformer recurrence tumor region in the frontal/insular right after CT-\nand MRI-guided radiation planning with 6 MV-photons in helical\ntomotherapy technique with a single dose of 2 Gy up to a total dose of\n60 Gy with 5 fractions per week. Daily position controls by CT.\n\n2\\) Subsequently, local dose saturation of the macroscopic tumor remnant\nwas performed.\n\nInsular right stereotactic ablative radiosurgery at the gamma knee to\nsaturate the macroscopic GammaKnife (Cobalt-60: 1.17 MeV and 1.33 MeV\nphotons) in mask fixation after CT- and MRI-guided radiotherapy planning\nunder image-guided setting (ConeBeam-CT) with a dose of 6 Gy in 2 Gy\nsingle dose to the 68% isodose up to a total cumulative dose of 66 Gy.\n\nChemotherapy:\n\nConcurrent chemotherapy with 75mg/m²KOF temozolomide daily (120 mg\ndaily).\n\nAbsolute dose: 5000 mg.\n\nTreatment Period:\n\nRadiotherapy 03/09/2021 -- 04/21/2021\n\nChemotherapy 03/09/2021 -- 04/21/2021\n\n**Course under therapy:**\n\nWe took over Mr. Miller on 03/06/2021 in reduced general and slightly\nreduced nutritional condition (Kanofsky index: 70 %, BMI: 18.5 kg/m²)\nfrom the Clinic for Neurosurgery for adjuvant re-radiochemotherapy on\nour radiooncology ward. At the time of admission, the patient had arm\n\nright hemiparesis (strength grades arm: 2/5, leg: 3/5). The patient was\nambulatory with assistance. Cranial nerve status was unremarkable.\nHeadache, nausea or dizziness were denied.\n\nOn 09/03/2021, combined re-radiochemotherapy was initiated.\n\nDuring the course of therapy with temozolomide, mild nausea occurred,\nwhich was treated with ondansetron 4mg as needed and dimenhydrinate\nSustained-release tablets 150 mg as needed. Under this treatment the\nsymptoms clearly regressed. Mild constipation was treated. Laboratory\ntests revealed mild leukopenia I° and anemia II° (CTCAE).\n\nOtherwise, the re-radiochemotherapy was very well tolerated overall.\n\nMr. Miller received physiotherapeutic exercise and psychotherapy during\nthe entire physiotherapeutic training and psycho-oncological support.\nUnder the physiotherapeutic treatment, his motor skills improved\nsignificantly. At the end of the therapy, the patient was also mobile\noutside the\n\nhouse without any aids.\n\nOn 04/22/2021 we discharged Mr. Miller to the outpatient care by his\nfamily doctor.\n\n04/11/2021: MR brain post contrast\n\nAfter renewed radiochemotherapy for a glioblastoma recurrence, a\nresidual suspicious barrier disturbance adjacent to the adjacent to the\nright cerebral artery. Stable nodular contrast enhancement\n\nPostoperative/reactive changes as described above. MR perfusion\nsequences show residual, contrast-absorbing tumor portions along the\nright A. cerebri media. Lateral to this, new nodular contrast-absorbing\nlesion, possibly postoperative reactive change. Previously known\nischemia at the right caput nuclei caudatii, putamen, and globus\npallidus. Unchanged medullary edema with midline shift to the left by\napproximately 9mm.\n\nLast lab:\n\nMCHC 29.4 g/dL (32 - 36) 04/20/2021\n\nMCH 25 pg (27 - 32) 04/20/2021\n\nLeukocytes 3.32 G/l (4.0 - 9.0) 04/20/2021\n\nHematocrit 31.6 % (37 - 43) 04/20/2021\n\nHemoglobin 9.3 g/dL (12 - 16) 04/20/2021\n\nErythrocytes 3.7 T/l (4.1 - 5.4) 04/20/2021\n\nUric acid 2.2 mg/dl (2.5 - 5.5) 04/20/2021\n\n**Further Procedure:**\n\nFurther skin care and behavior regarding side effects were explained to\nthe patient in detail.\n\nA first radiooncological control appointment was scheduled for\n06/05/2021 at 12:00 AM in our outpatient clinic. Prior to this, on\n06/02/2021 at 10:30 AM, an imaging exam (brain MRI) is scheduled.\n\nA further neuro-oncological connection is planned close to home via the\ntreating oncologist.\n\nAfter radiation therapy, we recommend annual ophthalmological check-ups\nand annual endocrinologic.\n\nwith testing of the hypothalamic-pituitary hormone axes.\n\n\n\n### text_6\n**Dear colleague, **\n\nThis is a report on our mutual patient, Mr. John Miller, born\n04/07/1961:\n\nDiagnosis:\n\nRecurrent manifestation of glioblastoma\n\nWHO CNS grade 4\n\nTumor localization: Right isle/frontal\n\nSecondary diagnoses: Symptomatic epilepsy\n\nHypothyroidism Previous\n\nTreatments / Therapies\n\nResection and revisions\n\nAdjuvant radiochemotherapy\n\nTwo wound revisions and flap plasty for atrophic wound healing disorder\n\nNew FLAIR-positive tumor manifestation insular on the right side\n(02/2021)\n\nStereotactic biopsy with histopathology with evidence of glioblastoma\n\nTumor Board: Recommended new radiochemotherapy up to a total dose of 60\nGy à 2 Gy single dose. Subsequent local dose saturation of the\nmacroscopic tumor remnant as radiosurgery on GammaKnife with a dose of 6\nGy à 2 Gy single dose (\\@68% isodose).\n\n03-4/2021 Repeat stereotactic RTx in the area of the basal ganglia and\nthe resection cavity right frontal on the Gamma Knife with 46 Gy à 2 Gy;\n3 doses of Bevacizumab 7.5 mg/kg i.v.\n\n**Summary:**\n\nOn 07/03/2023, we conducted an initial telephone follow-up with the\npatient, Mr. Miller, for a radio-oncology consultation. Presently, Mr.\nMiller is undergoing rehabilitation, from which he feels he is deriving\nsubstantial benefits. His recent radiotherapy was well-received without\nany complications. Since the onset of his symptoms, there have been no\nnew developments. Symptoms related to intracranial pressure or new\nneurological deficits were denied. Fortunately, while on anticonvulsant\ntherapy with Lacosamide, Mr. Miller experienced no epileptic seizures.\nHis skin condition is normal. However, Mr. Miller did mention some\ncognitive challenges that minimally impact his daily activities,\nalongside feelings of fatigue and grade I CTCAE symptoms. The cMRI scan\nfrom 06/02/2021 revealed a notable reduction in the barrier disturbance\nof the right-sided basal ganglia. This was accompanied by small, mildly\nhyperperfused residual findings near the third ventricle. Moreover, the\npinpoint contrast enhancement in the left parietal lobe appeared\nunchanged, suggesting it is a scarring reaction. In collaboration with\nthe neurooncology team, Mr. Miller has discussed starting chemotherapy.\nThe next imaging assessment is scheduled for mid-September. We have also\nscheduled another radio-oncologic follow-up with Mr. Miller for\nSeptember 28th, per his preference, via telephone. For patient safety,\nMr. Miller is prohibited from operating private or commercial vehicles\nfor 3 months post-intracerebral radiotherapy. This duration may extend\nif there are existing or progressing brain conditions. Following\nradiotherapy, we are mandated by the Radiation Protection Act to\nfacilitate regular checks. Hence, we encourage enrollment in the\naftercare calendar, prompt reporting of any significant findings, and\nattendance of scheduled follow-ups. Alongside these, regular oncological\ncheck-ups by specialist practitioners are mandatory. Mr. Miller has been\nduly informed of all these requirements.\n\n\n\n\nHere is the query:\nWhat was the height of Mr. Miller as indicated in one of the reports?\n\nChoose the correct answer from the following options:\nA. 169 cm\nB. 160 cm\nC. 180 cm\nD. 175 cm\nE. 170 cm\n\n\nYour response:\n", "role": "user" }, { "content": "175 cm", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nPatient: Miller, John, born 04/07/1961\n\nWe report to you about our common patient, Mr. John Miller, who is in\nour inpatient treatment since 07/30/2019.\n\n**Diagnoses:**\n\n\\- Suspected right cerebral glioblastoma (first diagnosis)\n\n\\- Symptoms: Aphasia, passive confusion\n\n**Patient history: **\n\nMr. Miller was admitted as an emergency. He was on the phone with a\nfriend when he suddenly began to exhibit speech difficulties and\nstruggled to find the right words. Consequently, his friend called 911.\n\nUpon the ambulance\\'s arrival, Mr. Miller was disoriented and exhibited\naggressive behavior. There was evidence of a torn door. He had blood on\nhis right forearm and around his mouth, but there were no indications of\na tongue bite or urinary incontinence.\n\nUpon admission, Mr. Miller was coherent and showed no speech issues. He\nattributed a mild weakness in his right arm to pre-existing pain in the\nupper arm. An immediate CT scan revealed a mass suggestive of a\nglioblastoma in the right cerebral hemisphere, leading to a\nneurosurgical consultation.\n\nGiven the possibility of an epileptic seizure, Mr. Miller was\nhospitalized and started on Levetiracetam. He is currently unaware of\nhis regular medications but takes antihypertensives and diabetes\nmedications, among others. His friend and brother have been notified and\nare ensuring that a detailed medication list is provided.\n\nAfter a brief stay in ward ABC, Mr. Miller was transferred to the\nneurosurgery team for further evaluation and treatment. We appreciate\nthe prompt transfer and are available for any further inquiries.\n\nPlanned Procedures:\n\n-Schedule EEG\n\n-Clarify routine medications\n\n**Surgery Report**\n\n**Diagnosis:** Suspected HGG (high-grade glioma) of the right hemisphere\n\n**Procedure:** Microsurgical navigation-guided resection of the tumor\nwith intraoperative neuromonitoring (stable MEPs) and intraoperative MRI\nusing 5-ALA. Pathology samples taken (Preliminary: HGG; Final to be\nconfirmed). Resection was followed by duragen placement, watertight\ndural closure, and multilayer wound closure, with skin sutures.\n\n**Time:**\n\n-Start: 11:12 am\n\n-Finish: 3:54 pm\n\n-Duration: 4 hours 42 minutes\n\n**Assessment:**\n\nMr. Miller presented with a seizure characterized by speech disturbance\nand disorientation. Imaging revealed a significant right hemispheral\nmass, likely representing a high-grade brain tumor. The need for\nsurgical resection was determined following discussions at our\ninterdisciplinary tumor board. After being informed about the procedure,\nalternative treatments, the operation\\'s urgency, benefits, and\npotential risks, Mr. Miller provided written consent following ample\ntime for consideration and the opportunity to ask further questions.\n\n**Procedure Details:**\n\nThe patient was positioned supine with his head secured in a Nova clamp.\nNavigation data were read, followed by skin preparation, and the\nsurgical field was sterilized and draped. An arch-shaped incision was\nmade, followed by hemostasis, deep tissue dissection, placement of a\nburr hole, and the creation of a large bone flap over the lesion. The\nbone flap was then elevated. Multiple washings were performed, followed\nby dural opening under microscopic visualization. A corticotomy was\ncarried out with bipolar forceps, CUSA, and suction to progressively\nreduce the tumor, utilizing 5-ALA fluorescence and continuous\nneurophysiological monitoring. An intraoperative MRI showed residual\ntumor, prompting further resection. Hemostasis was achieved, and the\nwound was closed using tabotamp, followed by duragen placement and dural\nsuturing. The bone flap was refixed using Dogbone plates. The wound area\nwas irrigated extensively once more, followed by subcutaneous and skin\nsutures.\n\n**Date:** 10/01/2019\n\n**Clinical Indication:**Suspected recurrence of GBM in the right\nhemisphere\n\n**Requested Imaging:**cMRI with or without contrast + DTI.\n\n**Findings:***Imaging Modality (GE 3.0T):* 3D FLAIR, DTI, SWI, T2\\*\nperfusion, 3D T1 with and without contrast, 3D T2,\nsubtraction.Following resection of a right hemispheric glioblastoma in\n08/19, and compared to the last two scans (external: 07/19, internal:\n08/19), there is a notable expansion of the prior detected flair\nhyperintense regions. These now span from the right parietal-subcortical\narea across the right basal ganglia to the right temporo-occipital/right\ntemporal pole. Specifically, at the dorsocranial edge of the resection\ncavity, the hyperintense regions appear to have grown since 08/19. These\ncoincide with hyperperfused regions in the T2\\* perfusion. Linear SWI\nsignal changes are suggestive of mild post-surgical bleeding. No\nsignificant postoperative hemorrhage or territorial ischemia is\ndetected. A normal venous sinus drainage is observed. Right temporal\nhorn appears congested, possibly due to CSF trapping.\n\n**Assessment:**\n\nFollowing the resection of the right hemispheric glioblastoma in 08/19:\n\n-Markedly progressive flair edema and evolving barrier disturbance.\nRegions especially towards the dorsal side of the resection cavity show\nthis alongside associated hyperperfusion. With the recent PET imaging\nfrom 10/19, there is an indication of progressive disease as per RANO\ncriteria.\n\n-Long-term progressive congestion of the right temporal horn, likely CSF\ntrapping.\n\n**Surgery Report****Diagnosis:**Tumor recurrence after resection of a\nglioblastoma (IDH wild type, WHO CNS grade 4) of the right hemisphere in\n08/2019. The patient underwent combined radiochemotherapy at the local\nclinical center.\n\n**Procedure:**Navigated, microsurgical resection supported by 5-ALA,\nwith stable MEPs through the previous right temporal access. iMRI\nconducted between 11:10 and 11:50. Used Duragen/TachoSil, dog bones for\nclosure, followed by layered wound closure and skin sutures.\n\n**Timing:**\n\n-Incision: 09:23 am on 10/12/19\n\n-Suture: 12:32 pm on 10/12/19\n\n**Assessment:**The patient had previously undergone surgery for a\nglioblastoma and a recurrence was detected on imaging. The tumor board\nhad already deliberated on the surgery. The patient was informed about\nthe surgical procedure, particularly about conducting an extensive\nresection caudally without impacting function post-mapping. The patient\nconsented, understanding the potential for longer progression-free\nsurvival.\n\n**Procedure Details:**The patient was placed in a supine position with\nthe head turned to the side and fixed using the Noras clamp. The right\nshoulder was padded. The surgical area was prepared by trimming hair\naround the previous scar, followed by sterilization and draping. After a\nteam time-out, prophylactic antibiotics were administered. The previous\nscar was reopened and old plates were removed. The microscope was then\nswung into position and the dura was opened. Navigation proceeded\nbeneath the labbé vein, with tumor resection as guided by ALA\nfluorescence. Post-tumor removal, extensive hemostasis was achieved\nusing absorbent cotton and TABOTAMP. Intraoperative MRI confirmed a\ncomplete resection of the tumor. The dura was sealed using DuraGen,\nensuring a watertight closure. The bone flap was reinserted, followed by\nsubcutaneous suturing, skin suturing, and sterile dressing of the wound.\n\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe write to update you regarding our shared patient, Mr. John Miller,\nborn on 07/04/1961, who visited us on 12/02/2019.\n\n**Diagnosis:**Glioblastoma recurrence, IDH 1 wild type.\n\n**Tumor Location:**Right hemisphere including temporal regions.\n\n**Clinical History & Treatment:**\n\n-07/2019: Mr. Miller experienced speech disturbances and confusion.\n\n-08/01/2019: Brain PET-MRI revealed a suspected malignancy in the right\nhemisphere, including temporal areas.\n\n-08/11/2019: Glioblastoma was resected at our facility.\n\n-08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy\nwith a boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local\nclinical center.\n\n-10/01/2019: cMRI with suspected recurrence.\n\n-10/12/2019: A recurrent resection was performed at our facility.\n\n-11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n**Recent Evaluation (12/01/2019):**Mr. Miller visited our facility with\nhis brother. Our assessment, based on CTCAE criteria, indicated that he\nis in a fair but stable general and nutritional health (KPS 70-80%,\nweight undisclosed, height 175 cm). Neurological and general evaluations\nrevealed a degree of aphasia, mainly with word-finding difficulty, and\nshort-term memory impairment. However, he remains fully oriented and\nindependent in daily life.\n\n**Additional Observations:**\n\nHis surgical wound has healed well.\n\n**Pre-existing Conditions:** Arterial hypertension, Diabetes Mellitus\nType II\n\n**Allergies:** None\n\n**Current Medications:** Antihypertensive drugs and insulin.\n\nPostoperatively, Mr. Miller remains in good health. A recent brain MRI\nnoted that the suspected recurring GBM lesion near the superior border\nof the surgical site was entirely resected. Furthermore, CT scans at the\nanterior medial and lateral edges suggest that a complete resection was\nmost likely achieved.\n\nGiven the presumed complete resection of the glioblastoma recurrence, we\nhave recommended Mr. Miller for a neuro-oncology review and a follow-up\nwith PET-MRI in three months.\n\n**Next Steps:**\n\n-He has a scheduled appointment in neuro-oncology on 01/23/2020 at 10:00\nAM.\n\n-A follow-up PET-MRI is set for 01/29/2020 at 12:45 PM. We have advised\nMr. Miller to fast for 4 hours prior and to bring a referral from his\nprimary care physician, along with a recent creatinine test result.\n\n-A review of these findings will be held in our outpatient department on\n01/30/2020 at 2:00 PM.\n\nThank you for your continued care and collaboration. Please do not\nhesitate to reach out for any additional information.\n\nWarm regards,\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nRegarding our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nGlioblastoma recurrence, IDH 1 wild type\n\n**Tumor Location**:\n\nRight hemisphere/temporal.\n\n**Medical History**:\n\n07/2019: Onset of speech arrest and confusion.\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\nMr. Miller came in on 12/01/2019 with his brother. Clinical examination\nfindings are as follows:\n\n-General health: Stable with reduced vitality.\n\n-Nutritional status: Stable (KPS 70-80%, weight in kg, height 169 cm).\n\n-No evident motor, sensory, visual, or cranial nerve deficits.\n\n-Neurocognitive deficits: Short-term memory issues.\n\n-Aphasia: Grade II (mainly word-finding disorders). The patient is fully\noriented and independent in daily life.\n\n-No evidence of recurrence in PET-MRI. Next imaging scheduled in\n03/2020.\n\n**Past Medical Conditions**:\n\n-Hypertension\n\n-Type II Diabetes Mellitus\n\n**Allergies**: None.\n\n**Medications**:\n\n-Antihypertensive medications\n\n-Insulin\n\nBest Regards,\n\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nUpdating you on our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nRecurrent Glioblastoma, IDH 1 wild type (ICD-10: 71.8).\n\n**Molecular Pathology**:\n\nNo p.R132H mutation in IDH.\n\nNo combined 1p/19q loss.\n\nSuspected CDKN2A/B deletion.\n\n**Medical History**:\n\nNo pain or B symptoms.\n\nIntermittent dizziness and headaches since the last check-up.\n\n**Neurological Findings**:\n\nPatient is alert and oriented.\n\nWeight: 80 kg (total loss: 15 kg), Height: 175 cm.\n\nKarnofsky Performance Score: 80%.\n\nMotor function and sensory assessments were unremarkable.\n\n**Allergies**: None.\n\n**Medications**:\n\nLisinopril 10mg once daily in the morning\n\nBisoprolol 2.5mg once daily at bedtime\n\nJanuvia 50mg twice daily\n\nAllopurinol 100mg once daily in the morning\n\nEzetimibe 10mg once daily at bedtime\n\nLevetiracetam 1000mg once daily in the morning Insulin as per regimen\n\n**Secondary Diagnoses**:\n\nHypertension\n\nType II Diabetes Mellitus\n\n**Medical Course**:\n\nDetails from 07/2019 through 03/2020 provided, including surgeries,\nradiochemotherapies, and diagnostics.\n\nIn summary, Mr. Miller\\'s glioblastoma diagnosis in 07/2019 led to\nvarious treatments, including radiochemotherapy and surgeries. His\nrecent PET/MRI on 01/2020 indicates potential recurrent areas.\n\nBest regards,\n\n**Patient:** John Miller\n\n**DOB:** 04/07/1961\n\n**Admission Date:** 04/11/2020\n\n**Discharge Date:** 04/18/2020\n\n**Admission Diagnosis:**\n\nRecurrent tumor in the hippocampal region and along the prior resection\ncavity.\n\nHistory of glioblastoma (IDH wild type, WHO CNS grade 4) in the right\nhemisphere, resected on 08/2019.\n\nHistory of combined radiochemotherapy with Temodar (Temozolomide) from\nAugust to September 2019 at the local clinical center.\n\nSubsequent first re-resection in 10/2019.\n\n**Presenting Complaint:**\n\nMr. Miller presented to the neurosurgical outpatient department\naccompanied by his wife. Recent imaging indicated a potential recurrence\nof the glioblastoma. The neuro-oncological board on 04/12/2020\nrecommended a re-resection.\n\n**Physical eon Admission:**\n\nAlert, oriented x4, cooperative.\n\nNon-fluent aphasia.\n\nCranial nerves intact.\n\nNo sensory or motor deficits in the extremities.\n\nSurgical scar clean and dry.\n\nNo signs of neurogenic bladder or rectal dysfunction.\n\nKPSS 70%.\n\n**Medications on Admission:**\n\n-Lisinopril 10mg daily\n\n-Bisoprolol 2.5mg nightly\n\n-Januvia 50mg twice daily\n\n-Allopurinol 100mg daily\n\n-Atorvastatin 40mg nightly\n\n-Ezetimibe 10mg nightly\n\n-Levetiracetam 1000mg twice daily\n\n-Actraphane insulin as prescribed\n\n**Surgical Intervention (04/12/2020):**\n\nNavigated microsurgical resection of tumor spots assisted with 5-ALA.\nStable MEPs were maintained. An intraoperative MRI (iMRI) was utilized.\nPost-resection, the surgical area was managed using Tabotamp, Duragen,\nTachoSil, and dog-bone plates, concluding with layered wound closure.\n\n**Postoperative Course:**\n\nUncomplicated recovery.\n\nPost-op MRI showed no residual tumor.\n\nSurgical site remained clean, dry, and showed no signs of infection or\nirritation.\n\n**Discharge Diagnosis:**\n\nRecurrence of known glioblastoma, WHO CNS grade 4.\n\n**Interdisciplinary Neuro-oncological Tumor Board Recommendation\n(04/20/2020):**\n\nMolecular tumor board review.\n\nOffer reinitiation of Temozolomide chemotherapy.\n\n**Physical Examination on Discharge:**\n\nSimilar to admission, with suture in place and wound site in good\ncondition.\n\nKPSS 70%.\n\n**Medications on Discharge:**\n\n-Allopurinol 100mg daily (morning)\n\n-Atorvastatin 40mg nightly (evening)\n\n-Bisoprolol 2.5mg nightly (evening)\n\n-Ezetimibe 10mg nightly (evening)\n\n-Sitagliptin (Januvia) 50mg twice daily (morning and evening)\n\n-Levetiracetam (Keppra) 1000mg twice daily (morning and evening)\n\n-Lisinopril 10mg daily (morning)\n\n-Acetaminophen 500mg as needed for pain or fever\n\n-Actraphane insulin as prescribed\n\n**Surgery Report **\n\n**Diagnosis**:\n\nTumor recurrence in the right hippocampal region and along the resection\ncavity post glioblastoma resection on 8/11/2019.\n\nPrevious treatments include radiochemotherapy at our clinic. Local\ntherapy center (from August to September 2019) and re-resection on\n10/12/2019.\n\n**Surgery Type**:\n\nRe-opening of the temporal region with navigation, microsurgery using\n5-ALA assistance, iMRI, and re-resection, among other procedures.\n\n**Procedure Details**:\n\nStart: 11:50 pm on 04/12/2020\n\nEnd: 4:00 pm on 04/12/2020\n\nDuration: 4 hours 10 minutes.\n\n**Assessment**:\n\nEvidence of recurrent glioblastoma areas warranted another biopsy and\nresection. After informing Mr. Miller about the procedure\\'s risks and\nbenefits, he provided written consent.\n\n**Operation**:\n\nDetails on the positioning, pre-operative preparations, resection, and\npost-operative procedures are provided.\n\nBest regards,\n\nMEDICAL HISTORY:\n\nMr. Miller underwent surgery because of tumor recurrence in the right\nhemisphere last November to treat a right temporal glioblastoma. He\npresented to our private outpatient clinic due to a wound complication,\nspecifically a wound dehiscence measuring about 1 cm. On closer\nexamination, pus was noted. Despite being symptom-free otherwise, a\nconsultation with Dr. Doe was scheduled. After discussion, it was\ndecided to clean the wound, trim the deteriorated wound edges, and clean\nthe bone flap with an antibiotic solution before reinserting it. The\npatient was thoroughly educated about the nature and risks of the\nprocedure and gave consent.\n\nOPERATION:\n\nThe patient was placed in a supine position. The hair surrounding the\nsurgical site was trimmed, followed by skin disinfection and sterile\ndraping. The bicoronal skin incision was reopened. Deteriorated wound\nedges were excised and the wound was extensively cleaned with\nirrigation. The bone flap was removed and immersed in a Refobacin\nsolution. The epidural pannus tissue was removed. The dura was\ncompletely sutured. Multiple samples were collected both subgaleally and\nepidurally. A sponge was applied, followed by the reinsertion of the\nbone flap using a dog bone miniplate fixation and local application of\nvancomycin powder. A subgaleal drain was placed, and the skin was closed\nusing Donati continuous sutures. A sterile staple dressing was applied,\nand the patient was transferred to recovery.\n\nCLINICAL NOTES:\n\nEpidural pannus suggestive of infection. Past surgical history includes\nglioblastoma removal in 8/11/2019 and subsequent surgeries because of\nrecurrence, the last of these in 04/12/2020. Nature and type of growth?\n\nMACROSCOPIC EXAMINATION:\n\nFixed tissue samples measuring 1.2 x 1.0 x 0.4 cm were entirely\nembedded.\n\nSTAINING: 1 block, Hematoxylin & Eosin (HE), Periodic Acid Schiff (PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology shows entirely necrotic tissue and some bony fragments. No\nmicroorganisms were detected in the PAS stain.\n\nFINDINGS:\n\nFully necrotic tissue. No signs of inflammation or malignancy in the\navailable samples.\n\nOPERATIVE REPORT:\n\nDiagnosis: Wound healing disruption high on the forehead, following a\nresection of recurrent gioblastoma in the right hemisphere in\n04/12/2020.\n\nProcedure: Wound revision, thorough wound cleaning, reinsertion of the\nautologous bone flap.\n\nTime of incision: 3:30 PM, 06/01/2020\n\nTime of suture completion: 4:35, 06/01/2020\n\nDuration: 65 minutes\n\nPATIENT HISTORY:\n\nThe patient had two prior surgeries with our team. The most recent was a\nrevision due to a wound healing complication. The patient was informed\nabout the procedure\\'s nature, extent, risks, and potential outcomes,\nand was given ample opportunity to ask questions. After thoughtful\nconsideration, written consent was obtained.\n\nOPERATION:\n\nThe patient was positioned supine with the head in a neutral position.\nThe surgical area was sterilized and draped. Antibiotic prophylaxis was\nadministered, and a timeout procedure was conducted. The old wound was\nreopened and slightly extended by about 1 cm in both directions. The\nbone flap was removed, inspected, and cleaned. It was then reinserted\nafter refreshing the bone edges. The wound edges were refreshed, and the\nwound was irrigated again before closure.\n\nSUMMARY:\n\nSuccessful wound revision without complications for a wound healing\ncomplication post-glioblastoma surgery.\n\nCLINICAL NOTES:\n\nComplication in wound healing after glioblastoma removal and radiation\ntherapy. Possible inflammation? Evaluate for pus. Nature and type of\ngrowth?\n\nMACROSCOPIC EXAMINATION:\n\nSubcutaneous tissue samples, 1.2 x 1.0 x 0.4 cm, were completely\nembedded after being cut into two.\n\nEpidural tissue samples, 5.6 x 5.3 x 1.0 cm, were partially embedded.\n\nSTAINING: 2 blocks, Hematoxylin & Eosin (HE), Periodic Acid Schiff\n(PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology displays connective tissue surrounded by a pronounced\ninflammatory infiltrate, comprised of neutrophils, lymphocytes, and\nnumerous eosinophils. Additionally, budding capillaries were seen. No\nspecific findings in the PAS stain.\n\nHistologically, connective tissue infiltrated by predominantly\nlymphocytic inflammation was observed. Eosinophils and abundant necrotic\ntissue were also seen. Additionally, polarizable material was noted,\noccasionally engulfed by multinucleated giant cells. Hemorrhagic signs\nwere indicated by hemosiderin deposits. No specific findings in the PAS\nstain.\n\nFINDINGS:\n\n1 & 2. Soft tissue displays acute phlegmonous inflammation and chronic\ngranulating inflammation.\n\n**Brief report (07/15/2020): **\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 06/01/2020.\n\nWound healing disorder right parietal at the site of previous right-side\nglioblastoma, last revision 04/12/2020.\n\n-Single right body focal seizure 04/20/2020, single generalized seizure\n05/12/2020\n\n-Previous resection on 10/12/2019\n\n-Wound healing disorder with subsequent wound revision (06/2020)\n\n-Last cMRI on 05/03/2020: no recurrence observed.\n\nSecondary diagnoses:\n\nHypothyroidism\n\nSurgery type: injection of Ropivacaine, smear for microbiology,\nreadaptation of three small wound dehiscence, tobacco bag suture,\noverlay polyhexanide gel, plaster application\n\nInstructions: Return next Tuesday for wound check. Sutures to remain in\nplace for 10 days. Check microbiology results on Thursday. Clinically,\nno signs of infection observed.\n\nSurgical report:\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 04/20/2020.\n\nASSESSMENT:\n\nThe patient was presented at the emergency unit after observing a small\nwound dehiscence after the aforementioned surgery for a wound healing\ndisorder. The treating surgeon recommended a second local wound revision\nattempting to readapt the wound with a minor surgery. The patient\nprovided written consent for the procedure. The intervention was\nconducted with standard coagulation parameters.\n\nSURGERY:\n\nSterile preparation and draping of the surgical area. Initial injection\nof Ropivacaine. This was followed by swab collection for microbiology.\nThe wound edges were excised and the wound dehiscence was readapted\nusing a tobacco bag suture. Afterward, polyhexanide gel was applied,\nfollowed by a sterile plaster dressing.\n\nSurgery report:\n\nDiagnosis: significant scalp wound healing disorder in the prior\nsurgical access area post-resection and irradiation of a glioblastoma\nmultiforme.\n\nOperating time: 49 minutes\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nwe report on Mr. Miller, John, born 04/07/1961, who was in our inpatient\ntreatment from 09/12/2020 to 10/07/2020.\n\nDischarge diagnosis: Recurrence of the pre-described glioblastoma right\ninsular, WHO CNS grade 4 (IDH wild type, MGMT methylated).\n\nPhysical examination on admission:\n\nPatient awake, fully oriented, cooperative. Non-fluent aphasia. Speech\nclear and fluent. Latent left hemisymptomatic with strength grades 4+/5,\nstance and gait unsteady. Cranial nerve status regular. Scar conditions\nnon-irritant except for frontal superficial erosion at frontal wound\npole of pterional approach. Karnofsky 70%.\n\nMedication on Admission:\n\nLevothyroxine sodium 50 μg/1 pc (Synthroid® 50 micrograms, tablets)\n1-0-0-0\n\nLorazepam 0.5 mg/1 pc (Ativan® 0.5 mg, tablets) 1-1-1-1\n\nLacosamide 100 mg/1 pc (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\n**Imaging: **\n\ncMRI +/- contrast agent dated 09/15/2020: There is a contrast enhancing\nformation on the right temporo-mesial with approach to the insular\ncistern with suspected tumor recurrence.\n\nPET dated 09/10/2020 (external): Significant tracer multinodulation with\nactive areas in the islet region is seen.\n\n**Surgery of 09/18/2020: **\n\nReopening of existing skin incision and extension of craniotomy\ncranially, microsurgical navigated tumor resection right insular (IONM:\nMEP waste lower extremity with incomplete recovery) CUSA; extensive\nhemostasis, intraoperative MRI, sutures, reimplantation of bone flap\nwith multilayer wound closure. Skin suture.\n\nHistopathological report:\n\nRecurrence of pre-described glioblastoma, WHO CNS grade 4 (IDH wild\ntype, MGMT methylated).\n\nCourse:\n\nThe patient initially presented postoperatively with left hemiplegia in\nthe sense of SMA. This regressed significantly during the inpatient\nstay. Postoperative imaging revealed a regular resection finding. In\ncase of a possible adjustment disorder, the patient was treated with\nsertraline and lorazepam. The wound was dry and non-irritant during the\ninpatient stay. The patient received regular physiotherapeutic exercise.\nThe patient\\'s case was discussed in our neuro-oncological tumor board\non 09/29/2020, where the decision was made for adjuvant definitive\nradiochemotherapy. An inpatient transfer was offered by the colleagues\nof radiotherapy.\n\nProcedure:\n\nWe transfer Mr. Miller today in good clinical general condition to your\nfurther treatment and thank you for the kind takeover. We ask for\nregular wound controls as well as regular ECG controls to exclude a\nQTc-time prolongation under sertraline. Furthermore, the medication with\nlorazepam should be further phased out in the course of time. In case of\nacute neurological deterioration, a re-presentation in our neurosurgical\noutpatient clinic or surgical emergency room is possible at any time.\n\nClinical examination findings at discharge:\n\nPatient awake, fully oriented, cooperative. Speech clear and fluent.\nCranial nerve status without pathological findings. Hemiparesis\nleft-sided strength grade 4/5, right-sided no sensorimotor deficit.\nStance and gait unsteady. Non-fluent aphasia. Wound dry, without\nirritation. Karnofsky 70%.\n\n**Medication at Discharge:**\n\nLevothyroxine sodium 50 μg (Synthroid® 50 micrograms, tablets) 1-0-0-0\n\nLorazepam 0.5 mg (Ativan® 0.5 mg, tablets) as needed\n\nLacosamide 100 mg (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\nAcetaminophen 500 mg (Tylenol® 500 mg tablets) 1-1-1-1\n\nSertraline 50 mg (Zoloft® 50 mg film-coated tablets) by regimen\n\n**Magnetic Resonance Imaging (MRI) Report**\n\nDate of Examination: 02/02/2021\n\nClinical Indication: Multifocal glioblastoma WHO grade IV, IDH wild\ntype, MGMT methylated.\n\nClinical Query: Hemiparesis on the right side. Is there a structural\ncorrelate? Tumor progression?\n\n**Previous Imaging**: Multiple prior studies. The most recent contrasted\nMRI was on 09/15/2020.\n\n**Findings**:\n\n**Imaging Device**: GE 3T; Protocol: 3D FLAIR, 3D T1 Mprage with and\nwithout contrast, SWI, DWI, 3D T2, axial T2\\*, perfusion, DTI.\n\n1. **Report: **\n\n Known multimodal pretreated GBM since 2019, recently post-surgical\n resection for tumor progression in the frontotemporal region on\n 09/18/2020. Also noted is a post-surgical resection of additional\n foci in the right insular region. The resection cavity in the right\n frontal, insular, and temporal regions appears unchanged in size and\n configuration. Residual blood products are noted within.\n\n There are increased areas of contrast enhancement compared to the\n immediate post-operative images. There is a minor growth in a\n nodular enhancement posterior to the right middle cerebral artery.\n Adjacent to this, there\\'s a new nodular enhancement, which could be\n a postoperative reactive change or a new tumor lesion.\n\n Ongoing diffusion abnormalities are observed in the right caput\n nuclei caudatus, putamen, and globus pallidus, especially pronounced\n in posterior sections.\n\n Persistent FLAIR-hyperintense peritumoral edema in the right\n hemisphere remains unchanged. The midline shift is approximately 9mm\n to the left, which remains unchanged.\n\n Post-operative swelling and fluid accumulation are noted at the\n surgical entry point. The bone flap is in place. The width of both\n the internal and external CSF spaces remains constant, with no\n evidence of obstruction.\n\n The orbital contents are symmetrical. Paranasal sinuses and mastoid\n air cells are aerated appropriately.\n\n**Impression**:\n\nResidual tumor segments along the right middle cerebral artery showing\ngrowth. Adjacent to it, a new nodular area of contrast enhancement\nsuggests either a postoperative change or a new tumor lesion.\n\nPreviously identified ischemic changes in the right caput nuclei\ncaudatus, putamen, and globus pallidus. Persistent brain edema with a\nleftward midline shift of approximately 9mm remains unchanged.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nHerewith we report on our common patient Mr. John Miller, born\n04/07/1961, who was at our clinic between 02/04/2021 to 04/22/2021.\n\n-Recurrent manifestation of a glioblastoma\n\n-Stage: WHO CNS grade 4\n\n**Histology:**\n\nRecurrence of the pre-described glioblastoma, WHO CNS grade 4.\n\nMolecular pathological findings:\n\nIDH status: no p.R132H mutation (immunohistochemical).\n\nATRX: preservation of nuclear expression (immunohistochemical).\n\np53: technically not evaluable (immunohistochemical).\n\n1p/19q status: no combined loss (850k methylation analysis).\n\nCDKN2A/B: Deleted (850k methylation analysis).\n\nMGMT promoter: Methylated (850k methylation analysis).\n\nTumor localization: Islet/frontal right\n\nSecondary diagnoses:\n\nSymptomatic epilepsy\n\nHypothyroidism\n\nNausea\n\nLeukopenia I° (CTCAE)\n\nAnemia II° (CTCAE)\n\nPrevious course / therapies:\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n03/2020: Suspected recurrence\n\n04/2020: Revision surgery\n\n06-07/2020 Wound revisions and flap plasty for atrophic wound healing\ndisorder\n\n02/2021: Suspected recurrence with new FLAIR-positive tumor\nmanifestation insular on the right side. Stereotactic biopsy with\nevidence of glioblastoma.\n\nPathology: Renewed manifestation of a glioblastoma.\n\nRecommended radiochemotherapy.\n\nAccording to the interdisciplinary neuro-oncology board of 01/26/2021,\nwe gave the indication for adjuvant radiochemotherapy for the recurrence\nof glioblastoma.\n\n**Radiochemotherapy: **\n\nTechnique:\n\n1\\) Percutaneous intensity-modulated radiotherapy was administered to the\nformer recurrence tumor region in the frontal/insular right after CT-\nand MRI-guided radiation planning with 6 MV-photons in helical\ntomotherapy technique with a single dose of 2 Gy up to a total dose of\n60 Gy with 5 fractions per week. Daily position controls by CT.\n\n2\\) Subsequently, local dose saturation of the macroscopic tumor remnant\nwas performed.\n\nInsular right stereotactic ablative radiosurgery at the gamma knee to\nsaturate the macroscopic GammaKnife (Cobalt-60: 1.17 MeV and 1.33 MeV\nphotons) in mask fixation after CT- and MRI-guided radiotherapy planning\nunder image-guided setting (ConeBeam-CT) with a dose of 6 Gy in 2 Gy\nsingle dose to the 68% isodose up to a total cumulative dose of 66 Gy.\n\nChemotherapy:\n\nConcurrent chemotherapy with 75mg/m²KOF temozolomide daily (120 mg\ndaily).\n\nAbsolute dose: 5000 mg.\n\nTreatment Period:\n\nRadiotherapy 03/09/2021 -- 04/21/2021\n\nChemotherapy 03/09/2021 -- 04/21/2021\n\n**Course under therapy:**\n\nWe took over Mr. Miller on 03/06/2021 in reduced general and slightly\nreduced nutritional condition (Kanofsky index: 70 %, BMI: 18.5 kg/m²)\nfrom the Clinic for Neurosurgery for adjuvant re-radiochemotherapy on\nour radiooncology ward. At the time of admission, the patient had arm\n\nright hemiparesis (strength grades arm: 2/5, leg: 3/5). The patient was\nambulatory with assistance. Cranial nerve status was unremarkable.\nHeadache, nausea or dizziness were denied.\n\nOn 09/03/2021, combined re-radiochemotherapy was initiated.\n\nDuring the course of therapy with temozolomide, mild nausea occurred,\nwhich was treated with ondansetron 4mg as needed and dimenhydrinate\nSustained-release tablets 150 mg as needed. Under this treatment the\nsymptoms clearly regressed. Mild constipation was treated. Laboratory\ntests revealed mild leukopenia I° and anemia II° (CTCAE).\n\nOtherwise, the re-radiochemotherapy was very well tolerated overall.\n\nMr. Miller received physiotherapeutic exercise and psychotherapy during\nthe entire physiotherapeutic training and psycho-oncological support.\nUnder the physiotherapeutic treatment, his motor skills improved\nsignificantly. At the end of the therapy, the patient was also mobile\noutside the\n\nhouse without any aids.\n\nOn 04/22/2021 we discharged Mr. Miller to the outpatient care by his\nfamily doctor.\n\n04/11/2021: MR brain post contrast\n\nAfter renewed radiochemotherapy for a glioblastoma recurrence, a\nresidual suspicious barrier disturbance adjacent to the adjacent to the\nright cerebral artery. Stable nodular contrast enhancement\n\nPostoperative/reactive changes as described above. MR perfusion\nsequences show residual, contrast-absorbing tumor portions along the\nright A. cerebri media. Lateral to this, new nodular contrast-absorbing\nlesion, possibly postoperative reactive change. Previously known\nischemia at the right caput nuclei caudatii, putamen, and globus\npallidus. Unchanged medullary edema with midline shift to the left by\napproximately 9mm.\n\nLast lab:\n\nMCHC 29.4 g/dL (32 - 36) 04/20/2021\n\nMCH 25 pg (27 - 32) 04/20/2021\n\nLeukocytes 3.32 G/l (4.0 - 9.0) 04/20/2021\n\nHematocrit 31.6 % (37 - 43) 04/20/2021\n\nHemoglobin 9.3 g/dL (12 - 16) 04/20/2021\n\nErythrocytes 3.7 T/l (4.1 - 5.4) 04/20/2021\n\nUric acid 2.2 mg/dl (2.5 - 5.5) 04/20/2021\n\n**Further Procedure:**\n\nFurther skin care and behavior regarding side effects were explained to\nthe patient in detail.\n\nA first radiooncological control appointment was scheduled for\n06/05/2021 at 12:00 AM in our outpatient clinic. Prior to this, on\n06/02/2021 at 10:30 AM, an imaging exam (brain MRI) is scheduled.\n\nA further neuro-oncological connection is planned close to home via the\ntreating oncologist.\n\nAfter radiation therapy, we recommend annual ophthalmological check-ups\nand annual endocrinologic.\n\nwith testing of the hypothalamic-pituitary hormone axes.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nThis is a report on our mutual patient, Mr. John Miller, born\n04/07/1961:\n\nDiagnosis:\n\nRecurrent manifestation of glioblastoma\n\nWHO CNS grade 4\n\nTumor localization: Right isle/frontal\n\nSecondary diagnoses: Symptomatic epilepsy\n\nHypothyroidism Previous\n\nTreatments / Therapies\n\nResection and revisions\n\nAdjuvant radiochemotherapy\n\nTwo wound revisions and flap plasty for atrophic wound healing disorder\n\nNew FLAIR-positive tumor manifestation insular on the right side\n(02/2021)\n\nStereotactic biopsy with histopathology with evidence of glioblastoma\n\nTumor Board: Recommended new radiochemotherapy up to a total dose of 60\nGy à 2 Gy single dose. Subsequent local dose saturation of the\nmacroscopic tumor remnant as radiosurgery on GammaKnife with a dose of 6\nGy à 2 Gy single dose (\\@68% isodose).\n\n03-4/2021 Repeat stereotactic RTx in the area of the basal ganglia and\nthe resection cavity right frontal on the Gamma Knife with 46 Gy à 2 Gy;\n3 doses of Bevacizumab 7.5 mg/kg i.v.\n\n**Summary:**\n\nOn 07/03/2023, we conducted an initial telephone follow-up with the\npatient, Mr. Miller, for a radio-oncology consultation. Presently, Mr.\nMiller is undergoing rehabilitation, from which he feels he is deriving\nsubstantial benefits. His recent radiotherapy was well-received without\nany complications. Since the onset of his symptoms, there have been no\nnew developments. Symptoms related to intracranial pressure or new\nneurological deficits were denied. Fortunately, while on anticonvulsant\ntherapy with Lacosamide, Mr. Miller experienced no epileptic seizures.\nHis skin condition is normal. However, Mr. Miller did mention some\ncognitive challenges that minimally impact his daily activities,\nalongside feelings of fatigue and grade I CTCAE symptoms. The cMRI scan\nfrom 06/02/2021 revealed a notable reduction in the barrier disturbance\nof the right-sided basal ganglia. This was accompanied by small, mildly\nhyperperfused residual findings near the third ventricle. Moreover, the\npinpoint contrast enhancement in the left parietal lobe appeared\nunchanged, suggesting it is a scarring reaction. In collaboration with\nthe neurooncology team, Mr. Miller has discussed starting chemotherapy.\nThe next imaging assessment is scheduled for mid-September. We have also\nscheduled another radio-oncologic follow-up with Mr. Miller for\nSeptember 28th, per his preference, via telephone. For patient safety,\nMr. Miller is prohibited from operating private or commercial vehicles\nfor 3 months post-intracerebral radiotherapy. This duration may extend\nif there are existing or progressing brain conditions. Following\nradiotherapy, we are mandated by the Radiation Protection Act to\nfacilitate regular checks. Hence, we encourage enrollment in the\naftercare calendar, prompt reporting of any significant findings, and\nattendance of scheduled follow-ups. Alongside these, regular oncological\ncheck-ups by specialist practitioners are mandatory. Mr. Miller has been\nduly informed of all these requirements.\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_3\n**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n\nHere is the query:\nComparing the lab results, how did Mr. Davies' creatinine levels change from August 2016 to June 2019?\n\nChoose the correct answer from the following options:\nA. Increased from 1.10 mg/dL to 1.22 mg/dL\nB. Decreased from 1.22 mg/dL to 1.10 mg/dL\nC. Remained constant at 1.22 mg/dL\nD. Increased above the reference range\nE. Decreased below the reference range\n\n\nYour response:\n", "role": "user" }, { "content": "Decreased from 1.22 mg/dL to 1.10 mg/dL", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/18/2018 to\n03/01/2018.\n\n**Diagnoses: **\n\n- Malignant melanoma of the left scapula, TD 16 mm, exophytic\n ulcerating, invasion stage - III, R0\n\n- **Mutation analysis:** BRAF status: mutated. PD-L1 status: PD-L1\n tumor proportion score (TPS): \\<1%. Immune cell infiltrate (IC): 2%\n of tumor area. PD-L1 combined-positive score (CPS): 2.\n\n- **History:** Ms. Done was admitted to the hospital with high grade\n suspicion of malignant melanoma of the back. The patient reported a\n skin lesion that had been present for approximately 4 weeks. The\n lesion had grown rapidly during this time and appeared to be oozing\n and bleeding. She presented to our outpatient clinic, where she was\n advised to undergo surgical excision in case of suspected\n malignancy.\n\n- Questions about B-symptoms, AP complaints, stool or urine\n abnormalities were negated.\n\n- System Therapy (Adjuvant Treatment for Stage III Melanoma): 1\n\n02/22/18: 1st dose pembrolizumab 200mg\n\n03/15/18: 2nd dose Pembrolizumab 200mg\n\n04/05/18: 3rd dose Pembrolizumab 200mg\n\n04/26/18: 4th dose Pembrolizumab 200mg\n\n05/17/18: 5th dose Pembrolizumab 200mg\n\n06/07/18: 6th dose Pembrolizumab 200mg\n\n06/28/18: 7th dose Pembrolizumab 200mg\n\n07/19/18: 8th dose Pembrolizumab 200mg\n\n08/09/18: 9th dose Pembrolizumab 200mg i.v.\n\n**Physical examination findings:** 52-year-old female patient in normal\ngeneral condition, nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement normal. Pupils are equal and\nreactive to light and accommodation. Regular, normocardial heart rate\nduring recording. Cor and pulmo auscultatory and percutaneously\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall, liver\nand spleen not enlarged, no pain to palpation, no resistance to\npalpation, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged cervical, submandibular, supra- and infraclavicular, axillary\nand inguinal lymph nodes palpable. inguinal lymph nodes palpable.\nFurther internal and orienting neurological examination neurological\nexamination remained without pathological findings.\n\n**Skin findings:** In the area of the left scapula, a table tennis-ball\nsized area with a slightly fissured, oozing, pink-black pigmented\nsurface. On the cranial side an irregularly black-brown pigmented macula\nof about 3.2x1.2 cm is visible.\n\n**PET/CT with 203 MBq (F-18)-Fluorodeoxyglucose from 02/18/2018: **\n\nWeight: 66 kg, blood glucose: 118 mg/dL. 20 mg furosemide; acquisition\nstart 91 min after tracer injection; 821 mm scan length á () mm/s in\nflow technique (neck to proximal thigh); oral and i.v. contrast (1.5\nmL/kg, i.v., max. 120 mL). Quantitative analysis of\nattenuation-corrected image data using SUV calculation.\n\n**Findings:**\n\nCT: In case of known contrast agent allergy, premedication was performed\nwith one ampoule each of H1 and H2 antihistamine. The contrast-enhanced\nexamination proceeded without complications during the course.\n\nNeck: Symmetrical visualization of the soft tissues of the neck. No\nevidence of pathologically enlarged cervical lymph nodes. Struma nodosa\nwith several hypodense nodes on the right side up to max. approx. 1 cm.\n\nThorax: Cutaneous/subcutaneous irregular-shaped lesion caudal to the\nright scapula. Limited assessability in the lung window with motion\nartifacts and shallow inspiration depth. As far as assessable, no\nevidence of larger suspicious intrapulmonary pulmonary round foci. No\ninfiltrate. No pleural effusion. No evidence of pathologically enlarged\nlymph nodes mediastinal, hilar and axillary bilaterally.\n\nAbdomen/pelvis: Normal contrast of liver parenchyma without evidence of\nsuspicious focal liver lesions. Portal vein and hepatic veins perfused\nregularly. Gallbladder without irritation. Spleen with accessory spleen,\npancreas and adrenal glands bds. regular. Kidneys perfused at the same\nside. No urinary retention. Nephrolithiasis on the right side.\nVisualization of the parenchymatous upper abdominal organs. No evidence\nof pathologically enlarged coeliacal, mesenteric, retroperitoneal,\niliac, and inguinal lymph nodes. Inhomogeneously contrasted enlarged\nprostate. Urinary bladder wall, as far as assessable with low filling\ncircumferentially wall thickened.\n\nSkeleton: no evidence of suspicious osteodestructive lesions. Osteopenia\nwith degenerative skeletal changes.\n\nPET:\n\nIncreased tracer enhancement of the suspicious lesion caudal to left\nscapula, indicative of a melanoma (SUVmax 67). Focal intense tracer\nenhancement in the right thyroid lobe (SUVmax approximately 7.9).\nElongated intense tracer enhancement in the lower abdomen ventrally\nmedian without clear correlate, most consistent with contamination.\nOtherwise, unremarkable activity distribution in the study area.\n\nAssessment:\n\nNo evidence of metabolically active metastases in the study area.\n\n**Operation report from** **02/22/2018**:\n\nProcedure: Excision of malignant melanoma on the left upper back.\n\nPreoperative Diagnosis: Malignant melanoma, left upper back.\n\nPostoperative Diagnosis: Malignant melanoma, left upper back.\n\nAnesthesia: Local anesthesia using 70 mL tumescent solution comprising\n0.21% Lidocaine/Ropivacaine with epinephrine.\n\nProcedure Details: The surgical area was prepped using Betadine. The\narea was draped in a sterile fashion. Excision of the exophytic tumor\nwas performed, measuring 51 x 20 x 15 mm. A safety margin of 10 mm was\nmaintained in depth, with the excision extending slightly into the\nsubcutaneous tissue but not beyond the fascia. This resulted in a total\ndefect size of 75 x 45 mm. The defect could not be closed with a simple\nprimary suture. Perforator vessels were coagulated, and the defect was\nbridged using skin flaps. Additional resection of Burow triangles was\ndone according to aesthetic units. The wound was closed using an\nintracutaneous suture technique. A continuous overhand blocked suture\nwas used with 3-0 Vicryl. The patient was advised that the visible\nsuture material could be removed between postoperative days 14 and 16. A\ndressing was applied, followed by a pressure dressing to minimize\nswelling and promote healing. Comments: The patient tolerated the\nprocedure well and was provided postoperative care instructions.\n\nPlan: Follow up in clinic for suture removal and wound assessment\nbetween postoperative days 14 and 16.\n\n**Histology Dermatohistology:** **02/23/2018.**\n\n**Gross Examination:** A roughly oval excision specimen measuring 48 x\n36 x 14 mm. The specimen is serially sectioned into lamellar stages A\nthrough H (8 cassettes).\n\n**Microscopic Examination:**\n\nStage A: Displays a benign epidermis and dermis without evidence of\nmelanocytic tumor cells.\n\nStage B: Features an irregularly thickened epidermis. At the center of\nthe section, melanocytic tumor cells are observed at the dermoepidermal\njunction (positive for MelanA stain). Additionally, abundant\nmelanophages and pigment deposits are noted. The lateral safety margin\nmeasures at least 8 mm.\n\nStage C: Resembles stage B. Atypical melanocytic tumor cells are present\nat the dermoepidermal junction. Upper dermis displays fibrosis,\ninflammation, and numerous melanophages (confirmed by positive MelanA\nstaining). The lateral safety margin is at least 6 mm.\n\nStage D: Central region shows melanocytic tumor cells in both the\nepidermis and upper dermis. There is significant inflammation,\nmelanophages, and pigment deposition (confirmed by MelanA staining).\n\nThe maximum lateral safety margin here is approximately 8 mm. A small\nlymph node in the subcutaneous fat tissue is also seen, infiltrated by\nmelanocytic tumor cells.\n\nThe tumor shows stages E, F, G and H: Exophytic, bovist-like growing\nulcerated hemorrhagic tumor consisting of completely pleomorphic tumor\ncells. These cells vary in morphology, appearing both nested and\nspindle-shaped, with clear cytoplasm and conspicuous nucleoli. Notable\npigment production is observed, as are numerous atypical mitoses.\nControl staining in stage F with MelanA is completely positive. The\nsections are entirely excised.\n\n**Diagnosis:** Exophytic, ulcerated malignant melanoma with a tumor\nthickness of at least 15 mm. The tumor invasion is categorized as stage\nIII.\n\n**Medication upon discharge: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ----------------------------------------- --------------- -------------- ------------------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Oral Once daily in the morning\n Enoxaparin (Lovenox) 0.2 mL Subcutaneous In the evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Oral Morning and evening\n Leuprorelin (Lupron Depot) 3.75 mg Depot Subcutaneous Every 4 weeks\n Fentanyl Transdermal System (Duragesic) 12 μg/hr Transdermal Changed every 3 days\n Pantoprazole (Protonix) 40 mg Oral Once daily in the morning\n Sevelamer (Renagel) 800 mg Oral Once daily in the morning\n Multivitamin One tablet Oral Once daily in the morning\n Torsemide (Demadex) 200 mg Oral Once daily in the morning\n Cholecalciferol (Dekristol) 20,000 IU Oral Once weekly\n Sodium Bicarbonate (Bicanorm) One tablet Oral Once daily in the morning\n Calcitriol (Rocaltrol) 0.25 μg Oral Once daily in the morning\n Valacyclovir (Valtrex) 500 mg Oral Half-tablet daily in the morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Oral Mornings on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Oral In the morning on day 1 and day 2 following daratumumab administration\n\n\n\n### text_1\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 10/23/2020 to\n11/01/2020.\n\n- Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\n according to UICC.\n\n- Therapies to date:\n\n- Resection of primary tumor (malignant melanoma) on the left upper\n back (02/2018)\n\n- 01/20 Microsurgical resection right frontal tumor\n\n- 02/20 Excision of empyema\n\n- 02-03/20: Radiation therapy\n\n- 05/02/20: Start of immunotherapy with Nivolumab & 05/26/20: Start of\n combination immunotherapy 60 mg nivolumab, 200 mg ipilimumab (-\\>\n drug exanthema)\n\n**Physical examination findings: **\n\nOn admission, the patient was awake and adequately oriented. Height:\n166cm, weight: 56kg. Nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement regular. Pupils equal, pupillary\nreflex responsive to accommodation and light. Regular, normocardial\nheart rate on admission. Heart and lung: auscultatory and percutaneous\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall Liver\nand spleen are not enlarged, no tenderness, no rebound palpable.\nResistences palpable, loud bowel sounds. No enlarged No enlarged\ncervical, submandibular, supra- and infraclavicular lymph nodes\npalpable. **Skin findings:** Pronounced xerosis cutis, raised skin\nfolds, some with erythema and fine lamellar scale and fine lamellar\nscale, especially on the arms and face. **Microbiology:** Nasal swab:\nnormal flora, no MRSA. Throat swab: Normal flora, no MRSA Virology:\n10/23/2020: No detection of SARS-CoV-2 by PCR in the submitted material.\n\n**Therapy and Progression:**\n\n**Summary:** The patient presented with exsiccation eczema on the arms,\nlegs, and face.\n\n**Treatment Details:** Topical Treatment for Eczema: Applied Desonide\nCream once daily to the affected areas. For maintenance, applied Eucerin\nCream daily to the body and a moisturizing ointment like Cetaphil to the\nface.\n\n**Antipruritic Treatment:** Prescribed Benadryl tablets, to be taken as\nneeded.\n\n**Oncology Consultation:** The patient was educated by our oncologist,\nDr. Ex, regarding adjuvant therapy options. The potential benefits and\nrisks of a combination immunotherapy with Nivolumab and Ipilimumab were\ndiscussed. The patient had already started Nivolumab 200 mg therapy on\n05/26/2020.\n\n**Incident on 10/28/2020**: The patient had an unattended fall,\nresulting in a hematoma on the left forehead. An emergency CT scan\nshowed no new fractures or acute hemorrhage but confirmed the presence\nof previously known cystic metastasis.\n\n**Operation report (01/02/2020): **\n\n**Diagnosis:** Hemorrhaged right frontal metastasis from previously\ndiagnosed malignant melanoma (ID 2018)\n\n**Procedure:** Microsurgical resection of right frontal mass with\nintraoperative neuromonitoring (MEPs stable) and neuronavigation via a\nleft frontolateral craniotomy.\n\nTime: 10:34 am Closure Time: 1:04 pm. Total Duration: 2 hours 30 minutes\n\n**Preoperative Evaluation:** Imaging identified a hemorrhage in the\nright frontal lobe. Given the patient\\'s history of malignant melanoma,\na hemorrhagic melanoma metastasis was suspected. No other intracranial\nmetastases were detected. The patient and their family were informed of\nthe surgical benefits and risks. After ample time for consideration and\nquestions, written informed consent was obtained.\n\n**Procedure Details:** The patient was positioned supine and intubated.\nThe head was secured in a Mayfield clamp and rotated 60° to the right.\nThe navigation dataset was reviewed. Using the navigation system, a left\nfrontotemporal craniotomy was planned. An arcuate incision line was\ndrawn. The surgical area was shaved, cleaned, and sterilized.\nProphylactic antibiotics and mannitol were administered. A time-out was\nconducted preoperatively. The skin was incised, and Raney clips were\ninserted. The left temporal muscle was split. Using the navigation\nsystem for guidance, a left frontolateral craniotomy was performed. The\nbone flap was carefully removed and preserved in an antibiotic solution\nfor later reimplantation. The dura mater was opened, and the operating\nmicroscope was introduced. Upon inspection, the tumor was evident.\n\n**MRI brain report (01/04/2020): **\n\n**Clinical Information:** Postoperative assessment following\nmicrosurgical resection of a left frontal hemorrhaged metastasis from\npreviously diagnosed malignant melanoma.\n\n**Technique:** Multiplanar, multisequence MRI of the brain, including\nT1-weighted, T2-weighted, FLAIR, diffusion-weighted imaging (DWI), and\npost-contrast T1-weighted sequences.\n\n**Findings:** There is evidence of a right frontotemporal craniotomy\nwith associated post-surgical changes in the right frontal region.\nTitanium plates and screws are noted securing the bone flap, causing\nminimal artifact. The previous tumor site in the right frontal lobe\nshows post-surgical changes with a well-circumscribed cavity. There is\nno evidence of residual enhancing tumor within this cavity on\npost-contrast sequences, suggesting complete resection. Surrounding this\ncavity, there\\'s mild edema, consistent with expected post-operative\nchanges. No other intracranial metastases. The ventricles are of normal\nsize and symmetric. There is no evidence of hydrocephalus. No midline\nshift or mass effect is observed. There are scattered foci of\nsusceptibility artifact in the surgical bed on gradient echo sequences,\nconsistent with expected postoperative blood products. Major\nintracranial vessels appear patent with no evidence of vascular\nocclusion or significant stenosis. The remaining brain parenchyma\nappears normal in signal intensity and morphology on all sequences. No\nother significant abnormalities are identified.\n\n**Impression:** Post-surgical changes in the left frontal lobe\nconsistent with recent tumor resection. There is no evidence of residual\ntumor in the surgical bed. Expected postoperative edema and blood\nproducts adjacent to the resection site. No new metastatic foci\nidentified. No evidence of complications such as hydrocephalus, midline\nshift, or vascular abnormalities.\n\n**Operation report (02/04/2020): **\n\n**Diagnosis:** Subfascial, epidural, and subdural empyema following\nresection of right frontal metastasis for malignant melanoma.\n\n**Procedure:** Empyema removal (subfascial, epidural, subdural) S\nIncision Time: 15:23 Closure Time: 04:01 PM Total Duration: 2 hours 31\nminutes\n\n**Preoperative Evaluation:** The patient had a prior surgical resection\nof a right frontal metastasis due to known malignant melanoma. On a\nrecent outpatient visit, a cerebrospinal fluid (CSF) cushion was\nidentified and punctured, revealing the presence of pathogens. Imaging\nindicated deep and subcutaneous abscesses, necessitating revision\nsurgery. The patient was adequately informed about the procedure,\nunderstood the associated risks, and provided written consent.\n\n**Procedure Details:** The patient was positioned supine with the head\nrotated approximately 60° in a Mayfield clamp. The surgical area was\nwashed and sterilized, focusing on the pre-existing access point. A team\ntime-out was conducted. Perioperative antibiotics were withheld until\nall samples for microbiology were obtained. The skin was incised,\nrevealing multiple layers of muscle. These were carefully dissected,\nleading to the identification and evacuation of the subcutaneous\nepifascial abscess. Infected muscle tissue and abscess walls were\nresected. The skull flap appeared loosened. A miniplate was removed, and\nupon further inspection, the dura mater appeared strained. It was\nincised and revealed turbid fluid, indicating a deep abscess. The dura\nmater was mobilized, though adherence to the cortex was observed around\nthe resection cavity, suggesting possible tumor regrowth. Affected areas\nwere carefully resected. After thorough irrigation, a drainage system\nwas inserted into the resection cavity. A duraplasty was performed,\nfollowed by the reimplantation of the bone flap using a miniplate. The\npatient was also included in a bone flap study and was randomized for\nflap reimplantation. After further irrigation, the wound was\nmeticulously closed, and a subfascial drain was inserted. The final\nclosure was completed with single button sutures. Under the guidance of\nthe operating microscope, the tumor was meticulously dissected from the\nsurrounding healthy tissue. Special care was taken to minimize damage to\nthe surrounding brain structures. The intraoperative neuromonitoring\nindicated stable MEPs throughout, suggesting that motor pathways\nremained undisturbed during the procedure. Throughout the resection,\nperiodic hemostasis was achieved using bipolar electrocautery to control\nbleeding. Following the complete resection of the tumor, the surgical\ncavity was irrigated with sterile saline to remove any residual debris.\nThe integrity of the surrounding brain tissue was assessed, and no\nimmediate complications were observed. The dura mater was sutured,\nensuring a watertight closure. A synthetic dural graft was used to\nreinforce the suture line. The preserved bone flap was reimplanted and\nsecured in place using titanium plates and screws. The temporal muscle\nand soft tissues were reapproximated and sutured in layers. The skin was\nclosed using a combination of absorbable sutures for the subcutaneous\nlayer and non-absorbable sutures for the skin. Sterile dressings were\napplied to the incision site. Postoperative Assessment: The procedure\nwas completed without complications. Immediate postoperative\nneurological examination revealed no new deficits. The patient was\ntransferred to the recovery room in stable condition, awaiting\nextubation by the anesthesiology team.\n\n**Recommendations:** Close monitoring in the neurological intensive care\nunit (NICU) is advised for the first 24 hours. Postoperative imaging,\ntypically an MRI, should be scheduled within the next 48 hours to assess\nthe extent of tumor resection and to rule out any postoperative\ncomplications.\n\n**Summary:** Mrs. Done\\'s recent hospital course was complicated by the\ndetection and subsequent excision of a hemorrhagic metastasis from a\nknown history of malignant melanoma. She continues to be on targeted\ntherapy with close monitoring. No new metastasis or recurrence has been\ndetected as of the last evaluation. The interdisciplinary approach\ninvolving the neurosurgery and oncology teams has been pivotal in her\nmanagement. Given the aggressive nature of melanoma, regular\nsurveillance and immediate action upon detection of new\nlesions/metastasis are paramount for her prognosis.\n\n**02-03/20: Radiation therapy **\n\nDiagnosis: Metastatic malignant melanoma with a focus on the right\nfrontal metastasis. Technique: Stereotactic radiosurgery (SRS) using a\nlinear accelerator (LINAC). Fractionation: Given the aggressive nature\nof malignant melanoma, a hypofractionated regimen was adopted. The\npatient underwent five sessions, each delivering a dose of 6 Gy for a\ncumulative total dose of 30 Gy.\n\nTreatment Planning: A simulation CT scan with a 1mm slice thickness was\nperformed in the treatment position, with a thermoplastic mask for\nimmobilization. The treatment planning system utilized the simulation\nCT, along with MRI for better tumor delineation. The target volume and\ncritical structures like the eyes, optic nerves, chiasm, and brainstem\nwere contoured. The radiation plan was optimized to ensure maximal dose\nto the target while sparing the critical structures.\n\nProcedure: At each session, patient positioning was verified using\ncone-beam CT (CBCT) to ensure precise targeting. Real-time monitoring\nwas employed to account for any intrafraction motion.\n\nSide Effects: The patient tolerated the treatment well. She reported\ntransient fatigue and mild scalp irritation, which resolved with\nconservative measures. No acute radiation-induced neurotoxicity was\nobserved.\n\n**Patient History Update: Mrs. Jane Done (DOB: 01/01/1966)**\n\n**General Status (10/03/2020):**\n\nMrs. Done presented in stable condition with stable vital signs.\nNeurologically, she\\'s intact with no new focal deficits. The surgical\nscars in the frontal region from previous operations are not fully\nhealed and there is some dehiscence and swelling, indicative of\ninfection. This wound complication can be traced back to her previous\nhistory of an empyema which required surgical intervention.\n\n**Dermatological Assessment:**\n\nThe previous exsiccation eczema, prominent on her arms, legs, and face,\nhas improved markedly. The treatment regimen involving consistent\nmoisturization and targeted topical therapies seems effective.\nImportantly, there were no new suspicious skin lesions or nodules noted\nduring her most recent full-body skin check.\n\n**Oncology Status:**\n\nMrs. Done remains on her immunotherapy regimen, specifically the\ncombination of Nivolumab and Ipilimumab. Her response has been positive,\nwith no new metastatic sites identified in the latest assessments. She\nhas displayed commendable compliance with this regimen and regular\nfollow-up evaluations.\n\n**Recent MRI Brain (09/30/2020):**\n\nHer latest multiplanar, multisequence MRI revealed post-surgical\nalterations in the right frontal lobe, consistent with previous\nobservations. Encouragingly, there was no sign of any residual or\nrecurrent tumor activity. Moreover, the MRI did not show any new\nintracranial metastatic sites or other significant abnormalities.\n\n**Thoracic CT Scan (10/01/2020): **\n\nTechnique: Post complication-free bolus i.v. administration of Imeron\n400, a multiline spiral CT was performed through the thorax during the\nvenous contrast phase, supplemented with thin-section, coronary, and\nsagittal secondary reconstructions.\n\nFindings: Multiple roundish subsolid nodules found bipulmonary, notably\na 4mm nodule in the right upper lobe. Blurred subpleural condensations\nin the left upper lobe. Another blurred bronchus-associated\nconsolidation was observed in the left upper lobe and pleurally in the\nleft dorsal lower lobe. No evidence of pathologically enlarged lymph\nnodes in the hilar, mediastinal, or axillary regions. Unchanged\npresentation of the left adrenal gland from the preliminary examination.\nThickened imprinting of the gastric wall noted. Ventrally emphasized\nspondylophytic attachments observed in the thoracic spine. No\nosteodestructive processes detected.\n\n**Impression:** Presence of multiple subsolid pulmonary nodules;\nrecommended follow-up in 4-6 weeks for potential (post-) inflammatory or\nmalignant genesis. No evidence of pathologically enlarged lymph nodes.\n\n**Abdomen/Pelvis CT Scan (10/01/2023): **\n\nTechnique: A low dose CT scan was taken of the abdomen and pelvis.\n\n**Findings:** Regular visualization of the acquired basal lung sections.\nOrthotopic kidneys without urinary stasis. No evidence of urinary\ncalculi. Suspected uterine fibroids attached to the uterus wall.\nEnlarged right ovary with minor calcifications. Assessment: Absence of\nurinary calculi. Possible uterine fibroids and an enlarged right ovary,\nsuggesting a specialized gynecological examination.\n\n**PICC Line Installation (10/02/2020)**\n\n**Diagnosis:**\n\nHome antibiotics required for wound healing disorder following discharge\ndue to an empyema.\n\n**Type of Surgery:**\n\nInstallation of a PICC line in the left basilic vein.\n\n**Anesthesia:**\n\nLocal anesthesia\n\n**Procedure Details:**\n\nThe patient was presented for long-term antibiotic treatment due to a\nwound healing disturbance post the discharge of an epidural abscess. The\nprimary aim was to apply a PICC-line catheter for the antibiotic\nregimen. A written informed consent was duly obtained prior to the\nprocedure.\n\nThe standard procedure began with the washing off and draping of the\npatient. A preoperative sonography of the arm veins was conducted. Based\non the sonographic results, it was decided to insert the catheter via\nthe left basilica vein.\n\nUnder venous congestion and following local anesthesia with 2mL Mecain,\na 2mm skin incision was made. The sonographically guided puncture was\nperformed successfully. Post this, the peel-away sheath was inserted.\nWith the wire in place, the catheter was advanced with its tip\npositioned approximately 2cm below the carina. The wire was subsequently\nremoved. Following this, the catheter was aspirated and flushed with\nNaCl to ensure its patency. A sterile fixation was then applied, and the\nwound was dressed.\n\n**Notes:**\n\nNo complications were observed during the procedure. The patient was\nadvised on the care and maintenance of the PICC line. Regular follow-ups\nare recommended to monitor the wound healing and the effectiveness of\nthe antibiotic treatment.\n\nThe patient was discharged with instructions and is scheduled for a\nfollow-up in two weeks.\n\n**Additional Therapeutic Engagements:**\n\nFor her overall well-being and to counter the side effects of her\ntreatment journey, Mrs. Done has been actively involved in physical\ntherapy sessions. These sessions focus on enhancing her strength and\nbalance, especially given the previous incident of an unattended fall.\nTo address the inevitable psychological strains of her diagnosis, she\nhas also been attending counseling sessions.\n\n**Current Recommendations:**\n\n-Continue the ongoing immunotherapy without changes.\n\n-Dermatological check-ups every month are advised for early detection of\nany potential skin abnormalities.\n\n-Regular neurological evaluations are crucial to ensure no emergence of\nnew deficits.\n\n-Imaging should be scheduled every six months for proactive monitoring.\n\n-Her physical therapy regimen should be ongoing to maintain and improve\nmobility.\n\n-Continue counseling to support her emotional and psychological\nwell-being.\n\n**Summary and Notes:**\n\nMrs. Done\\'s resilience and adherence to her treatments are commendable.\nHer progress is a testament to the integrated care approach she has been\nreceiving. Maintaining a proactive surveillance stance will be essential\nfor her long-term prognosis and quality of life.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe wish to provide an update regarding our mutual patient, Mrs. Jane\nDone, born on 01.01.1966. She was admitted to our clinic from 11/23/2020\nto 12/01/2020.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done presented for a follow-up visit on 11/23/2020. Over the past\nfew months, she reported fatigue and intermittent bouts of nausea. Of\nsignificant concern were newly identified skin changes located on her\nright arm.\n\n**Clinical Findings:**\n\nSkin: Multiple macules and patches on the right arm, the largest\nmeasuring about 1.5cm in diameter, hyperpigmented with irregular\nborders.\n\n**US: **\n\nUltrasound imaging of the right arm revealed no deep extension or\ninvasion of underlying structures. This preliminary assessment was\ncrucial, suggesting that if malignancy is present, it might be in early\nstages.\n\n**Histology: **\n\nHistological examination: Gross Description: The sample consists of\nmultiple tan-pink soft tissue fragments, aggregating to 1.8 cm in the\ngreatest dimension.\n\nMicroscopic description: Sections show a proliferation of atypical\nmelanocytes arranged in nests and as single units at the dermoepidermal\njunction. Some of these cells infiltrate the papillary dermis.\n\nImmunohistochemistry: The atypical cells are positive for HMB-45 and\nS-100. Melan A is focally positive. Ki-67 proliferation index is about\n10%.\n\nFinal Diagnosis: Dysplastic nevus with severe atypia; margins appear\nclear. Further excision is recommended to ensure complete removal and to\nrule out invasive melanoma.\n\n**Lab results: **\n\nComplete Blood Count (CBC):\n\nHemoglobin: 12.3 g/dL (Normal range: 12-16 g/dL)\n\nWhite Blood Cell Count: 6,200 cells/µL (Normal range: 4,000-11,000\ncells/µL)\n\nPlatelet Count: 290,000 cells/µL (Normal range: 150,000-450,000\ncells/µL)\n\nDifferential:\n\nNeutrophils 65%, Lymphocytes 25%, Monocytes 8%, Eosinophils 2%. B.\n\nLiver Function Tests (LFTs):\n\nALT (Alanine Aminotransferase): 40 U/L (Normal range: 7-56 U/L)\n\nAST (Aspartate Aminotransferase): 38 U/L (Normal range: 10-40 U/L)\n\nALP (Alkaline Phosphatase): 90 U/L (Normal range: 44-147 U/L)\n\nTotal Bilirubin: 1.0 mg/dL (Normal range: 0.1-1.2 mg/dL)\n\nAlbumin: 4.2 g/dL (Normal range: 3.4-5.4 g/dL)\n\nAssessment/Recommendations:\n\nGiven her history and the suspicious nature of the new skin changes, we\nhave decided to send the biopsy for urgent histological assessment.\n\nFurthermore, considering her reported symptoms, we have conducted a\nthorough internal check-up, including blood tests and liver function\ntests, to rule out any systemic side effects of the immunotherapy.\n\nWe recommend continuous monitoring of Mrs. Done's condition and kindly\nrequest your valuable input in managing her case optimally. A\nmultidisciplinary approach, given her complicated medical history, will\nbe most beneficial for the patient.\n\nPlease find attached the detailed examination and investigative reports\nfor your reference.\n\nWith kind regards,\n\n\n\n### text_3\n**Dear colleague, **\n\nWe wish to provide a comprehensive update regarding our mutual patient,\nMrs. Jane Done, born on 01.01.1966. She has had a history of various\nmedical conditions and treatments, which we believe is essential to\ndiscuss for her optimal management and was admitted to our clinical from\n01/01/2021 to 01/28/2021.\n\n**Previous Diagnoses and Therapies:**\n\nMetastatic malignant melanoma (presumed ID 2018); M1, stage IV according\nto UICC. Resection of primary tumor (malignant melanoma) on the left\nupper back (02/2018)\n\n01/20 Microsurgical resection right frontal tumor\n\n02/20 Excision of empyema\n\n02-03/20: Radiation therapy\n\n05/02/20: Start of immunotherapy with Nivolumab\n\n05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\nImaging 01/02/2021: PET/CT: Cervical lymph node metastasis;\n\ncMRI: no evidence of metastases. Contrast-enhancing meninges.\n\n**Virology: **\n\nUpon Admission: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load\nof 7,000 Geq/mL and a Ct value of 32.\n\nAt Discharge: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load of\n2,350 Geq/mL and a Ct value of 32.\n\n**Microbiology: **\n\nMRSA Screening Upon Admission: Nasal Swab: Normal flora detected; MRSA\nnot present. Throat Swab: Normal flora detected; MRSA not present.\n\nProcedures:\n\n\\- Presentation to neurology for CSF puncture (e.g., exclude\nmeningeosis)\n\n\\- Panel sequencing complement\n\n\\- Surgery/therapy: Neck dissection followed by adjuvant therapy with\npembrolizumab.\n\nClinical examination:\n\nExamination findings: Patient in normal general and nutritional\ncondition, consciousness unremarkable. Cranial mobility free, ocular\nmobility normal. Pupils are isocor, pupillary reflex prompt to\naccommodation and light. Regular, normocardial heart rate on admission.\nNo typical heart murmurs. Abdomen: abdominal wall soft, liver and spleen\nnot enlarged, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged in the axillary or inguinal region palpable.\n\nPET-CT from 01/02/2021:\n\nIntense metabolically active lymph node metastases, otherwise no\nevidence of vital tumor tissue in the study area.\n\n**PET CT report from 01/02/2021: **\n\nProcedure: PET/CT with 246 MBq (F-18)-fluorodeoxyglucose and a 60-minute\nuptake period.\n\nFindings: CT Findings: Neck: Right Level II: Three lymph nodes, largest\nmeasuring 2.1 x 1.8 cm with central necrosis. Right Level III: Two lymph\nnodes, largest measuring 1.5 x 1.2 cm. Left Level II: One lymph node\nmeasuring 1.3 x 1.1 cm. Left Level IV: Two lymph nodes, largest\nmeasuring 1.7 x 1.4 cm. Retropharyngeal space: One lymph node measuring\n1.0 x 0.9 cm.\n\nPET Findings: Neck: Right Level II: Increased FDG uptake with SUVmax of\n7.8, consistent with metastatic disease. Right Level III: Increased FDG\nuptake with SUVmax of 6.5. Left Level II: Increased FDG uptake with\nSUVmax of 6.0. Left Level IV: Increased FDG uptake with SUVmax of 7.2.\nRetropharyngeal space: Increased FDG uptake with SUVmax of 6.1.\nImpression: Cervical Lymph Nodes: Multiple pathologically enlarged\ncervical lymph nodes in bilateral level II, right level III, left level\nIV, and retropharyngeal space with increased FDG uptake, highly\nsuggestive of metastatic involvement from the known primary melanoma.\n\n**Surgery report 01/05/2021: **\n\nThe surgery commenced with a collaborative discussion with the\nanesthesia team and a standard team time-out was executed. The patient\nwas properly positioned, and the surgical site was aseptically draped.\nThe facial neuromonitoring system was set up and verified. Local\nanesthesia was then administered at the site of the skin incision, which\nwas located near the previous scar. This incision followed the anterior\nborder of the sternocleidomastoid muscle in a curved pattern. Upon\nincising the subcutaneous tissue, the external jugular vein became\nvisible and was selectively ligated. The encountered tissue appeared\nnotably fibrotic and scarred. A skin incision extended from the mastoid\nregion down nearly to the clavicle. The platysma muscle was subsequently\ncut. Due to the presence of a lymph node mass, the auricularis magnus\nnerve had to be severed. The sternocleidomastoid muscle and the\nposterior belly of the digastric muscle were then exposed. Multiple\ndarkened lymph node metastases were identified, both beneath the skin\nand within the sternocleidomastoid muscle. In subsequent steps, efforts\nwere made to distinguish the internal jugular vein from the surrounding\nscarred tissue. A lymph node mass, which exhibited characteristics\nhighly suggestive of metastasis (given its darkened color), was removed.\nThe accessory nerve was identified and preserved. Further dissection was\ndone posteriorly to the sternocleidomastoid muscle, in the direction of\nlevel V. An expansive mass of lymph nodes was excised in this region.\nThe trapezoid branch of the accessory nerve was visualized, and its\nfunction was monitored and preserved with the aid of neuromonitoring.\nThe removed lymph node mass, some excised tissue, and portions of the\nsternocleidomastoid muscle with embedded lymph nodes were sent for\nhistological analysis. During the procedure, care was taken to avoid\ndamaging major neck vessels and nerves. Concluding the procedure, 8 and\n10 French Redon drains were placed, the wound was closed in layers, and\nthen covered with a spray-on bandage, steristrips, and a pressure\ndressing. The surgical site appeared bloodless at the conclusion of the\nsurgery.\n\n**Macroscopy:**\n\n**Macroscopic Description:**\n\nDimensions: 6.8 x 0.7 x 0.4 cm spindle-shaped, non-oriented skin and\nsubcutaneous tissue resection. Central area shows an irritation-free,\nfine scar measuring up to 6.3 x 4.8 cm. The cut surface appears\nconsistently off-white.\n\nInk markings: soft tissue margin of specimen = green. A: central\nlamellae B: spindle tips perpendicular\n\nAnterior Margin of Upper Third of Sternocleidomastoid Muscle:\nDimensions: Four combined tissue samples totaling 4.7 x 3.8 x 1.1 cm.\n\nAppearance: Tan, fibrous soft tissues with multiple uniformly dark\nnodules on the cut surface, each measuring up to 1.1 cm.\n\nA, B: one nodule each halved C, D: other nodular sections E: remaining\ntan fibrous sections Anterior Margin of Lower Third of\nSternocleidomastoid Muscle: Largest measurement: 3.4 cm.\n\nAppearance: Grayish-brown with some fibrous regions and homogeneously\ndark-brown nodes up to 1.5 cm in size on the cut surface. A, B: one node\neach halved C: other nodes D: brown-fibrous sections Region V Occipital:\nLargest measurement: Two samples, each up to 3.8 cm.\n\nAppearance: Mixture of grayish-tan and light brown fibrous soft tissue\nwith nodes up to 2.2 cm, uniformly dark brown.\n\nA, B: one node halved C, D: another node halved each Processing: 16\nparaffin blocks, HE stained.\n\nMicroscopic Description: Dermis and subcutaneous resection shows\nscarring with fibrosis. Epidermis is regular, without any atypical\ncells. No evidence of melanoma or carcinoma. 2./3.\n\nMultiple nodular tumor clusters present in the soft tissue and skeletal\nmuscles, lacking lymph node structure. Tumor cells are polygonal, with\nsome spindle-shaped cells having moderately large, irregular nuclei and\nnoticeable nucleoli. Cytoplasm appears slightly granular with a light\nbrownish pigment.\n\nSeven lymph nodes (measuring up to 3.6 cm) indicate metastasis from the\npreviously mentioned tumor, with extracapsular spread. Four other lymph\nnodes are free from the tumor.\n\n**Critical Findings:** Multiple nodular soft tissue metastases, with the\nlargest measuring 1.3 cm, indicative of melanoma present in both soft\ntissue and muscle. Resection margins are mostly free of tumor, with the\nclosest approach being less than 0.15 cm (points 2 and 3). Seven lymph\nnodes (up to 3.6 cm in size) show metastasis from the melanoma, with\nextracapsular spread. Four lymph nodes are tumor-free (7 out of 11\nnodes, ECE positive) (point 4). Dermis and subcutaneous excision shows\nscarring fibrosis (point 1).\n\nFor the optimal management of Mrs. Done, close monitoring and a\nmultidisciplinary approach will be essential. Thank you for your\ncontinued collaboration in ensuring the best care for our mutual\npatient.\n\n**Lab values upon discharge: **\n\n **Parameter** **Result** **Reference Range** **Interpretation**\n -------------------------------- -------------- ---------------------------------------- ---------------------\n **Complete Blood Count (CBC)** \n Hemoglobin (Hb) 12.4 g/dL 12.0 - 16.0 g/dL Within normal range\n White Blood Cell (WBC) 9.2 x10\\^9/L 4.0 - 10.0 x10\\^9/L Within normal range\n Platelets 250 x10\\^9/L 150 - 400 x10\\^9/L Within normal range\n **Liver Function Tests (LFT)** \n AST 28 U/L 10 - 35 U/L Within normal range\n ALT 32 U/L 10 - 40 U/L Within normal range\n Total Bilirubin 0.8 mg/dL 0.2 - 1.2 mg/dL Within normal range\n **Kidney Function Test** \n Serum Creatinine 0.9 mg/dL 0.5 - 1.2 mg/dL Within normal range\n Blood Urea Nitrogen (BUN) 15 mg/dL 7 - 20 mg/dL Within normal range\n **Electrolytes** \n Sodium 138 mEq/L 135 - 145 mEq/L Within normal range\n Potassium 4.2 mEq/L 3.5 - 5.0 mEq/L Within normal range\n Chloride 101 mEq/L 95 - 105 mEq/L Within normal range\n **Thyroid Function Tests** \n TSH 3.1 mU/L 0.5 - 5.0 mU/L Within normal range\n Free T4 1.4 ng/dL 0.9 - 2.4 ng/dL Within normal range\n **Lipid Profile** \n Total Cholesterol 190 mg/dL \\< 200 mg/dL Desirable\n LDL Cholesterol 100 mg/dL \\< 100 mg/dL Optimal\n HDL Cholesterol 55 mg/dL \\> 40 mg/dL (Men), \\> 50 mg/dL (Women) Normal\n Triglycerides 110 mg/dL \\< 150 mg/dL Normal\n\n**Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ---------------- ------------ ----------- -----------------------------\n Pembrolizumab 200mg IV Every 3 weeks\n Nivolumab 60mg IV As per oncologist\\'s advice\n Ipilimumab 200mg IV As per oncologist\\'s advice\n Paracetamol 500mg Oral Every 4-6 hours as needed\n Omeprazole 20mg Oral Once daily\n\n\n\n### text_4\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/14/2022 to\n03/01/2022.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done showed multiple metastases in her CT examination. On physical\nexamination, Mrs. Done appears well-nourished and in no acute distress.\nHer vital signs are stable. Cardiovascular examination reveals regular\nheart sounds with no murmurs. Respiratory examination shows clear breath\nsounds bilaterally. Abdominal examination reveals no palpable masses or\norganomegaly. Neurological examination is within normal limits.\n\n**Radiology/Nuclear Medicine**\n\n**CT thorax/abdomen/pelvis + Contrast from 02/10/2022**\n\n**Technique:** Multi-phase, multi-slice computed tomography of the\nthorax, abdomen, and pelvis was performed following the intravenous\nadministration of contrast material. Coronal and sagittal\nreconstructions were obtained.\n\n**Thorax:** In the thoracic region, the lungs are notable for multiple\nnodular opacities across both lung fields, consistent with metastatic\ndeposits. The most sizable lesion is seen in the right upper lobe,\napproximately 1.5 cm in diameter. No associated cavitation or pleural\neffusion is detected. A concerning 2 cm mass abutting the lateral wall\nof the left ventricle is noted, raising the suspicion for cardiac\nmetastasis. The mediastinum also exhibits lymphadenopathy with a\ndominant node in the prevascular space, measuring 2.2 cm. Further, there\nare lytic lesions involving the sternum and right 4th rib, consistent\nwith osseous metastatic disease.\n\n**Abdomen/pelvis**: Liver shows multiple hypodense lesions throughout\nboth lobes, indicative of metastatic spread. The dominant lesion in the\nright lobe measures 3 cm. The kidneys, however, are unremarkable without\ndiscernible metastatic deposits. Retroperitoneal lymphadenopathy is also\npresent, highlighted by a node anterior to the aorta of 1.8 cm. In\naddition, there is a 2.5 cm mass identified within the left psoas\nmuscle, consistent with muscular metastasis. Both the left acetabulum\nand the right iliac wing manifest with lytic lesions, suggestive of\nmetastatic involvement. There is also enlargement of the bilateral\ninternal iliac lymph nodes, with the left side\\'s node measuring up to\n1.6 cm. Bladder, prostate, and rectum with no discernible pathology.\n\n**Impression**: Multiple pulmonary nodules consistent with pulmonary\nmetastases. Cardiac lesion suggestive of metastatic involvement.\nEvidence of skeletal metastases in the thorax and pelvis. Hepatic and\nmuscular metastases, indicative of disseminated disease. Lymphadenopathy\nin the mediastinal, retroperitoneal, and pelvic regions.\n\n**PET-CT scan from 02/11/2022**\n\n**Clinical Indication:** Follow-up evaluation of a known case of\nMetastatic Melanoma, Stage IV, M1c with notable findings from a CT scan\ndated 12/01/2014.\n\n**Technique:** Whole-body PET-CT scan was conducted after intravenous\nadministration of 18F-FDG. The patient fasted for 6 hours prior to the\nscan, and blood glucose levels were confirmed to be within the\nacceptable range. Both CT and PET images were acquired, and images were\nco-registered for optimal evaluation. Standard uptake values (SUVs) were\ncalculated for areas of interest.\n\n**Findings: **\n\n**Thorax:** Both lungs depict several hypermetabolic foci, corroborating\nthe CT findings of multiple nodules. The largest lesion in the right\nupper lobe demonstrates an SUVmax of 8.2, indicative of active metabolic\ndisease. The cardiac mass adjacent to the left ventricle, measuring\napproximately 2 cm, also reveals increased 18F-FDG uptake with an SUVmax\nof 9.5, strengthening the suspicion of cardiac metastasis. Enlarged\nmediastinal lymph nodes, particularly the node in the prevascular space,\nshows marked hypermetabolism with an SUVmax of 7.4. Notably, the lytic\nskeletal lesions identified on the CT in the sternum and right 4th rib\nalso display increased metabolic activity, consistent with metastatic\nbone disease.\n\n**Abdomen/Pelvis:** Hepatic lesions are congruent with the findings of\nthe preceding CT, showing heightened metabolic activity. The most\nprominent lesion in the right lobe exhibits an SUVmax of 8.8.\nRetroperitoneal lymph nodes are metabolically active, with the anterior\naortic node demonstrating an SUVmax of 6.9. The 2.5 cm left psoas muscle\nmass also reveals increased uptake with an SUVmax of 7.3, suggesting\nactive muscular metastasis. In the pelvic region, the lytic lesions\nidentified in the left acetabulum and right iliac wing on the CT confirm\ntheir malignant nature with notable metabolic activity. Bilateral\ninternal iliac lymph nodes show hypermetabolism with the left node\\'s\nSUVmax reaching 7.1. Other pelvic organs, including the bladder,\nprostate, and rectum, did not show any significant 18F-FDG uptake, in\nline with the unremarkable CT findings.\n\n**Impression:** The PET-CT findings are consistent with active\nmetastatic disease. There is evidence of hypermetabolic pulmonary\nnodules, a likely cardiac metastasis, hepatic and muscular metastases,\nand metabolically active skeletal lesions in both the thorax and pelvis.\nAdditionally, there is hypermetabolism in the lymph nodes across\nmultiple regions. These findings align closely with the previously\ndiagnosed metastatic melanoma, Stage IV, M1c**. **\n\n**Discussion**\n\nMrs. Done has been diagnosed with recurrent metastatic melanoma with\nlymph node involvement. This poses significant implications for her\nprognosis, emphasizing the need for urgent and comprehensive\nintervention.\n\nHer molecular profile has revealed the presence of the BRAF V600E\nmutation.\n\nOur recommended therapeutic combination includes Vemurafenib and\nCobimetinib, both of which are aimed at disrupting the aberrant BRAF-MEK\nsignaling cascade. Complementing this, we suggest the administration of\nPembrolizumab.\n\nMrs. Done is scheduled for six cycles of this treatment regimen. We will\nmonitor her laboratory parameters, such as blood counts, electrolytes,\nand hepatic and renal profiles, bi-weekly. It is imperative to note that\nany fevers surpassing 38.3°C warrant immediate medical attention.\n\nComprehensive patient education module has been designed to enable Mrs.\nDone to identify and manage any potential side effects efficiently.\n\nWe will ensure rigorous monitoring of her blood pressure and lipid\nmetrics, with the possibility of introducing alternative medications if\nclinical scenarios demand.\n\nWe deeply value your collaboration in Mrs. Done\\'s healthcare journey.\nOur team remains at your disposal for any queries or clarifications.\n\n\n\n\n\nHere is the query:\nWhat was the total duration of Mrs. Jane Done's hospital stay during her most recent admission?\n\nChoose the correct answer from the following options:\nA. 11 days (02/18/2018 to 03/01/2018)\nB. 1 month (02-03-/20)\nC. 15 days (02/14/2022 to 03/01/2022)\nD. 24 days (05/ß2/20 - 05/26/20)\nE. 14 days (03/16/2021 - 03/30/2021)\n\n\nYour response:\n", "role": "user" }, { "content": "15 days (02/14/2022 to 03/01/2022)", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/18/2018 to\n03/01/2018.\n\n**Diagnoses: **\n\n- Malignant melanoma of the left scapula, TD 16 mm, exophytic\n ulcerating, invasion stage - III, R0\n\n- **Mutation analysis:** BRAF status: mutated. PD-L1 status: PD-L1\n tumor proportion score (TPS): \\<1%. Immune cell infiltrate (IC): 2%\n of tumor area. PD-L1 combined-positive score (CPS): 2.\n\n- **History:** Ms. Done was admitted to the hospital with high grade\n suspicion of malignant melanoma of the back. The patient reported a\n skin lesion that had been present for approximately 4 weeks. The\n lesion had grown rapidly during this time and appeared to be oozing\n and bleeding. She presented to our outpatient clinic, where she was\n advised to undergo surgical excision in case of suspected\n malignancy.\n\n- Questions about B-symptoms, AP complaints, stool or urine\n abnormalities were negated.\n\n- System Therapy (Adjuvant Treatment for Stage III Melanoma): 1\n\n02/22/18: 1st dose pembrolizumab 200mg\n\n03/15/18: 2nd dose Pembrolizumab 200mg\n\n04/05/18: 3rd dose Pembrolizumab 200mg\n\n04/26/18: 4th dose Pembrolizumab 200mg\n\n05/17/18: 5th dose Pembrolizumab 200mg\n\n06/07/18: 6th dose Pembrolizumab 200mg\n\n06/28/18: 7th dose Pembrolizumab 200mg\n\n07/19/18: 8th dose Pembrolizumab 200mg\n\n08/09/18: 9th dose Pembrolizumab 200mg i.v.\n\n**Physical examination findings:** 52-year-old female patient in normal\ngeneral condition, nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement normal. Pupils are equal and\nreactive to light and accommodation. Regular, normocardial heart rate\nduring recording. Cor and pulmo auscultatory and percutaneously\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall, liver\nand spleen not enlarged, no pain to palpation, no resistance to\npalpation, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged cervical, submandibular, supra- and infraclavicular, axillary\nand inguinal lymph nodes palpable. inguinal lymph nodes palpable.\nFurther internal and orienting neurological examination neurological\nexamination remained without pathological findings.\n\n**Skin findings:** In the area of the left scapula, a table tennis-ball\nsized area with a slightly fissured, oozing, pink-black pigmented\nsurface. On the cranial side an irregularly black-brown pigmented macula\nof about 3.2x1.2 cm is visible.\n\n**PET/CT with 203 MBq (F-18)-Fluorodeoxyglucose from 02/18/2018: **\n\nWeight: 66 kg, blood glucose: 118 mg/dL. 20 mg furosemide; acquisition\nstart 91 min after tracer injection; 821 mm scan length á () mm/s in\nflow technique (neck to proximal thigh); oral and i.v. contrast (1.5\nmL/kg, i.v., max. 120 mL). Quantitative analysis of\nattenuation-corrected image data using SUV calculation.\n\n**Findings:**\n\nCT: In case of known contrast agent allergy, premedication was performed\nwith one ampoule each of H1 and H2 antihistamine. The contrast-enhanced\nexamination proceeded without complications during the course.\n\nNeck: Symmetrical visualization of the soft tissues of the neck. No\nevidence of pathologically enlarged cervical lymph nodes. Struma nodosa\nwith several hypodense nodes on the right side up to max. approx. 1 cm.\n\nThorax: Cutaneous/subcutaneous irregular-shaped lesion caudal to the\nright scapula. Limited assessability in the lung window with motion\nartifacts and shallow inspiration depth. As far as assessable, no\nevidence of larger suspicious intrapulmonary pulmonary round foci. No\ninfiltrate. No pleural effusion. No evidence of pathologically enlarged\nlymph nodes mediastinal, hilar and axillary bilaterally.\n\nAbdomen/pelvis: Normal contrast of liver parenchyma without evidence of\nsuspicious focal liver lesions. Portal vein and hepatic veins perfused\nregularly. Gallbladder without irritation. Spleen with accessory spleen,\npancreas and adrenal glands bds. regular. Kidneys perfused at the same\nside. No urinary retention. Nephrolithiasis on the right side.\nVisualization of the parenchymatous upper abdominal organs. No evidence\nof pathologically enlarged coeliacal, mesenteric, retroperitoneal,\niliac, and inguinal lymph nodes. Inhomogeneously contrasted enlarged\nprostate. Urinary bladder wall, as far as assessable with low filling\ncircumferentially wall thickened.\n\nSkeleton: no evidence of suspicious osteodestructive lesions. Osteopenia\nwith degenerative skeletal changes.\n\nPET:\n\nIncreased tracer enhancement of the suspicious lesion caudal to left\nscapula, indicative of a melanoma (SUVmax 67). Focal intense tracer\nenhancement in the right thyroid lobe (SUVmax approximately 7.9).\nElongated intense tracer enhancement in the lower abdomen ventrally\nmedian without clear correlate, most consistent with contamination.\nOtherwise, unremarkable activity distribution in the study area.\n\nAssessment:\n\nNo evidence of metabolically active metastases in the study area.\n\n**Operation report from** **02/22/2018**:\n\nProcedure: Excision of malignant melanoma on the left upper back.\n\nPreoperative Diagnosis: Malignant melanoma, left upper back.\n\nPostoperative Diagnosis: Malignant melanoma, left upper back.\n\nAnesthesia: Local anesthesia using 70 mL tumescent solution comprising\n0.21% Lidocaine/Ropivacaine with epinephrine.\n\nProcedure Details: The surgical area was prepped using Betadine. The\narea was draped in a sterile fashion. Excision of the exophytic tumor\nwas performed, measuring 51 x 20 x 15 mm. A safety margin of 10 mm was\nmaintained in depth, with the excision extending slightly into the\nsubcutaneous tissue but not beyond the fascia. This resulted in a total\ndefect size of 75 x 45 mm. The defect could not be closed with a simple\nprimary suture. Perforator vessels were coagulated, and the defect was\nbridged using skin flaps. Additional resection of Burow triangles was\ndone according to aesthetic units. The wound was closed using an\nintracutaneous suture technique. A continuous overhand blocked suture\nwas used with 3-0 Vicryl. The patient was advised that the visible\nsuture material could be removed between postoperative days 14 and 16. A\ndressing was applied, followed by a pressure dressing to minimize\nswelling and promote healing. Comments: The patient tolerated the\nprocedure well and was provided postoperative care instructions.\n\nPlan: Follow up in clinic for suture removal and wound assessment\nbetween postoperative days 14 and 16.\n\n**Histology Dermatohistology:** **02/23/2018.**\n\n**Gross Examination:** A roughly oval excision specimen measuring 48 x\n36 x 14 mm. The specimen is serially sectioned into lamellar stages A\nthrough H (8 cassettes).\n\n**Microscopic Examination:**\n\nStage A: Displays a benign epidermis and dermis without evidence of\nmelanocytic tumor cells.\n\nStage B: Features an irregularly thickened epidermis. At the center of\nthe section, melanocytic tumor cells are observed at the dermoepidermal\njunction (positive for MelanA stain). Additionally, abundant\nmelanophages and pigment deposits are noted. The lateral safety margin\nmeasures at least 8 mm.\n\nStage C: Resembles stage B. Atypical melanocytic tumor cells are present\nat the dermoepidermal junction. Upper dermis displays fibrosis,\ninflammation, and numerous melanophages (confirmed by positive MelanA\nstaining). The lateral safety margin is at least 6 mm.\n\nStage D: Central region shows melanocytic tumor cells in both the\nepidermis and upper dermis. There is significant inflammation,\nmelanophages, and pigment deposition (confirmed by MelanA staining).\n\nThe maximum lateral safety margin here is approximately 8 mm. A small\nlymph node in the subcutaneous fat tissue is also seen, infiltrated by\nmelanocytic tumor cells.\n\nThe tumor shows stages E, F, G and H: Exophytic, bovist-like growing\nulcerated hemorrhagic tumor consisting of completely pleomorphic tumor\ncells. These cells vary in morphology, appearing both nested and\nspindle-shaped, with clear cytoplasm and conspicuous nucleoli. Notable\npigment production is observed, as are numerous atypical mitoses.\nControl staining in stage F with MelanA is completely positive. The\nsections are entirely excised.\n\n**Diagnosis:** Exophytic, ulcerated malignant melanoma with a tumor\nthickness of at least 15 mm. The tumor invasion is categorized as stage\nIII.\n\n**Medication upon discharge: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ----------------------------------------- --------------- -------------- ------------------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Oral Once daily in the morning\n Enoxaparin (Lovenox) 0.2 mL Subcutaneous In the evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Oral Morning and evening\n Leuprorelin (Lupron Depot) 3.75 mg Depot Subcutaneous Every 4 weeks\n Fentanyl Transdermal System (Duragesic) 12 μg/hr Transdermal Changed every 3 days\n Pantoprazole (Protonix) 40 mg Oral Once daily in the morning\n Sevelamer (Renagel) 800 mg Oral Once daily in the morning\n Multivitamin One tablet Oral Once daily in the morning\n Torsemide (Demadex) 200 mg Oral Once daily in the morning\n Cholecalciferol (Dekristol) 20,000 IU Oral Once weekly\n Sodium Bicarbonate (Bicanorm) One tablet Oral Once daily in the morning\n Calcitriol (Rocaltrol) 0.25 μg Oral Once daily in the morning\n Valacyclovir (Valtrex) 500 mg Oral Half-tablet daily in the morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Oral Mornings on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Oral In the morning on day 1 and day 2 following daratumumab administration\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 10/23/2020 to\n11/01/2020.\n\n- Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\n according to UICC.\n\n- Therapies to date:\n\n- Resection of primary tumor (malignant melanoma) on the left upper\n back (02/2018)\n\n- 01/20 Microsurgical resection right frontal tumor\n\n- 02/20 Excision of empyema\n\n- 02-03/20: Radiation therapy\n\n- 05/02/20: Start of immunotherapy with Nivolumab & 05/26/20: Start of\n combination immunotherapy 60 mg nivolumab, 200 mg ipilimumab (-\\>\n drug exanthema)\n\n**Physical examination findings: **\n\nOn admission, the patient was awake and adequately oriented. Height:\n166cm, weight: 56kg. Nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement regular. Pupils equal, pupillary\nreflex responsive to accommodation and light. Regular, normocardial\nheart rate on admission. Heart and lung: auscultatory and percutaneous\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall Liver\nand spleen are not enlarged, no tenderness, no rebound palpable.\nResistences palpable, loud bowel sounds. No enlarged No enlarged\ncervical, submandibular, supra- and infraclavicular lymph nodes\npalpable. **Skin findings:** Pronounced xerosis cutis, raised skin\nfolds, some with erythema and fine lamellar scale and fine lamellar\nscale, especially on the arms and face. **Microbiology:** Nasal swab:\nnormal flora, no MRSA. Throat swab: Normal flora, no MRSA Virology:\n10/23/2020: No detection of SARS-CoV-2 by PCR in the submitted material.\n\n**Therapy and Progression:**\n\n**Summary:** The patient presented with exsiccation eczema on the arms,\nlegs, and face.\n\n**Treatment Details:** Topical Treatment for Eczema: Applied Desonide\nCream once daily to the affected areas. For maintenance, applied Eucerin\nCream daily to the body and a moisturizing ointment like Cetaphil to the\nface.\n\n**Antipruritic Treatment:** Prescribed Benadryl tablets, to be taken as\nneeded.\n\n**Oncology Consultation:** The patient was educated by our oncologist,\nDr. Ex, regarding adjuvant therapy options. The potential benefits and\nrisks of a combination immunotherapy with Nivolumab and Ipilimumab were\ndiscussed. The patient had already started Nivolumab 200 mg therapy on\n05/26/2020.\n\n**Incident on 10/28/2020**: The patient had an unattended fall,\nresulting in a hematoma on the left forehead. An emergency CT scan\nshowed no new fractures or acute hemorrhage but confirmed the presence\nof previously known cystic metastasis.\n\n**Operation report (01/02/2020): **\n\n**Diagnosis:** Hemorrhaged right frontal metastasis from previously\ndiagnosed malignant melanoma (ID 2018)\n\n**Procedure:** Microsurgical resection of right frontal mass with\nintraoperative neuromonitoring (MEPs stable) and neuronavigation via a\nleft frontolateral craniotomy.\n\nTime: 10:34 am Closure Time: 1:04 pm. Total Duration: 2 hours 30 minutes\n\n**Preoperative Evaluation:** Imaging identified a hemorrhage in the\nright frontal lobe. Given the patient\\'s history of malignant melanoma,\na hemorrhagic melanoma metastasis was suspected. No other intracranial\nmetastases were detected. The patient and their family were informed of\nthe surgical benefits and risks. After ample time for consideration and\nquestions, written informed consent was obtained.\n\n**Procedure Details:** The patient was positioned supine and intubated.\nThe head was secured in a Mayfield clamp and rotated 60° to the right.\nThe navigation dataset was reviewed. Using the navigation system, a left\nfrontotemporal craniotomy was planned. An arcuate incision line was\ndrawn. The surgical area was shaved, cleaned, and sterilized.\nProphylactic antibiotics and mannitol were administered. A time-out was\nconducted preoperatively. The skin was incised, and Raney clips were\ninserted. The left temporal muscle was split. Using the navigation\nsystem for guidance, a left frontolateral craniotomy was performed. The\nbone flap was carefully removed and preserved in an antibiotic solution\nfor later reimplantation. The dura mater was opened, and the operating\nmicroscope was introduced. Upon inspection, the tumor was evident.\n\n**MRI brain report (01/04/2020): **\n\n**Clinical Information:** Postoperative assessment following\nmicrosurgical resection of a left frontal hemorrhaged metastasis from\npreviously diagnosed malignant melanoma.\n\n**Technique:** Multiplanar, multisequence MRI of the brain, including\nT1-weighted, T2-weighted, FLAIR, diffusion-weighted imaging (DWI), and\npost-contrast T1-weighted sequences.\n\n**Findings:** There is evidence of a right frontotemporal craniotomy\nwith associated post-surgical changes in the right frontal region.\nTitanium plates and screws are noted securing the bone flap, causing\nminimal artifact. The previous tumor site in the right frontal lobe\nshows post-surgical changes with a well-circumscribed cavity. There is\nno evidence of residual enhancing tumor within this cavity on\npost-contrast sequences, suggesting complete resection. Surrounding this\ncavity, there\\'s mild edema, consistent with expected post-operative\nchanges. No other intracranial metastases. The ventricles are of normal\nsize and symmetric. There is no evidence of hydrocephalus. No midline\nshift or mass effect is observed. There are scattered foci of\nsusceptibility artifact in the surgical bed on gradient echo sequences,\nconsistent with expected postoperative blood products. Major\nintracranial vessels appear patent with no evidence of vascular\nocclusion or significant stenosis. The remaining brain parenchyma\nappears normal in signal intensity and morphology on all sequences. No\nother significant abnormalities are identified.\n\n**Impression:** Post-surgical changes in the left frontal lobe\nconsistent with recent tumor resection. There is no evidence of residual\ntumor in the surgical bed. Expected postoperative edema and blood\nproducts adjacent to the resection site. No new metastatic foci\nidentified. No evidence of complications such as hydrocephalus, midline\nshift, or vascular abnormalities.\n\n**Operation report (02/04/2020): **\n\n**Diagnosis:** Subfascial, epidural, and subdural empyema following\nresection of right frontal metastasis for malignant melanoma.\n\n**Procedure:** Empyema removal (subfascial, epidural, subdural) S\nIncision Time: 15:23 Closure Time: 04:01 PM Total Duration: 2 hours 31\nminutes\n\n**Preoperative Evaluation:** The patient had a prior surgical resection\nof a right frontal metastasis due to known malignant melanoma. On a\nrecent outpatient visit, a cerebrospinal fluid (CSF) cushion was\nidentified and punctured, revealing the presence of pathogens. Imaging\nindicated deep and subcutaneous abscesses, necessitating revision\nsurgery. The patient was adequately informed about the procedure,\nunderstood the associated risks, and provided written consent.\n\n**Procedure Details:** The patient was positioned supine with the head\nrotated approximately 60° in a Mayfield clamp. The surgical area was\nwashed and sterilized, focusing on the pre-existing access point. A team\ntime-out was conducted. Perioperative antibiotics were withheld until\nall samples for microbiology were obtained. The skin was incised,\nrevealing multiple layers of muscle. These were carefully dissected,\nleading to the identification and evacuation of the subcutaneous\nepifascial abscess. Infected muscle tissue and abscess walls were\nresected. The skull flap appeared loosened. A miniplate was removed, and\nupon further inspection, the dura mater appeared strained. It was\nincised and revealed turbid fluid, indicating a deep abscess. The dura\nmater was mobilized, though adherence to the cortex was observed around\nthe resection cavity, suggesting possible tumor regrowth. Affected areas\nwere carefully resected. After thorough irrigation, a drainage system\nwas inserted into the resection cavity. A duraplasty was performed,\nfollowed by the reimplantation of the bone flap using a miniplate. The\npatient was also included in a bone flap study and was randomized for\nflap reimplantation. After further irrigation, the wound was\nmeticulously closed, and a subfascial drain was inserted. The final\nclosure was completed with single button sutures. Under the guidance of\nthe operating microscope, the tumor was meticulously dissected from the\nsurrounding healthy tissue. Special care was taken to minimize damage to\nthe surrounding brain structures. The intraoperative neuromonitoring\nindicated stable MEPs throughout, suggesting that motor pathways\nremained undisturbed during the procedure. Throughout the resection,\nperiodic hemostasis was achieved using bipolar electrocautery to control\nbleeding. Following the complete resection of the tumor, the surgical\ncavity was irrigated with sterile saline to remove any residual debris.\nThe integrity of the surrounding brain tissue was assessed, and no\nimmediate complications were observed. The dura mater was sutured,\nensuring a watertight closure. A synthetic dural graft was used to\nreinforce the suture line. The preserved bone flap was reimplanted and\nsecured in place using titanium plates and screws. The temporal muscle\nand soft tissues were reapproximated and sutured in layers. The skin was\nclosed using a combination of absorbable sutures for the subcutaneous\nlayer and non-absorbable sutures for the skin. Sterile dressings were\napplied to the incision site. Postoperative Assessment: The procedure\nwas completed without complications. Immediate postoperative\nneurological examination revealed no new deficits. The patient was\ntransferred to the recovery room in stable condition, awaiting\nextubation by the anesthesiology team.\n\n**Recommendations:** Close monitoring in the neurological intensive care\nunit (NICU) is advised for the first 24 hours. Postoperative imaging,\ntypically an MRI, should be scheduled within the next 48 hours to assess\nthe extent of tumor resection and to rule out any postoperative\ncomplications.\n\n**Summary:** Mrs. Done\\'s recent hospital course was complicated by the\ndetection and subsequent excision of a hemorrhagic metastasis from a\nknown history of malignant melanoma. She continues to be on targeted\ntherapy with close monitoring. No new metastasis or recurrence has been\ndetected as of the last evaluation. The interdisciplinary approach\ninvolving the neurosurgery and oncology teams has been pivotal in her\nmanagement. Given the aggressive nature of melanoma, regular\nsurveillance and immediate action upon detection of new\nlesions/metastasis are paramount for her prognosis.\n\n**02-03/20: Radiation therapy **\n\nDiagnosis: Metastatic malignant melanoma with a focus on the right\nfrontal metastasis. Technique: Stereotactic radiosurgery (SRS) using a\nlinear accelerator (LINAC). Fractionation: Given the aggressive nature\nof malignant melanoma, a hypofractionated regimen was adopted. The\npatient underwent five sessions, each delivering a dose of 6 Gy for a\ncumulative total dose of 30 Gy.\n\nTreatment Planning: A simulation CT scan with a 1mm slice thickness was\nperformed in the treatment position, with a thermoplastic mask for\nimmobilization. The treatment planning system utilized the simulation\nCT, along with MRI for better tumor delineation. The target volume and\ncritical structures like the eyes, optic nerves, chiasm, and brainstem\nwere contoured. The radiation plan was optimized to ensure maximal dose\nto the target while sparing the critical structures.\n\nProcedure: At each session, patient positioning was verified using\ncone-beam CT (CBCT) to ensure precise targeting. Real-time monitoring\nwas employed to account for any intrafraction motion.\n\nSide Effects: The patient tolerated the treatment well. She reported\ntransient fatigue and mild scalp irritation, which resolved with\nconservative measures. No acute radiation-induced neurotoxicity was\nobserved.\n\n**Patient History Update: Mrs. Jane Done (DOB: 01/01/1966)**\n\n**General Status (10/03/2020):**\n\nMrs. Done presented in stable condition with stable vital signs.\nNeurologically, she\\'s intact with no new focal deficits. The surgical\nscars in the frontal region from previous operations are not fully\nhealed and there is some dehiscence and swelling, indicative of\ninfection. This wound complication can be traced back to her previous\nhistory of an empyema which required surgical intervention.\n\n**Dermatological Assessment:**\n\nThe previous exsiccation eczema, prominent on her arms, legs, and face,\nhas improved markedly. The treatment regimen involving consistent\nmoisturization and targeted topical therapies seems effective.\nImportantly, there were no new suspicious skin lesions or nodules noted\nduring her most recent full-body skin check.\n\n**Oncology Status:**\n\nMrs. Done remains on her immunotherapy regimen, specifically the\ncombination of Nivolumab and Ipilimumab. Her response has been positive,\nwith no new metastatic sites identified in the latest assessments. She\nhas displayed commendable compliance with this regimen and regular\nfollow-up evaluations.\n\n**Recent MRI Brain (09/30/2020):**\n\nHer latest multiplanar, multisequence MRI revealed post-surgical\nalterations in the right frontal lobe, consistent with previous\nobservations. Encouragingly, there was no sign of any residual or\nrecurrent tumor activity. Moreover, the MRI did not show any new\nintracranial metastatic sites or other significant abnormalities.\n\n**Thoracic CT Scan (10/01/2020): **\n\nTechnique: Post complication-free bolus i.v. administration of Imeron\n400, a multiline spiral CT was performed through the thorax during the\nvenous contrast phase, supplemented with thin-section, coronary, and\nsagittal secondary reconstructions.\n\nFindings: Multiple roundish subsolid nodules found bipulmonary, notably\na 4mm nodule in the right upper lobe. Blurred subpleural condensations\nin the left upper lobe. Another blurred bronchus-associated\nconsolidation was observed in the left upper lobe and pleurally in the\nleft dorsal lower lobe. No evidence of pathologically enlarged lymph\nnodes in the hilar, mediastinal, or axillary regions. Unchanged\npresentation of the left adrenal gland from the preliminary examination.\nThickened imprinting of the gastric wall noted. Ventrally emphasized\nspondylophytic attachments observed in the thoracic spine. No\nosteodestructive processes detected.\n\n**Impression:** Presence of multiple subsolid pulmonary nodules;\nrecommended follow-up in 4-6 weeks for potential (post-) inflammatory or\nmalignant genesis. No evidence of pathologically enlarged lymph nodes.\n\n**Abdomen/Pelvis CT Scan (10/01/2023): **\n\nTechnique: A low dose CT scan was taken of the abdomen and pelvis.\n\n**Findings:** Regular visualization of the acquired basal lung sections.\nOrthotopic kidneys without urinary stasis. No evidence of urinary\ncalculi. Suspected uterine fibroids attached to the uterus wall.\nEnlarged right ovary with minor calcifications. Assessment: Absence of\nurinary calculi. Possible uterine fibroids and an enlarged right ovary,\nsuggesting a specialized gynecological examination.\n\n**PICC Line Installation (10/02/2020)**\n\n**Diagnosis:**\n\nHome antibiotics required for wound healing disorder following discharge\ndue to an empyema.\n\n**Type of Surgery:**\n\nInstallation of a PICC line in the left basilic vein.\n\n**Anesthesia:**\n\nLocal anesthesia\n\n**Procedure Details:**\n\nThe patient was presented for long-term antibiotic treatment due to a\nwound healing disturbance post the discharge of an epidural abscess. The\nprimary aim was to apply a PICC-line catheter for the antibiotic\nregimen. A written informed consent was duly obtained prior to the\nprocedure.\n\nThe standard procedure began with the washing off and draping of the\npatient. A preoperative sonography of the arm veins was conducted. Based\non the sonographic results, it was decided to insert the catheter via\nthe left basilica vein.\n\nUnder venous congestion and following local anesthesia with 2mL Mecain,\na 2mm skin incision was made. The sonographically guided puncture was\nperformed successfully. Post this, the peel-away sheath was inserted.\nWith the wire in place, the catheter was advanced with its tip\npositioned approximately 2cm below the carina. The wire was subsequently\nremoved. Following this, the catheter was aspirated and flushed with\nNaCl to ensure its patency. A sterile fixation was then applied, and the\nwound was dressed.\n\n**Notes:**\n\nNo complications were observed during the procedure. The patient was\nadvised on the care and maintenance of the PICC line. Regular follow-ups\nare recommended to monitor the wound healing and the effectiveness of\nthe antibiotic treatment.\n\nThe patient was discharged with instructions and is scheduled for a\nfollow-up in two weeks.\n\n**Additional Therapeutic Engagements:**\n\nFor her overall well-being and to counter the side effects of her\ntreatment journey, Mrs. Done has been actively involved in physical\ntherapy sessions. These sessions focus on enhancing her strength and\nbalance, especially given the previous incident of an unattended fall.\nTo address the inevitable psychological strains of her diagnosis, she\nhas also been attending counseling sessions.\n\n**Current Recommendations:**\n\n-Continue the ongoing immunotherapy without changes.\n\n-Dermatological check-ups every month are advised for early detection of\nany potential skin abnormalities.\n\n-Regular neurological evaluations are crucial to ensure no emergence of\nnew deficits.\n\n-Imaging should be scheduled every six months for proactive monitoring.\n\n-Her physical therapy regimen should be ongoing to maintain and improve\nmobility.\n\n-Continue counseling to support her emotional and psychological\nwell-being.\n\n**Summary and Notes:**\n\nMrs. Done\\'s resilience and adherence to her treatments are commendable.\nHer progress is a testament to the integrated care approach she has been\nreceiving. Maintaining a proactive surveillance stance will be essential\nfor her long-term prognosis and quality of life.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding our mutual patient, Mrs. Jane\nDone, born on 01.01.1966. She was admitted to our clinic from 11/23/2020\nto 12/01/2020.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done presented for a follow-up visit on 11/23/2020. Over the past\nfew months, she reported fatigue and intermittent bouts of nausea. Of\nsignificant concern were newly identified skin changes located on her\nright arm.\n\n**Clinical Findings:**\n\nSkin: Multiple macules and patches on the right arm, the largest\nmeasuring about 1.5cm in diameter, hyperpigmented with irregular\nborders.\n\n**US: **\n\nUltrasound imaging of the right arm revealed no deep extension or\ninvasion of underlying structures. This preliminary assessment was\ncrucial, suggesting that if malignancy is present, it might be in early\nstages.\n\n**Histology: **\n\nHistological examination: Gross Description: The sample consists of\nmultiple tan-pink soft tissue fragments, aggregating to 1.8 cm in the\ngreatest dimension.\n\nMicroscopic description: Sections show a proliferation of atypical\nmelanocytes arranged in nests and as single units at the dermoepidermal\njunction. Some of these cells infiltrate the papillary dermis.\n\nImmunohistochemistry: The atypical cells are positive for HMB-45 and\nS-100. Melan A is focally positive. Ki-67 proliferation index is about\n10%.\n\nFinal Diagnosis: Dysplastic nevus with severe atypia; margins appear\nclear. Further excision is recommended to ensure complete removal and to\nrule out invasive melanoma.\n\n**Lab results: **\n\nComplete Blood Count (CBC):\n\nHemoglobin: 12.3 g/dL (Normal range: 12-16 g/dL)\n\nWhite Blood Cell Count: 6,200 cells/µL (Normal range: 4,000-11,000\ncells/µL)\n\nPlatelet Count: 290,000 cells/µL (Normal range: 150,000-450,000\ncells/µL)\n\nDifferential:\n\nNeutrophils 65%, Lymphocytes 25%, Monocytes 8%, Eosinophils 2%. B.\n\nLiver Function Tests (LFTs):\n\nALT (Alanine Aminotransferase): 40 U/L (Normal range: 7-56 U/L)\n\nAST (Aspartate Aminotransferase): 38 U/L (Normal range: 10-40 U/L)\n\nALP (Alkaline Phosphatase): 90 U/L (Normal range: 44-147 U/L)\n\nTotal Bilirubin: 1.0 mg/dL (Normal range: 0.1-1.2 mg/dL)\n\nAlbumin: 4.2 g/dL (Normal range: 3.4-5.4 g/dL)\n\nAssessment/Recommendations:\n\nGiven her history and the suspicious nature of the new skin changes, we\nhave decided to send the biopsy for urgent histological assessment.\n\nFurthermore, considering her reported symptoms, we have conducted a\nthorough internal check-up, including blood tests and liver function\ntests, to rule out any systemic side effects of the immunotherapy.\n\nWe recommend continuous monitoring of Mrs. Done's condition and kindly\nrequest your valuable input in managing her case optimally. A\nmultidisciplinary approach, given her complicated medical history, will\nbe most beneficial for the patient.\n\nPlease find attached the detailed examination and investigative reports\nfor your reference.\n\nWith kind regards,\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe wish to provide a comprehensive update regarding our mutual patient,\nMrs. Jane Done, born on 01.01.1966. She has had a history of various\nmedical conditions and treatments, which we believe is essential to\ndiscuss for her optimal management and was admitted to our clinical from\n01/01/2021 to 01/28/2021.\n\n**Previous Diagnoses and Therapies:**\n\nMetastatic malignant melanoma (presumed ID 2018); M1, stage IV according\nto UICC. Resection of primary tumor (malignant melanoma) on the left\nupper back (02/2018)\n\n01/20 Microsurgical resection right frontal tumor\n\n02/20 Excision of empyema\n\n02-03/20: Radiation therapy\n\n05/02/20: Start of immunotherapy with Nivolumab\n\n05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\nImaging 01/02/2021: PET/CT: Cervical lymph node metastasis;\n\ncMRI: no evidence of metastases. Contrast-enhancing meninges.\n\n**Virology: **\n\nUpon Admission: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load\nof 7,000 Geq/mL and a Ct value of 32.\n\nAt Discharge: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load of\n2,350 Geq/mL and a Ct value of 32.\n\n**Microbiology: **\n\nMRSA Screening Upon Admission: Nasal Swab: Normal flora detected; MRSA\nnot present. Throat Swab: Normal flora detected; MRSA not present.\n\nProcedures:\n\n\\- Presentation to neurology for CSF puncture (e.g., exclude\nmeningeosis)\n\n\\- Panel sequencing complement\n\n\\- Surgery/therapy: Neck dissection followed by adjuvant therapy with\npembrolizumab.\n\nClinical examination:\n\nExamination findings: Patient in normal general and nutritional\ncondition, consciousness unremarkable. Cranial mobility free, ocular\nmobility normal. Pupils are isocor, pupillary reflex prompt to\naccommodation and light. Regular, normocardial heart rate on admission.\nNo typical heart murmurs. Abdomen: abdominal wall soft, liver and spleen\nnot enlarged, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged in the axillary or inguinal region palpable.\n\nPET-CT from 01/02/2021:\n\nIntense metabolically active lymph node metastases, otherwise no\nevidence of vital tumor tissue in the study area.\n\n**PET CT report from 01/02/2021: **\n\nProcedure: PET/CT with 246 MBq (F-18)-fluorodeoxyglucose and a 60-minute\nuptake period.\n\nFindings: CT Findings: Neck: Right Level II: Three lymph nodes, largest\nmeasuring 2.1 x 1.8 cm with central necrosis. Right Level III: Two lymph\nnodes, largest measuring 1.5 x 1.2 cm. Left Level II: One lymph node\nmeasuring 1.3 x 1.1 cm. Left Level IV: Two lymph nodes, largest\nmeasuring 1.7 x 1.4 cm. Retropharyngeal space: One lymph node measuring\n1.0 x 0.9 cm.\n\nPET Findings: Neck: Right Level II: Increased FDG uptake with SUVmax of\n7.8, consistent with metastatic disease. Right Level III: Increased FDG\nuptake with SUVmax of 6.5. Left Level II: Increased FDG uptake with\nSUVmax of 6.0. Left Level IV: Increased FDG uptake with SUVmax of 7.2.\nRetropharyngeal space: Increased FDG uptake with SUVmax of 6.1.\nImpression: Cervical Lymph Nodes: Multiple pathologically enlarged\ncervical lymph nodes in bilateral level II, right level III, left level\nIV, and retropharyngeal space with increased FDG uptake, highly\nsuggestive of metastatic involvement from the known primary melanoma.\n\n**Surgery report 01/05/2021: **\n\nThe surgery commenced with a collaborative discussion with the\nanesthesia team and a standard team time-out was executed. The patient\nwas properly positioned, and the surgical site was aseptically draped.\nThe facial neuromonitoring system was set up and verified. Local\nanesthesia was then administered at the site of the skin incision, which\nwas located near the previous scar. This incision followed the anterior\nborder of the sternocleidomastoid muscle in a curved pattern. Upon\nincising the subcutaneous tissue, the external jugular vein became\nvisible and was selectively ligated. The encountered tissue appeared\nnotably fibrotic and scarred. A skin incision extended from the mastoid\nregion down nearly to the clavicle. The platysma muscle was subsequently\ncut. Due to the presence of a lymph node mass, the auricularis magnus\nnerve had to be severed. The sternocleidomastoid muscle and the\nposterior belly of the digastric muscle were then exposed. Multiple\ndarkened lymph node metastases were identified, both beneath the skin\nand within the sternocleidomastoid muscle. In subsequent steps, efforts\nwere made to distinguish the internal jugular vein from the surrounding\nscarred tissue. A lymph node mass, which exhibited characteristics\nhighly suggestive of metastasis (given its darkened color), was removed.\nThe accessory nerve was identified and preserved. Further dissection was\ndone posteriorly to the sternocleidomastoid muscle, in the direction of\nlevel V. An expansive mass of lymph nodes was excised in this region.\nThe trapezoid branch of the accessory nerve was visualized, and its\nfunction was monitored and preserved with the aid of neuromonitoring.\nThe removed lymph node mass, some excised tissue, and portions of the\nsternocleidomastoid muscle with embedded lymph nodes were sent for\nhistological analysis. During the procedure, care was taken to avoid\ndamaging major neck vessels and nerves. Concluding the procedure, 8 and\n10 French Redon drains were placed, the wound was closed in layers, and\nthen covered with a spray-on bandage, steristrips, and a pressure\ndressing. The surgical site appeared bloodless at the conclusion of the\nsurgery.\n\n**Macroscopy:**\n\n**Macroscopic Description:**\n\nDimensions: 6.8 x 0.7 x 0.4 cm spindle-shaped, non-oriented skin and\nsubcutaneous tissue resection. Central area shows an irritation-free,\nfine scar measuring up to 6.3 x 4.8 cm. The cut surface appears\nconsistently off-white.\n\nInk markings: soft tissue margin of specimen = green. A: central\nlamellae B: spindle tips perpendicular\n\nAnterior Margin of Upper Third of Sternocleidomastoid Muscle:\nDimensions: Four combined tissue samples totaling 4.7 x 3.8 x 1.1 cm.\n\nAppearance: Tan, fibrous soft tissues with multiple uniformly dark\nnodules on the cut surface, each measuring up to 1.1 cm.\n\nA, B: one nodule each halved C, D: other nodular sections E: remaining\ntan fibrous sections Anterior Margin of Lower Third of\nSternocleidomastoid Muscle: Largest measurement: 3.4 cm.\n\nAppearance: Grayish-brown with some fibrous regions and homogeneously\ndark-brown nodes up to 1.5 cm in size on the cut surface. A, B: one node\neach halved C: other nodes D: brown-fibrous sections Region V Occipital:\nLargest measurement: Two samples, each up to 3.8 cm.\n\nAppearance: Mixture of grayish-tan and light brown fibrous soft tissue\nwith nodes up to 2.2 cm, uniformly dark brown.\n\nA, B: one node halved C, D: another node halved each Processing: 16\nparaffin blocks, HE stained.\n\nMicroscopic Description: Dermis and subcutaneous resection shows\nscarring with fibrosis. Epidermis is regular, without any atypical\ncells. No evidence of melanoma or carcinoma. 2./3.\n\nMultiple nodular tumor clusters present in the soft tissue and skeletal\nmuscles, lacking lymph node structure. Tumor cells are polygonal, with\nsome spindle-shaped cells having moderately large, irregular nuclei and\nnoticeable nucleoli. Cytoplasm appears slightly granular with a light\nbrownish pigment.\n\nSeven lymph nodes (measuring up to 3.6 cm) indicate metastasis from the\npreviously mentioned tumor, with extracapsular spread. Four other lymph\nnodes are free from the tumor.\n\n**Critical Findings:** Multiple nodular soft tissue metastases, with the\nlargest measuring 1.3 cm, indicative of melanoma present in both soft\ntissue and muscle. Resection margins are mostly free of tumor, with the\nclosest approach being less than 0.15 cm (points 2 and 3). Seven lymph\nnodes (up to 3.6 cm in size) show metastasis from the melanoma, with\nextracapsular spread. Four lymph nodes are tumor-free (7 out of 11\nnodes, ECE positive) (point 4). Dermis and subcutaneous excision shows\nscarring fibrosis (point 1).\n\nFor the optimal management of Mrs. Done, close monitoring and a\nmultidisciplinary approach will be essential. Thank you for your\ncontinued collaboration in ensuring the best care for our mutual\npatient.\n\n**Lab values upon discharge: **\n\n **Parameter** **Result** **Reference Range** **Interpretation**\n -------------------------------- -------------- ---------------------------------------- ---------------------\n **Complete Blood Count (CBC)** \n Hemoglobin (Hb) 12.4 g/dL 12.0 - 16.0 g/dL Within normal range\n White Blood Cell (WBC) 9.2 x10\\^9/L 4.0 - 10.0 x10\\^9/L Within normal range\n Platelets 250 x10\\^9/L 150 - 400 x10\\^9/L Within normal range\n **Liver Function Tests (LFT)** \n AST 28 U/L 10 - 35 U/L Within normal range\n ALT 32 U/L 10 - 40 U/L Within normal range\n Total Bilirubin 0.8 mg/dL 0.2 - 1.2 mg/dL Within normal range\n **Kidney Function Test** \n Serum Creatinine 0.9 mg/dL 0.5 - 1.2 mg/dL Within normal range\n Blood Urea Nitrogen (BUN) 15 mg/dL 7 - 20 mg/dL Within normal range\n **Electrolytes** \n Sodium 138 mEq/L 135 - 145 mEq/L Within normal range\n Potassium 4.2 mEq/L 3.5 - 5.0 mEq/L Within normal range\n Chloride 101 mEq/L 95 - 105 mEq/L Within normal range\n **Thyroid Function Tests** \n TSH 3.1 mU/L 0.5 - 5.0 mU/L Within normal range\n Free T4 1.4 ng/dL 0.9 - 2.4 ng/dL Within normal range\n **Lipid Profile** \n Total Cholesterol 190 mg/dL \\< 200 mg/dL Desirable\n LDL Cholesterol 100 mg/dL \\< 100 mg/dL Optimal\n HDL Cholesterol 55 mg/dL \\> 40 mg/dL (Men), \\> 50 mg/dL (Women) Normal\n Triglycerides 110 mg/dL \\< 150 mg/dL Normal\n\n**Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ---------------- ------------ ----------- -----------------------------\n Pembrolizumab 200mg IV Every 3 weeks\n Nivolumab 60mg IV As per oncologist\\'s advice\n Ipilimumab 200mg IV As per oncologist\\'s advice\n Paracetamol 500mg Oral Every 4-6 hours as needed\n Omeprazole 20mg Oral Once daily\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/14/2022 to\n03/01/2022.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done showed multiple metastases in her CT examination. On physical\nexamination, Mrs. Done appears well-nourished and in no acute distress.\nHer vital signs are stable. Cardiovascular examination reveals regular\nheart sounds with no murmurs. Respiratory examination shows clear breath\nsounds bilaterally. Abdominal examination reveals no palpable masses or\norganomegaly. Neurological examination is within normal limits.\n\n**Radiology/Nuclear Medicine**\n\n**CT thorax/abdomen/pelvis + Contrast from 02/10/2022**\n\n**Technique:** Multi-phase, multi-slice computed tomography of the\nthorax, abdomen, and pelvis was performed following the intravenous\nadministration of contrast material. Coronal and sagittal\nreconstructions were obtained.\n\n**Thorax:** In the thoracic region, the lungs are notable for multiple\nnodular opacities across both lung fields, consistent with metastatic\ndeposits. The most sizable lesion is seen in the right upper lobe,\napproximately 1.5 cm in diameter. No associated cavitation or pleural\neffusion is detected. A concerning 2 cm mass abutting the lateral wall\nof the left ventricle is noted, raising the suspicion for cardiac\nmetastasis. The mediastinum also exhibits lymphadenopathy with a\ndominant node in the prevascular space, measuring 2.2 cm. Further, there\nare lytic lesions involving the sternum and right 4th rib, consistent\nwith osseous metastatic disease.\n\n**Abdomen/pelvis**: Liver shows multiple hypodense lesions throughout\nboth lobes, indicative of metastatic spread. The dominant lesion in the\nright lobe measures 3 cm. The kidneys, however, are unremarkable without\ndiscernible metastatic deposits. Retroperitoneal lymphadenopathy is also\npresent, highlighted by a node anterior to the aorta of 1.8 cm. In\naddition, there is a 2.5 cm mass identified within the left psoas\nmuscle, consistent with muscular metastasis. Both the left acetabulum\nand the right iliac wing manifest with lytic lesions, suggestive of\nmetastatic involvement. There is also enlargement of the bilateral\ninternal iliac lymph nodes, with the left side\\'s node measuring up to\n1.6 cm. Bladder, prostate, and rectum with no discernible pathology.\n\n**Impression**: Multiple pulmonary nodules consistent with pulmonary\nmetastases. Cardiac lesion suggestive of metastatic involvement.\nEvidence of skeletal metastases in the thorax and pelvis. Hepatic and\nmuscular metastases, indicative of disseminated disease. Lymphadenopathy\nin the mediastinal, retroperitoneal, and pelvic regions.\n\n**PET-CT scan from 02/11/2022**\n\n**Clinical Indication:** Follow-up evaluation of a known case of\nMetastatic Melanoma, Stage IV, M1c with notable findings from a CT scan\ndated 12/01/2014.\n\n**Technique:** Whole-body PET-CT scan was conducted after intravenous\nadministration of 18F-FDG. The patient fasted for 6 hours prior to the\nscan, and blood glucose levels were confirmed to be within the\nacceptable range. Both CT and PET images were acquired, and images were\nco-registered for optimal evaluation. Standard uptake values (SUVs) were\ncalculated for areas of interest.\n\n**Findings: **\n\n**Thorax:** Both lungs depict several hypermetabolic foci, corroborating\nthe CT findings of multiple nodules. The largest lesion in the right\nupper lobe demonstrates an SUVmax of 8.2, indicative of active metabolic\ndisease. The cardiac mass adjacent to the left ventricle, measuring\napproximately 2 cm, also reveals increased 18F-FDG uptake with an SUVmax\nof 9.5, strengthening the suspicion of cardiac metastasis. Enlarged\nmediastinal lymph nodes, particularly the node in the prevascular space,\nshows marked hypermetabolism with an SUVmax of 7.4. Notably, the lytic\nskeletal lesions identified on the CT in the sternum and right 4th rib\nalso display increased metabolic activity, consistent with metastatic\nbone disease.\n\n**Abdomen/Pelvis:** Hepatic lesions are congruent with the findings of\nthe preceding CT, showing heightened metabolic activity. The most\nprominent lesion in the right lobe exhibits an SUVmax of 8.8.\nRetroperitoneal lymph nodes are metabolically active, with the anterior\naortic node demonstrating an SUVmax of 6.9. The 2.5 cm left psoas muscle\nmass also reveals increased uptake with an SUVmax of 7.3, suggesting\nactive muscular metastasis. In the pelvic region, the lytic lesions\nidentified in the left acetabulum and right iliac wing on the CT confirm\ntheir malignant nature with notable metabolic activity. Bilateral\ninternal iliac lymph nodes show hypermetabolism with the left node\\'s\nSUVmax reaching 7.1. Other pelvic organs, including the bladder,\nprostate, and rectum, did not show any significant 18F-FDG uptake, in\nline with the unremarkable CT findings.\n\n**Impression:** The PET-CT findings are consistent with active\nmetastatic disease. There is evidence of hypermetabolic pulmonary\nnodules, a likely cardiac metastasis, hepatic and muscular metastases,\nand metabolically active skeletal lesions in both the thorax and pelvis.\nAdditionally, there is hypermetabolism in the lymph nodes across\nmultiple regions. These findings align closely with the previously\ndiagnosed metastatic melanoma, Stage IV, M1c**. **\n\n**Discussion**\n\nMrs. Done has been diagnosed with recurrent metastatic melanoma with\nlymph node involvement. This poses significant implications for her\nprognosis, emphasizing the need for urgent and comprehensive\nintervention.\n\nHer molecular profile has revealed the presence of the BRAF V600E\nmutation.\n\nOur recommended therapeutic combination includes Vemurafenib and\nCobimetinib, both of which are aimed at disrupting the aberrant BRAF-MEK\nsignaling cascade. Complementing this, we suggest the administration of\nPembrolizumab.\n\nMrs. Done is scheduled for six cycles of this treatment regimen. We will\nmonitor her laboratory parameters, such as blood counts, electrolytes,\nand hepatic and renal profiles, bi-weekly. It is imperative to note that\nany fevers surpassing 38.3°C warrant immediate medical attention.\n\nComprehensive patient education module has been designed to enable Mrs.\nDone to identify and manage any potential side effects efficiently.\n\nWe will ensure rigorous monitoring of her blood pressure and lipid\nmetrics, with the possibility of introducing alternative medications if\nclinical scenarios demand.\n\nWe deeply value your collaboration in Mrs. Done\\'s healthcare journey.\nOur team remains at your disposal for any queries or clarifications.\n\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report to you about Mrs. Linda Mayer, born on 01/12/1948, who\npresented to our outpatient clinic on 07/13/19.\n\n**Diagnoses:**\n\n- BIRADS IV, recommended biopsy during breast diagnostics.\n\n- Left breast carcinoma: iT1b; iN0; MX; ER: 12/12; PR: 2/12; Her-2:\n neg; Ki67: 15%.\n\n**Other Diagnoses: **\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Pemphigus vulgaris under azathioprine therapy\n\n- Osteoporosis\n\n- Obesity with a BMI of 35\n\n- Undergoing immunosuppressive therapy with prednisolone\n\n**Family History:**\n\n- Sister deceased at age 39 from breast cancer.\n\n- Mother and grandmother (maternal and paternal) were diagnosed with\n breast cancer.\n\n**Medical History:** The CT thorax report indicates the presence of\ninflammatory foci, warranting further follow-up. The relevant data was\ndocumented and presented during the tumor conference. Subsequently, a\ntelephone conversation was conducted with the patient to discuss the\nnext steps.\n\n**Tumor board decision from 07/13/2019:**\n\n**Imaging: **\n\n1) MRI examination detected a unifocal lesion on the left external\n aspect, measuring approximately 2.4 cm in size.\n\n2) CT scan (thorax/abdomen 07/12/2019) revealed a previously known\n liver lesion, likely a hemangioma. No evidence of metastases was\n identified. Nonspecific, small foci were observed in the lungs,\n likely indicative of post-inflammatory changes.\n\n**Recommendations:**\n\n1. If no metastasis (M0): Fast-track BRCA testing is recommended.\n\n2. If BRCA testing returns negative: Proceed with a selective excision\n of the left breast after ultrasound-guided fine needle marking and\n sentinel lymph node biopsy on the left side. Additionally, perform\n Endopredict analysis on the surgical specimen.\n\n**Current Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ------------------------------- ------------ ----------- ---------------\n Aspirin 100mg Oral 1-0-0\n Simvastatin (Zocor) 40mg Oral 0-1-0\n Haloperidol (Haldol) 100mg Oral ½-0-½\n Zopiclone (Imovane) 7.5mg Oral 0-0-1\n Trazodone (Desyrel) 100mg Oral 0-0-½-\n Calcium Supplement (Caltrate) 500mg Oral 1-0-1\n Nystatin (Bio-Statin) As advised Oral 1-1-1-1\n Pantoprazole (Protonix) 40mg Oral 1-0-0\n Prednisolone (Prelone) 40mg Oral As advised\n Tramadol/Naloxone (Ultram) 50/4mg Oral 1-0-1\n Acyclovir (Zovirax) 800mg Oral 1-1-1\n\n**Mammography and Tomosynthesis from 07/8/2019:**\n\n[Findings]{.underline}**: **During the inspection and palpation, no\nsignificant findings were noted on either side. Some areas with higher\nmammographic density were observed, which slightly limited the\nassessment. However, during the initial examination, a small\narchitectural irregularity was identified on the outer left side. This\nirregularity appeared as a small, roundish compression measuring\napproximately 6mm and was visible only in the medio-lateral oblique\nimage, with a nipple distance of 8cm. Apart from this discovery, there\nwere no other suspicious focal findings on either side. No clustered or\nirregular microcalcifications were detected. Additionally, a long-term,\nunchanged observation noted some asymmetry with denser breast tissue\npresent on both sides, particularly on the outer aspects. Sonographic\nevaluation posed challenges due to the mixed echogenic glandular tissue.\nAs a possible corresponding feature to the questionable architectural\nirregularity on the outer left side, a blurred, echo-poor area with a\nvertical alignment measuring about 7x5mm was identified. Importantly, no\nother suspicious focal findings were observed, and there was no evidence\nof enlarged lymph nodes in the axilla on both sides.\n\n[Assessment]{.underline}**:** The observed finding on the left side\npresents an uncertain nature, categorized as BIRADS IVb. In contrast,\nthe finding on the right side appears benign, categorized as BIRADS II.\nTo gain a more conclusive understanding of the left-sided finding, we\nrecommend a histological assessment through a sonographically guided\nhigh-speed punch biopsy. An appointment has been scheduled with the\npatient to proceed with this biopsy and obtain a definitive\ndiagnosis.Formularbeginn\n\nFormularende**Current Recommendations:**\\\nA fast-track decision will be made regarding tumor genetics, and the\npatient will be notified of the appointment via telephone. The patient\nshould bring the pathology blocks from Fairview Clinic on the day of\nblood collection for genetic testing, along with a referral for an\nEndopredict test. A multidisciplinary team meeting will be convened\nafter the Endopredict test and genetic testing results are available. If\nthere is persistence or worsening of symptoms, we strongly advise the\npatient to seek immediate re-evaluation. Additionally, outside of\nregular office hours, the patient can seek assistance at the emergency\ncare unit in case of emergency.\n\n**MRI from 07/11/2019:**\n\n[Technique:]{.underline} Breast MRI (3T scanner) with dedicated mammary\nsurface coil: \n\n[Findings:]{.underline} The overall contrast enhancement was observed\nbilaterally to evaluate the Grade II findings. There was low to moderate\nsmall-spotted contrast enhancement with slightly limited assessability.\nThe contrast dynamics revealed a patchy, confluent, blurred, and\nelongated contrast enhancement, corresponding to the primary lesion,\nwhich measured approximately 2.4 cm on the lower left exterior. Single\nspicules were noted, and the lesion appeared hypointense in T1w imaging.\nNo suspicious focal findings with contrast enhancement were detected on\nthe right side. Small axillary lymph nodes were observed on the left\nside, but they did not appear suspicious based on MR morphology.\nAdditionally, there were no suspicious lymph nodes on the right side.\n\n[Assessment:]{.underline} An unifocal primary lesion measuring\napproximately 2.4 cm in diameter was identified on the lower left\nexterior. It exhibited patchy confluent enhancement and architectural\ndisturbance, with single spicules. No evidence of suspicious lymph nodes\nwas found. The left side is categorized as BIRADS 6, indicating a high\nsuspicion of malignancy, while the right side is categorized as BIRADS\n2, indicating a benign finding.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide you with an update on the medical condition of\nMrs. Linda Mayer, born on 01/12/1948, who attended our outpatient clinic\non 08/02/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast (17mm)\n\n- Histological grade G3, estrogen receptor (ER) and progesterone\n receptor (PR) negative.\n\n- Postmenopausal for the past eight years.\n\n- Previous surgical history includes an appendectomy.\n\n- Allergies: Hay fever\n\n \n\n**Current Presentation**: The patient sought consultation following a\nconfirmed diagnosis of DCIS (Ductal Carcinoma In Situ) in the right\nbreast, which was determined through a vacuum-assisted biopsy.\n\n**Physical Examination**: Upon physical examination, there is evidence\nof a post-intervention hematoma located in the upper right quadrant of\nthe right breast. However, the clip from the biopsy is not clearly\nvisible. A sonographic examination of the right axilla reveals no\nabnormalities.\n\n**Current Recommendations:**\n\n- Imaging studies have been conducted.\n\n- A case presentation is scheduled for our mammary conference\n tomorrow.\n\n- Subsequently, planning for surgery will commence, including the\n evaluation of sentinel lymph nodes following a right mastectomy and\n axillary lymph node dissection.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient care at our facility on 08/29/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast, measuring 17mm in size, classified as Grade 3, and\n testing negative for estrogen receptors (ER) and progesterone\n receptors (PR).\n\n- Mrs. Mayer has been postmenopausal for eight years.\n\n- Notable allergy: Hay fever\n\n**Tumor Board Decision:** Mammography imaging revealed a clip associated\nwith a focal finding in the right breast adjacent to calcifications.\n\n[Recommendation]{.underline}: Proceed with sentinel lymph node\nevaluation after right mastectomy, including clip localization on the\nright side.\n\n**Current Presentation**: During the patient\\'s recent outpatient visit,\nan extensive pre-operative consultation was conducted. This discussion\ncovered the indications for the surgery, details of the surgical\nprocess, potential alternative options, as well as general and specific\nrisks associated with the procedure. These risks included the\npossibility of an aesthetically suboptimal outcome and the chance of\nencountering an R1 situation. The patient did not have any further\nquestions and provided written consent for the procedure.\n\n**Physical Examination:** Both breasts appear normal upon inspection and\npalpation. The right axilla shows no abnormalities.\n\n**Medical History:** Mrs. Linda Mayer presented to our clinic with a\nvacuum biopsy-confirmed DCIS of the right breast for therapeutic\nintervention. The decision for surgery was reached following a\ncomprehensive review by our interdisciplinary breast board. After an\nextensive discussion of the procedure\\'s scope, associated risks, and\nalternative options, the patient provided informed consent for the\nproposed surgery.\n\n**Preoperative Procedure:** Sonographic and mammographic fine needle\nmarking of the remaining findings and the clip in the right breast.\n\n**Surgical Report:** Team time-out conducted with colleagues of\nanesthesia. Patient positioned in the supine position. Surgical site\ndisinfection and sterile draping. Marking of the incision site.\n\nA semicircular incision was made laterally on the right breast.\nVisualization and dissection along the marking wire towards the marked\nfinding. Excision of the marked findings, with a safety margin of\napproximately 1-2 cm. The excised specimen measured approximately 4 x 5\nx 3 cm. Markings using standard protocol (green thread cranially, blue\nthread ventrally). The excised specimen was sent for preparation\nradiography. Hemostasis was meticulously ensured. Insertion of a 10Ch\nBlake drain into the segmental cavity, followed by suturing.\nVerification of a blood-dry wound cavity. Preparation radiography\nincluded the marked area and the marking wires. The excised material was\ntransferred to our pathology colleagues for histological examination.\nSubdermal and intracutaneous sutures with Monocryl 3/0 in a continuous\nmanner. Application of Steristrips and dressing. Instruments, swabs, and\ncloths were accounted for per the nurse\\'s checklist. The patient was\ncorrectly positioned throughout the operation. The anesthesiologic\ncourse was without significant problems. A thorax compression bandage\nwas applied in the operating room as a preventive measure against\nbleeding.\n\n**Postoperative Procedure:** Pain management, thrombosis prophylaxis,\napplication of a pressure dressing, drainage under suction.\n\n**Examinations:** **Digital Mammography performed on 08/29/2019**\n\n[Clinical indication]{.underline}: DCIS right\n\n[Question]{.underline}: Please send specimen + Mx-FNM\n\n**Findings**: Sonographically guided wire marking of the maximum\nmicrocalcification group measuring about 12 mm. Local hematoma cavity\nand inset clip marking directly cranial to the finding. Stitch direction\nfrom lateral to medial. The wire is positioned with the tip caudal to\nthe clip in close proximity to the microcalcification. Additional\nmarking of the focal localization on the skin. Documentation of the wire\ncourse in two planes.\n\n- Telephone discussion of findings with the surgeon.\n\n- Preparation radiography and preparation sonography are recommended.\n\n- Marking wire and suspicious focal findings centrally included in the\n preparation.\n\n- Intraoperative report of findings has been conveyed to the surgeon.\n\n**Current Recommendations:**\n\n- Scheduled for inpatient admission on ward 22 tomorrow.\n\n- Right breast mastectomy with sentinel lymph node evaluation.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to update you on the clinical course of Mrs. Linda Mayer,\nborn on 01/12/1948, who was under our inpatient care from 08/30/2019 to\n09/12/2019.\n\n**Diagnosis:** Vacuum-assisted biopsy confirmed Ductal Carcinoma In Situ\n(DCIS) in the right breast, measuring 17mm, Grade 3, ER/PR negative.\n\n**Tumor Board Decision (07/13/2019):**\n\n[Imaging:]{.underline} Clip identified in focal lesion in the right\nbreast, adjacent to calcifications.\n\n[Recommendation]{.underline}**:** Spin Echo following fine-needle\nlocalization with mammography-guided control of the clip in the right\nbreast.\n\n[Subsequent Recommendation (08/27/2019):]{.underline} Radiation therapy\nto the right breast. Regular follow-up is advised.\n\n**Medical History:** Ms. Linda Mayer presented to our facility on\n08/30/2019 for the aforementioned surgical procedure. After a\ncomprehensive discussion regarding the surgical plan, potential risks,\nand possible complications, the patient consented to proceed. The\nsurgery was executed without complications on 09/01/2019. The\npostoperative course was unremarkable, allowing for Ms. Mayer\\'s\ndischarge on 09/12/2019 in stable condition and with no signs of wound\nirritation.\n\n**Histopathological Findings (09/01/2019):**\n\nThe resected segment from the right breast showed a maximum necrotic\nzone of 1.6 cm with foreign body reaction, chronic resorptive\ninflammation, fibrosis, and residual hemorrhage. These findings\nprimarily correspond to the pre-biopsy site. Surrounding this were areas\nof DCIS with solid and cribriform growth patterns and comedonecrosis,\nWHO Grade 3, Nuclear Grade 3, with a reconstructed extent of 3.5 cm.\nResection margins were as follows: ventral 0.15 cm, caudal 0.2 cm,\ndorsal 0.4 cm, with remaining margins exceeding 0.5 cm. TNM\nClassification (8th Edition, 2017): pTis (DCIS), R0, G3. Additional\nimmunohistochemical studies are underway to determine hormone receptor\nstatus; a supplementary report will follow.\n\n**Postoperative Plan:**\n\nThe patient was educated on standard postoperative care and the\nimportance of immediate re-evaluation for any persistent or worsening\nsymptoms. Radiation therapy to the right breast is planned, along with\nregular follow-up appointments.\n\nShould you have any questions or require further clarification, we are\nreadily available. For urgent concerns outside of regular office hours,\nemergency care is available at the Emergency Department.\n\n**Internal Histopathological Findings Report**\n\n**Clinical Data:** DCIS in the right breast (17 mm), Grade 3, ER/PR\nnegative.\n\n**Macroscopic Examination:**\n\nThe resected mammary segment from the right breast, marked with dual\nthreads and containing a fine-needle marker inserted ventro-laterally,\nmeasures 4.5 x 5.5 x 3 cm (HxWxD) and weighs 35 grams. The specimen was\nsectioned from medial to lateral into 14 lamellae. The cut surface\npredominantly shows yellowish, lobulated mammary parenchyma with sparse\nstriated whitish glandular components. A DCIS-suspected area, up to 2.1\ncm in size, is evident caudally and centro-ventrally (from lamellae\n4-10), displaying both reddish-hemorrhagic and whitish-nodular\nindurations. Minimal distances from the suspicious area to the resection\nmargins are as follows: cranial 2 cm, caudal 0.2 cm, dorsal 0.2 cm,\nventral 0.1 cm, medial 1.6 cm, lateral 2.5 cm. The suspect area was\ncompletely embedded. Ink markings: green/cranial, yellow/caudal,\nblue/ventral, black/dorsal.\n\n**Microscopic Examination:**\n\nHistological sections of the mammary parenchyma reveal fibro-lipomatous\nstroma and glandular lobules with a two-layered epithelial lining. In\nlamellae 3-6 and 11, solid and cribriform epithelial proliferations are\nevident. Cells are cuboidal with variably enlarged, predominantly\nmoderately pleomorphic, round to oval nuclei. Comedo-like necroses are\noccasionally observed in secondary lumina. Microscopic distances to the\ndeposition margins are consistent with the macroscopic findings. The\nsurrounding stroma in lamellae 6-9 shows extensive geographic adipose\ntissue necrosis, multinucleated foreign body-type giant cells, foamy\ncell macrophages, collagen fiber proliferation, and fresh hemorrhages.\n\n**Supplemental Immunohistochemical Findings\n(09/04/2019):** **Microscopy:** In the meantime, the material was\nfurther processed as announced.\n\nHere, the previously described intraductal epithelial growths, each with\nnegative staining reaction for the estrogen and progesterone receptor\n(with regular external and internal control reaction).\n\n \n\n**Critical Findings:**\n\nResected mammary segment with paracentral, max. 1.6 cm necrotic zone\nwith foreign body reaction, chronic resorptive. Chronic resorptive\ninflammation, fibrosis, and hemorrhage remnants (primarily corresponding\nto the pre-biopsy site), and surrounding portions of ductal carcinoma in\nsitu. Ductal carcinoma in situ, solid and rib-shaped growth type with\ncomedonecrosis, WHO grade 3, nuclear grade 3. The resection was locally\ncomplete with the following Safety margins: ventral 0.15 cm, caudal 0.2\ncm, dorsal 0.4 cm, and the remaining sedimentation margins more than 0.5\ncm.\n\nTNM classification (8th edition 2017): pTis (DCIS), R0, G3.\n\n[Hormone receptor status:]{.underline}\n\n- Estrogen receptor: negative (0%).\n\n- Progesterone receptor: negative (0%).\n\n \n\n \n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient treatment on 27/09/2019.\n\n**Diagnoses**: Left breast carcinoma; iT1c; iN0; MX; ER:12/12; PR:2/12;\nHer-2: neg; Ki67:15%, BRCA 2 mutation.\n\n**Other Diagnoses**:\n\n- Hailey-Hailey disease - currently regressing under prednisolone.\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 due to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage (Abrasio) in 2004\n\n- Hysterectomy in 2005\n\n**Allergies**: Hay fever\n\n**Imaging**:\n\n- CT revealed a cystic lesion in the liver, not suspicious for\n metastasis. Granulomatous, post-inflammatory changes in the lung.\n\n- An MRI of the left breast showed a unifocal lesion on the outer left\n side with a 2.4 cm extension.\n\n**Histology: **Gene score of 6.5, indicating a high-risk profile (pT2 or\npN1) if BRCA negative.\n\n**Recommendation**: If BRCA negative, SE left mamma after ultrasound-FNM\nwith correlation in Mx and SLNB on the left.\n\n**Current Presentation**: Mrs. Linda Mayer presented for pre-operative\nevaluation for left mastectomy. BRCA testing confirmed a BRCA2 mutation,\nwarranting bilateral subcutaneous mastectomy and SLNB on the left.\nReconstruction with implants and mesh is planned, along with a breast\nlift as requested by the patient.\n\n**Macroscopy:**\n\n**Left Subcutaneous Mastectomy (Blue/Ventral, Green/Cranial):**\n\n- Specimen Size: 17 x 15 x 6 cm (Height x Width x Depth), Weight: 410\n g\n\n- Description: Dual filament-labeled subcutaneous mastectomy specimen\n\n- Specimen Workup: 27 lamellae from lateral to medial\n\n- Tumor-Suspect Area (Lamellae 17-21): Max. 1.6 cm, white dermal,\n partly blurred\n\n- Margins from Tumor Area: Ventral 0.1 cm, Caudal 1 cm, Dorsal 1.2 cm,\n Cranial \\> 5 cm, Lateral \\> 5 cm, Medial \\> 2 cm\n\n- Remaining Mammary Parenchyma: Predominantly yellowish lipomatous\n with focal nodular appearance\n\n- Ink Markings: Cranial/Green, Caudal/Yellow, Ventral/Blue,\n Dorsal/Black\n\n - A: Lamella 17 - Covers dorsal and caudal\n\n - B: Lamella 18 - Covers ventral\n\n - C: Lamella 19 - Covers ventral\n\n - D: Blade 21 - Covers ventral\n\n - E: Lamella 20 - Reference cranial\n\n - F: Lamella 16 - Immediately laterally following mammary\n parenchyma\n\n - G: Blade 22 - Reference immediately medial following mammary\n tissue\n\n - H: Lamella 12 - Central section\n\n - I: Lamella 8 - Documented section top/outside\n\n - J: Lamella 3 - Vestigial section below/outside\n\n - K: Lamella 21 - White-nodular imposing area\n\n - L: Lamella 8 - Further section below/outside with nodular area\n\n - M: Lateral border lamella perpendicularly\n\n - N: Medial border lamella perpendicular (Exemplary)\n\n**Second Sentinel Lymph Node on the Left:**\n\n- Specimen: Maximum of 6 cm of fat tissue resectate with 1 to 2 cm of\n lymph nodes and smaller nodular indurations.\n\n- A, B: One lymph node each divided\n\n- C: Further nodular indurations\n\n**Palpable Lymph Nodes Level I:**\n\n- Specimen: One max. 4.5 cm large fat resectate with nodular\n indurations up to 1.5 cm in size\n\n- A: One nodular induration divided\n\n- B: Further nodular indurated portions\n\n**Right Subcutaneous Mastectomy:**\n\n- Specimen: Double thread-labeled 450 g subcutaneous mastectomy\n specimen\n\n- Assumed Suture Markings: Blue (Ventral) and Green (Cranial)\n\n- Dorsal Fascia Intact\n\n- [Specimen Preparation:]{.underline} 16 lamellae from medial to\n lateral\n\n- Predominantly yellowish lobulated with streaky, beige, impinging\n strands of tissue\n\n- Isolated hemorrhages in the parenchyma\n\n- Ink Markings: Green = Cranial, Yellow = Caudal, Blue = Ventral,\n Black = Dorsal\n\n<!-- -->\n\n- A: Medial border lamella perpendicular (Exemplary)\n\n- B: Lamella 5 with reference ventrally (below inside)\n\n- C: Lamella 8 with reference ventrally (below inside)\n\n- D: Lamella 6 with ventral and dorsal reference (upper inside)\n\n- E: Blade 8 with ventral and dorsal cover (top inside)\n\n- F: Blade 11 with cover dorsal and caudal (bottom outside)\n\n- G: Blade 13 with dorsal cover (bottom outside)\n\n- H: Blade 10 with ventral and dorsal cover (top outside)\n\n- I: Lamella 14 with reference cranial and dorsal and bleeding in\n (upper outer)\n\n- J: Lateral border lamella perpendicular (Exemplary)\n\n**Microscopy:**\n\n1\\) In the tumor-suspicious area, a blurred large fibrosis zone with\nstar-shaped extensions is visible. Intercalated are single-cell and\nstranded epithelial cells with a high nuclear-cytoplasmic ratio. The\nnuclei are monomorphic with finely dispersed chromatin, at most, very\nisolated mitoses. Adjacent distended glandular ducts with a discohesive\ncell proliferate with the same cytomorphology. Sporadically, preexistent\nglandular ducts are sheared disc-like by the infiltrative tumor cells.\nSamples from the nodular area of lamella 21 show areas of cell-poor\nhyaline sclerosis with partly ectatically dilated glandular ducts.\n\n2\\) Second lymph node with partial infiltrates of the neoplasia described\nabove. The cells here are relatively densely packed. Somewhat increased\nmitoses. In the lymph nodes, iron deposition is also in the sinus\nhistiocytes.\n\n3\\) Lymph nodes with partly sparse iron deposition. No epithelial foreign\ninfiltrates.\n\n4\\) Regular mammary gland parenchyma. No tumor infiltrates. Part of the\nglandular ducts are slightly cystically dilated.\n\n**Preliminary Critical Findings Report: **\n\nLeft breast carcinoma measuring max 1.6 cm diagnosed as moderately\ndifferentiated invasive lobular carcinoma, B.R.E. score 6 (3+2+1, G2).\nPresence of tumor-associated and peritumoral lobular carcinoma in situ.\nResection status indicates locally complete excision of both invasive\nand non-invasive carcinoma; minimal margins as follows: ventral \\<0.1\ncm, caudal 0.2 cm, dorsal 0.8 cm, remaining margins ≥0.5 cm. Nodal\nstatus reveals max 0.25 cm metastasis in 1/5 nodes, 0/2 additional\nnodes, without extracapsular spread. Right mammary gland from\nsubcutaneous mastectomy shows tumor-free parenchyma.\n\n**TNM classification (8th ed. 2017):** pT1c, pTis (LCIS), pN1a, G2, L0,\nV0, Pn0, R0. Investigations to determine tumor biology were initiated.\nAddendum follows.\n\n**Supplementary findings on 10/07/2019**\n\nEditing: immunohistochemistry:** **\n\nEstrogen receptor, Progesterone receptor, Her2neu, MIB-1 (block 1D).\n\n**Critical Findings Report:** Breast carcinoma on the left with a 1.6 cm\ninvasive lobular carcinoma, moderately differentiated, with a B.R.E.\nscore of 6 (3+2+1, G2). Additionally, tumor-associated and peritumoral\nlobular carcinoma in situ are noted. Resection status confirms locally\ncomplete excision of both invasive and non-invasive carcinomas; minimal\nresection margins are ventral \\<0.1 cm, caudal (LCIS) 0.2 cm, dorsal 0.8\ncm, and all other margins ≥0.5 cm. Nodal assessment reveals a single\nmetastasis with a maximum dimension of 0.25 cm among 7 lymph nodes,\nspecifically found in 1/5 nodes, with no additional metastasis in 0/2\nnodes and no extracapsular extension. Contralateral right mammary gland\nfrom subcutaneous mastectomy is tumor-free.\n\nTumor biology of the invasive carcinoma demonstrates strong positive\nestrogen receptor expression in 100% of tumor cells, strong positive\nprogesterone receptor expression in 1% of tumor cells, negative HER2/neu\nstatus (Score 1+), and a Ki67 (MIB-1) proliferation index of 25%.\n\n**TNM classification (8th Edition 2017):** pT1c, pTis (LCIS), pN1a (1/7\nECE-, sn), G2, L0, V0, Pn0, R0.\n\n**Surgery Report (Vac Change + Irrigation)**: Indication for VAC change.\nAfter a detailed explanation of the procedure, its risks, and\nalternatives, the patient agrees to the proposed procedure.\n\nThe course of surgery: Proper positioning in a supine position. Removal\nof the VAC sponge. A foul odor appears from the wound cavity. Careful\ndisinfection of the surgical area. Sterile draping. Detailed inspection\nof the wound conditions. Wound debridement with removal of fibrin\ncoatings and freshening of the wound. Resection of necrotic material in\nplaces with sharp spoon. Followed by extensive Irrigation of the entire\nwound bed and wound edges using 1 l Polyhexanide solution. Renewed VAC\nsponge application according to standard.\n\n**Postoperative procedure**: Pain medication, thrombosis prophylaxis,\ncontinuation of antibiotic therapy. In the case of abundant\nStaphylococcus aureus and isolated Pseudomosas in the smear and still\nclinical suspected infection, extension of antibiotic treatment to\nMeropenem.\n\n**Surgery Report: Implant Placement**\n\n**Type of Surgery:** Implant placement and wound closure.\n\n**Report:** After infection and VAC therapy, clean smears and planning\nof reinsertion. Informed consent. Intraoperative consults: Anesthesia.\n\n**Course of Surgery:** Team time out. Removal VAC sponge. Disinfection\nand covering. Irrigation of the wound cavity with Serasept. Blust\nirrigation. Fixation cranially and laterally with 4 fixation sutures\nwith Vircryl 2-0. Choice of trial implant. Temporary insertion. Control\nin sitting and lying positions. Choice of the implant. Repeated\ndisinfection. Change of gloves. Insertion of the implant into the\npocket. Careful hemostasis. Insertion of a Blake drain into the wound\ncavity. Suturing of the drainage. Subcutaneous sutures with Monocryl\n3-0.\n\n**Type of Surgery:** Prophylactic open Laparoscopy, extensive\nadhesiolysis\n\n**Type of Anesthesia:** ITN\n\n**Report:** Patient presented for prophylactic right adnexectomy in the\ncourse of hysterectomy and left adnexectomy due to genetic burden.\nIntraoperatively, secondary wound closure was to be performed in the\ncase of a right mammary wound weeping more than one year\npostoperatively. The patient agreed to the planned procedure in writing\nafter receiving detailed information about the extent, the risks, and\nthe alternatives.\n\n**Course of the Operation:** Team time out with anesthesia colleagues.\nFlat lithotomy positioning, disinfection, and sterile draping. Placement\nof permanent transurethral catheter. Subumbilical incision and\ndissection onto the fascia. Opening of the fascia and suturing of the\nsame. Exposure of the peritoneum and opening of the same. Insertion of\nthe 10-mm optic trocar. Insertion of three additional trocars into the\nlower abdomen (left and center right, each 5mm; right 10mm). The\nfollowing situation is seen: when the camera is inserted from the\numbilical region, an extensive adhesion is seen. Only by changing the\ncamera to the right lower bay is extensive adhesiolysis possible. The\nomentum is fused with the peritoneum and the serosa of the uterus. Upper\nabdomen as far as visible inconspicuous.\n\nAfter hysterectomy and adnexectomy on the left side, adnexa on the right\nside atrophic and inconspicuous. The peritoneum is smooth as far as can\nbe seen.\n\nVisualization of the right adnexa and the suspensory ligament of ovary.\n\nCoagulation of the suspensory ligament of ovary ligament after\nvisualization of the ureter on the same side. Stepwise dissection of the\nadnexa from the pelvic wall.\n\nRecovery via endobag. Hemostasis. Inspection of the situs.\n\nRemoval of instrumentation under vision and draining of\npneumoperitoneum.\n\nClosure of the abdominal fascia at the umbilicus and right lower\nabdomen. Suturing of the skin with Monocryl 3/0. Compression bandage at\neach trocar insertion site. Inspection of the right mamma. In the area\nof the surgical scar laterally/externally, 2-3 small epithelium-lined\npore-like openings are visible; here, on pressure, discharge of rather\nviscous/sebaceous, non-odorous, or purulent fluid. No dehiscence is\nvisible, suspected. fistula ducts to the implant cavity. After\nconsultation with the mamma surgeon, a two-stage procedure was planned\nfor the treatment of the fistula tracts. Correct positioning and\ninconspicuous anesthesiological course. Instrumentation, swabs, and\ncloths complete according to the operating room nurse. Postoperative\nprocedures include analgesia, mobilization, thrombosis prophylaxis, and\nwaiting for histology.\n\n**Internal Histopathological Report** \n\n[Clinical information/question]{.underline}: Fistula formation mammary\nright. Dignity?\n\n[Macroscopy]{.underline}**:** Skin spindle from scar mammary right: fix.\na 2.4 cm long, stranded skin-subcutaneous excidate. Lamellation and\ncomplete embedding.\n\n[Processing]{.underline}**:** 1 block, HE\n\n[Microscopy]{.underline}**:** Histologic skin/subcutaneous\ncross-sections with overlay by a multilayered keratinizing squamous\nepithelium. The dermis with few inset regular skin adnexal structures,\nsparse to moderately dense mononuclear-dominated inflammatory\ninfiltrates, and proliferation of cell-poor, fiber-rich collagenous\nconnective tissue.\n\n**Critical Findings Report:** \n\nSkin spindle on scar mamma right: skin/subcutaneous resectate with\nfibrosis and chronic inflammation. To ensure that all findings are\nrecorded, the material will be further processed. A follow-up report\nwill follow.\n\n[Microscopy]{.underline}**:** In the meantime, the material was further\nprocessed as announced. The van Gieson stain showed extensive\nproliferation of collagenous and, in some places elastic fibers. Also in\nthe additional immunohistochemical staining against no evidence of\natypical epithelial infiltrates.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n CRP 7.8 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 11.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 3.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to provide an update on Mrs. Linda Mayer, born on\n01/12/1948, who received inpatient care at our facility from 01/01/2021\nto 01/14/2021.\n\n**Diagnosis:** Hailey-Hailey disease.\n\n- Upon admission, the patient was under treatment with Acitretin 25mg.\n\n**Other Diagnoses**:\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 die to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage in 2004\n\n- Hysterectomy in 2005\n\n**Medical History:** Mrs. Linda Mayer was referred to our hospital for\nthe management of Hailey-Hailey disease after assessment in our\noutpatient clinic. She reported a worsening of painful skin erosions on\nher neck and inner thighs over a span of approximately 3 weeks.\nItchiness was not reported. Prior attempts at treatment, including the\ntopical use of Fucicort, Prednisolone with Octenidine, and Polidocanol\ngel, had provided limited relief. She denied any other physical\ncomplaints, dyspnea, B symptoms, infections, or irregularities in stool\nand micturition.\n\nHer history revealed the initial onset of Hailey-Hailey disease,\ninitially presenting as itching followed by skin erosions, which\nsubsequently healed with scarring. The diagnosis was established at the\nFairview Clinic. Previous therapeutic interventions included systemic\ncortisone shock therapy, as-needed application of Fucicort ointment, and\naxillary laser therapy.\n\n**Family History:**\n\n- Father: Hailey-Hailey Disease (M. Hailey-Hailey)\n\n- Mother and Sister: Breast carcinoma\n\n**Psychosocial History:** Socially, Ms. Linda Mayer is described as a\nretiree, having previously worked as a nurse.\n\n**Physical Examination on Admission:**\n\nHeight: 16 cm, Body Weight: 80.0 kg, BMI: 29.7\n\n**Physical Examination Findings:**\n\nGenerally stable condition with increased nutritional status. Her\nconsciousness was unremarkable, and cranial mobility was free. Ocular\nmobility was regular, with prompt pupillary reflexes to accommodation\nand light. She exhibited a normal heart rate, and cardiac and pulmonary\nexaminations were unremarkable. No heart murmurs were detected. Renal\nbed and spine were not palpable. Further internal and orienting\nneurological examinations revealed no pathological findings.\n\n**Skin Findings on Admission:** Sharp erosions, approximately 10x10 cm\nin size, with a livid-erythematous base, partly crusty, were observed on\nthe neck and proximal inner thighs.\n\nIn the axillary regions on both sides, there were marginal,\nlivid-erythematous, well-demarcated plaques interspersed with scarring\nstrands, more pronounced on the right side.\n\nSkin type II.\n\nMucous membranes appeared normal. Dermographism was noted to be ruber.\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------ ------------ -------------------------------\n Prednisolone (Deltasone) 5 mg 1.5-0-0-0-0-0\n Aspirin (Bayer) 100 mg 0-1-0-0-0-0\n Simvastatin (Zocor) 40 mg 0-0-0-0-1\n Pantoprazole (Protonix) 45.1 mg 1-0-0-0-0\n Acitretin (Soriatane) 25 mg 1-0-0-0-0\n Tetrabenazine (Xenazine) 111 mg 0.25-0.25-0.25-0.25-0.25-0.25\n Letrozole (Femara) 2.5 mg 0-0-1-0\n Risedronate Sodium (Actonel) 35 mg 1-0-0-0-0\n Acetaminophen (Tylenol) 500 mg 0-1-0-1\n Naloxone (Narcan) 8.8 mg 1-0-1-0\n Eszopiclone (Lunesta) 7.5 mg 0-0-1-0\n\n**Other Findings:** MRSA Smears:\n\n- Nasal Smear: Normal flora, no MRSA.\n\n- Throat Swab: Normal flora, no MRSA.\n\n- Non-lesional Skin Smear: Normal flora.\n\n- Lesional Skin Swab: Abundant Pseudomonas aeruginosa, abundant\n Klebsiella oxytoca, and abundant Serratia sp., sensitive to\n piperacillin-tazobactam.\n\n**Therapy and Progression:** Mrs. Linda Mayer was admitted on 01/01/2021\nas an inpatient for a refractory exacerbation of previously diagnosed\nHailey-Hailey disease. On admission, both bacteriological and\nmycological smears were conducted, which indicated abundant levels of\nPseudomonas aeruginosa, Klebsiella oxytoca, and Serratia sp. Lab tests\nshowed a CRP level of 2.83 mg/dL and a leukocyte count of 8.8 G/L.\n\nInitial topical therapy consisted of Zinc oxide ointment, Clotrimazole\npaste, and Triamcinolone Acetonide shake lotion. Treatment was modified\non 01/04/2021 to include Clotrimazole (Lotrimin) paste in the mornings\nand methylprednisolone emulsion in the evenings. Starting on 01/08,\neosin aqueous solution was introduced for application on the thighs,\nserving antiseptic and drying purposes. A hydrophilic prednicarbate\ncream at 0.25% concentration, combined with octenidine at 0.1%, was\napplied to the neck and thighs twice daily, also starting on 01/08. For\nshowering, octenidine-based wash lotion was utilized. Additionally, Mrs.\nLinda Mayer received an emulsifying ointment as part of her treatment.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are providing an update on our patient Mrs. Linda Mayer, born on\n01/12/1948, who presented to our outpatient clinic on 09/22/2021.\n\n**Diagnoses:** M. Hailey-Hailey\n\n**Medical History:**\n\n- Diagnosis of M. Hailey-Hailey at the Fairview Clinic\n\n<!-- -->\n\n- Treatment involved systemic steroid shock therapy, laser therapy,\n and the initiation of Acitretin in October 2021, with no observed\n improvement.\n\n<!-- -->\n\n- A dermabrasion procedure was scheduled on 03/18/2021, during a\n previous inpatient admission.\n\n- Acitretin 25mg has been administered daily, with favorable outcomes\n noted when using Triamcinolone/Triclosan or Prednisolone +\n Octenidine.\n\n- A history of mastectomy with Vacuum-Assisted Closure (VAC) has\n resulted in breast erosion.\n\n**Skin Findings:**\n\n- Erythematous and partially mottled lesions have been identified in\n the axillary and inguinal regions, with some scarring observed in\n the axillary area.\n\n- On 04/28/2021, somewhat erosive plaques were noted in the inguinal\n regions.\n\n- As of 05/05/2021 discrete erosions are currently present on both\n forearms.\n\n**Current Recommendations:**\n\n- Inpatient admission is scheduled for September 2021.\n\n- The prescribed treatment plan includes topical prednicarbate\n (Dermatop) 0.25% with Octenidine 0.1%, per NRF 11.145, in a 50g\n container, to be applied once daily for 1-2 weeks.\n\n- Hydrocortisone 5% in a suitable base, 200g, is to be applied daily.\n\n- The regimen also includes prednicarbate (Dermatop) combined with\n Octenidine.\n\n- Acitretin will be continued temporarily.\n\n- A follow-up appointment in the outpatient clinic is scheduled for\n three months from now.\n\n- Discontinuation of Acitretin.\n\n- It is recommended to avoid the use of compresses on the erosions to\n prevent constant trauma.\n\n- Topical therapy with petrolatum-based wound ointment and sterile\n compresses.\n\n\n\n\nHere is the query:\nAs per Mrs. Mayer's surgical report, what complication was encountered during the VAC change?\n\nChoose the correct answer from the following options:\nA. Hemorrhage\nB. Infection\nC. Extracapsular spread of the tumor\nD. Adhesion formation\nE. Anaphylactic reaction to anesthesia\n\n\nYour response:\n", "role": "user" }, { "content": "Infection", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report to you about Mrs. Linda Mayer, born on 01/12/1948, who\npresented to our outpatient clinic on 07/13/19.\n\n**Diagnoses:**\n\n- BIRADS IV, recommended biopsy during breast diagnostics.\n\n- Left breast carcinoma: iT1b; iN0; MX; ER: 12/12; PR: 2/12; Her-2:\n neg; Ki67: 15%.\n\n**Other Diagnoses: **\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Pemphigus vulgaris under azathioprine therapy\n\n- Osteoporosis\n\n- Obesity with a BMI of 35\n\n- Undergoing immunosuppressive therapy with prednisolone\n\n**Family History:**\n\n- Sister deceased at age 39 from breast cancer.\n\n- Mother and grandmother (maternal and paternal) were diagnosed with\n breast cancer.\n\n**Medical History:** The CT thorax report indicates the presence of\ninflammatory foci, warranting further follow-up. The relevant data was\ndocumented and presented during the tumor conference. Subsequently, a\ntelephone conversation was conducted with the patient to discuss the\nnext steps.\n\n**Tumor board decision from 07/13/2019:**\n\n**Imaging: **\n\n1) MRI examination detected a unifocal lesion on the left external\n aspect, measuring approximately 2.4 cm in size.\n\n2) CT scan (thorax/abdomen 07/12/2019) revealed a previously known\n liver lesion, likely a hemangioma. No evidence of metastases was\n identified. Nonspecific, small foci were observed in the lungs,\n likely indicative of post-inflammatory changes.\n\n**Recommendations:**\n\n1. If no metastasis (M0): Fast-track BRCA testing is recommended.\n\n2. If BRCA testing returns negative: Proceed with a selective excision\n of the left breast after ultrasound-guided fine needle marking and\n sentinel lymph node biopsy on the left side. Additionally, perform\n Endopredict analysis on the surgical specimen.\n\n**Current Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ------------------------------- ------------ ----------- ---------------\n Aspirin 100mg Oral 1-0-0\n Simvastatin (Zocor) 40mg Oral 0-1-0\n Haloperidol (Haldol) 100mg Oral ½-0-½\n Zopiclone (Imovane) 7.5mg Oral 0-0-1\n Trazodone (Desyrel) 100mg Oral 0-0-½-\n Calcium Supplement (Caltrate) 500mg Oral 1-0-1\n Nystatin (Bio-Statin) As advised Oral 1-1-1-1\n Pantoprazole (Protonix) 40mg Oral 1-0-0\n Prednisolone (Prelone) 40mg Oral As advised\n Tramadol/Naloxone (Ultram) 50/4mg Oral 1-0-1\n Acyclovir (Zovirax) 800mg Oral 1-1-1\n\n**Mammography and Tomosynthesis from 07/8/2019:**\n\n[Findings]{.underline}**: **During the inspection and palpation, no\nsignificant findings were noted on either side. Some areas with higher\nmammographic density were observed, which slightly limited the\nassessment. However, during the initial examination, a small\narchitectural irregularity was identified on the outer left side. This\nirregularity appeared as a small, roundish compression measuring\napproximately 6mm and was visible only in the medio-lateral oblique\nimage, with a nipple distance of 8cm. Apart from this discovery, there\nwere no other suspicious focal findings on either side. No clustered or\nirregular microcalcifications were detected. Additionally, a long-term,\nunchanged observation noted some asymmetry with denser breast tissue\npresent on both sides, particularly on the outer aspects. Sonographic\nevaluation posed challenges due to the mixed echogenic glandular tissue.\nAs a possible corresponding feature to the questionable architectural\nirregularity on the outer left side, a blurred, echo-poor area with a\nvertical alignment measuring about 7x5mm was identified. Importantly, no\nother suspicious focal findings were observed, and there was no evidence\nof enlarged lymph nodes in the axilla on both sides.\n\n[Assessment]{.underline}**:** The observed finding on the left side\npresents an uncertain nature, categorized as BIRADS IVb. In contrast,\nthe finding on the right side appears benign, categorized as BIRADS II.\nTo gain a more conclusive understanding of the left-sided finding, we\nrecommend a histological assessment through a sonographically guided\nhigh-speed punch biopsy. An appointment has been scheduled with the\npatient to proceed with this biopsy and obtain a definitive\ndiagnosis.Formularbeginn\n\nFormularende**Current Recommendations:**\\\nA fast-track decision will be made regarding tumor genetics, and the\npatient will be notified of the appointment via telephone. The patient\nshould bring the pathology blocks from Fairview Clinic on the day of\nblood collection for genetic testing, along with a referral for an\nEndopredict test. A multidisciplinary team meeting will be convened\nafter the Endopredict test and genetic testing results are available. If\nthere is persistence or worsening of symptoms, we strongly advise the\npatient to seek immediate re-evaluation. Additionally, outside of\nregular office hours, the patient can seek assistance at the emergency\ncare unit in case of emergency.\n\n**MRI from 07/11/2019:**\n\n[Technique:]{.underline} Breast MRI (3T scanner) with dedicated mammary\nsurface coil: \n\n[Findings:]{.underline} The overall contrast enhancement was observed\nbilaterally to evaluate the Grade II findings. There was low to moderate\nsmall-spotted contrast enhancement with slightly limited assessability.\nThe contrast dynamics revealed a patchy, confluent, blurred, and\nelongated contrast enhancement, corresponding to the primary lesion,\nwhich measured approximately 2.4 cm on the lower left exterior. Single\nspicules were noted, and the lesion appeared hypointense in T1w imaging.\nNo suspicious focal findings with contrast enhancement were detected on\nthe right side. Small axillary lymph nodes were observed on the left\nside, but they did not appear suspicious based on MR morphology.\nAdditionally, there were no suspicious lymph nodes on the right side.\n\n[Assessment:]{.underline} An unifocal primary lesion measuring\napproximately 2.4 cm in diameter was identified on the lower left\nexterior. It exhibited patchy confluent enhancement and architectural\ndisturbance, with single spicules. No evidence of suspicious lymph nodes\nwas found. The left side is categorized as BIRADS 6, indicating a high\nsuspicion of malignancy, while the right side is categorized as BIRADS\n2, indicating a benign finding.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide you with an update on the medical condition of\nMrs. Linda Mayer, born on 01/12/1948, who attended our outpatient clinic\non 08/02/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast (17mm)\n\n- Histological grade G3, estrogen receptor (ER) and progesterone\n receptor (PR) negative.\n\n- Postmenopausal for the past eight years.\n\n- Previous surgical history includes an appendectomy.\n\n- Allergies: Hay fever\n\n \n\n**Current Presentation**: The patient sought consultation following a\nconfirmed diagnosis of DCIS (Ductal Carcinoma In Situ) in the right\nbreast, which was determined through a vacuum-assisted biopsy.\n\n**Physical Examination**: Upon physical examination, there is evidence\nof a post-intervention hematoma located in the upper right quadrant of\nthe right breast. However, the clip from the biopsy is not clearly\nvisible. A sonographic examination of the right axilla reveals no\nabnormalities.\n\n**Current Recommendations:**\n\n- Imaging studies have been conducted.\n\n- A case presentation is scheduled for our mammary conference\n tomorrow.\n\n- Subsequently, planning for surgery will commence, including the\n evaluation of sentinel lymph nodes following a right mastectomy and\n axillary lymph node dissection.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient care at our facility on 08/29/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast, measuring 17mm in size, classified as Grade 3, and\n testing negative for estrogen receptors (ER) and progesterone\n receptors (PR).\n\n- Mrs. Mayer has been postmenopausal for eight years.\n\n- Notable allergy: Hay fever\n\n**Tumor Board Decision:** Mammography imaging revealed a clip associated\nwith a focal finding in the right breast adjacent to calcifications.\n\n[Recommendation]{.underline}: Proceed with sentinel lymph node\nevaluation after right mastectomy, including clip localization on the\nright side.\n\n**Current Presentation**: During the patient\\'s recent outpatient visit,\nan extensive pre-operative consultation was conducted. This discussion\ncovered the indications for the surgery, details of the surgical\nprocess, potential alternative options, as well as general and specific\nrisks associated with the procedure. These risks included the\npossibility of an aesthetically suboptimal outcome and the chance of\nencountering an R1 situation. The patient did not have any further\nquestions and provided written consent for the procedure.\n\n**Physical Examination:** Both breasts appear normal upon inspection and\npalpation. The right axilla shows no abnormalities.\n\n**Medical History:** Mrs. Linda Mayer presented to our clinic with a\nvacuum biopsy-confirmed DCIS of the right breast for therapeutic\nintervention. The decision for surgery was reached following a\ncomprehensive review by our interdisciplinary breast board. After an\nextensive discussion of the procedure\\'s scope, associated risks, and\nalternative options, the patient provided informed consent for the\nproposed surgery.\n\n**Preoperative Procedure:** Sonographic and mammographic fine needle\nmarking of the remaining findings and the clip in the right breast.\n\n**Surgical Report:** Team time-out conducted with colleagues of\nanesthesia. Patient positioned in the supine position. Surgical site\ndisinfection and sterile draping. Marking of the incision site.\n\nA semicircular incision was made laterally on the right breast.\nVisualization and dissection along the marking wire towards the marked\nfinding. Excision of the marked findings, with a safety margin of\napproximately 1-2 cm. The excised specimen measured approximately 4 x 5\nx 3 cm. Markings using standard protocol (green thread cranially, blue\nthread ventrally). The excised specimen was sent for preparation\nradiography. Hemostasis was meticulously ensured. Insertion of a 10Ch\nBlake drain into the segmental cavity, followed by suturing.\nVerification of a blood-dry wound cavity. Preparation radiography\nincluded the marked area and the marking wires. The excised material was\ntransferred to our pathology colleagues for histological examination.\nSubdermal and intracutaneous sutures with Monocryl 3/0 in a continuous\nmanner. Application of Steristrips and dressing. Instruments, swabs, and\ncloths were accounted for per the nurse\\'s checklist. The patient was\ncorrectly positioned throughout the operation. The anesthesiologic\ncourse was without significant problems. A thorax compression bandage\nwas applied in the operating room as a preventive measure against\nbleeding.\n\n**Postoperative Procedure:** Pain management, thrombosis prophylaxis,\napplication of a pressure dressing, drainage under suction.\n\n**Examinations:** **Digital Mammography performed on 08/29/2019**\n\n[Clinical indication]{.underline}: DCIS right\n\n[Question]{.underline}: Please send specimen + Mx-FNM\n\n**Findings**: Sonographically guided wire marking of the maximum\nmicrocalcification group measuring about 12 mm. Local hematoma cavity\nand inset clip marking directly cranial to the finding. Stitch direction\nfrom lateral to medial. The wire is positioned with the tip caudal to\nthe clip in close proximity to the microcalcification. Additional\nmarking of the focal localization on the skin. Documentation of the wire\ncourse in two planes.\n\n- Telephone discussion of findings with the surgeon.\n\n- Preparation radiography and preparation sonography are recommended.\n\n- Marking wire and suspicious focal findings centrally included in the\n preparation.\n\n- Intraoperative report of findings has been conveyed to the surgeon.\n\n**Current Recommendations:**\n\n- Scheduled for inpatient admission on ward 22 tomorrow.\n\n- Right breast mastectomy with sentinel lymph node evaluation.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to update you on the clinical course of Mrs. Linda Mayer,\nborn on 01/12/1948, who was under our inpatient care from 08/30/2019 to\n09/12/2019.\n\n**Diagnosis:** Vacuum-assisted biopsy confirmed Ductal Carcinoma In Situ\n(DCIS) in the right breast, measuring 17mm, Grade 3, ER/PR negative.\n\n**Tumor Board Decision (07/13/2019):**\n\n[Imaging:]{.underline} Clip identified in focal lesion in the right\nbreast, adjacent to calcifications.\n\n[Recommendation]{.underline}**:** Spin Echo following fine-needle\nlocalization with mammography-guided control of the clip in the right\nbreast.\n\n[Subsequent Recommendation (08/27/2019):]{.underline} Radiation therapy\nto the right breast. Regular follow-up is advised.\n\n**Medical History:** Ms. Linda Mayer presented to our facility on\n08/30/2019 for the aforementioned surgical procedure. After a\ncomprehensive discussion regarding the surgical plan, potential risks,\nand possible complications, the patient consented to proceed. The\nsurgery was executed without complications on 09/01/2019. The\npostoperative course was unremarkable, allowing for Ms. Mayer\\'s\ndischarge on 09/12/2019 in stable condition and with no signs of wound\nirritation.\n\n**Histopathological Findings (09/01/2019):**\n\nThe resected segment from the right breast showed a maximum necrotic\nzone of 1.6 cm with foreign body reaction, chronic resorptive\ninflammation, fibrosis, and residual hemorrhage. These findings\nprimarily correspond to the pre-biopsy site. Surrounding this were areas\nof DCIS with solid and cribriform growth patterns and comedonecrosis,\nWHO Grade 3, Nuclear Grade 3, with a reconstructed extent of 3.5 cm.\nResection margins were as follows: ventral 0.15 cm, caudal 0.2 cm,\ndorsal 0.4 cm, with remaining margins exceeding 0.5 cm. TNM\nClassification (8th Edition, 2017): pTis (DCIS), R0, G3. Additional\nimmunohistochemical studies are underway to determine hormone receptor\nstatus; a supplementary report will follow.\n\n**Postoperative Plan:**\n\nThe patient was educated on standard postoperative care and the\nimportance of immediate re-evaluation for any persistent or worsening\nsymptoms. Radiation therapy to the right breast is planned, along with\nregular follow-up appointments.\n\nShould you have any questions or require further clarification, we are\nreadily available. For urgent concerns outside of regular office hours,\nemergency care is available at the Emergency Department.\n\n**Internal Histopathological Findings Report**\n\n**Clinical Data:** DCIS in the right breast (17 mm), Grade 3, ER/PR\nnegative.\n\n**Macroscopic Examination:**\n\nThe resected mammary segment from the right breast, marked with dual\nthreads and containing a fine-needle marker inserted ventro-laterally,\nmeasures 4.5 x 5.5 x 3 cm (HxWxD) and weighs 35 grams. The specimen was\nsectioned from medial to lateral into 14 lamellae. The cut surface\npredominantly shows yellowish, lobulated mammary parenchyma with sparse\nstriated whitish glandular components. A DCIS-suspected area, up to 2.1\ncm in size, is evident caudally and centro-ventrally (from lamellae\n4-10), displaying both reddish-hemorrhagic and whitish-nodular\nindurations. Minimal distances from the suspicious area to the resection\nmargins are as follows: cranial 2 cm, caudal 0.2 cm, dorsal 0.2 cm,\nventral 0.1 cm, medial 1.6 cm, lateral 2.5 cm. The suspect area was\ncompletely embedded. Ink markings: green/cranial, yellow/caudal,\nblue/ventral, black/dorsal.\n\n**Microscopic Examination:**\n\nHistological sections of the mammary parenchyma reveal fibro-lipomatous\nstroma and glandular lobules with a two-layered epithelial lining. In\nlamellae 3-6 and 11, solid and cribriform epithelial proliferations are\nevident. Cells are cuboidal with variably enlarged, predominantly\nmoderately pleomorphic, round to oval nuclei. Comedo-like necroses are\noccasionally observed in secondary lumina. Microscopic distances to the\ndeposition margins are consistent with the macroscopic findings. The\nsurrounding stroma in lamellae 6-9 shows extensive geographic adipose\ntissue necrosis, multinucleated foreign body-type giant cells, foamy\ncell macrophages, collagen fiber proliferation, and fresh hemorrhages.\n\n**Supplemental Immunohistochemical Findings\n(09/04/2019):** **Microscopy:** In the meantime, the material was\nfurther processed as announced.\n\nHere, the previously described intraductal epithelial growths, each with\nnegative staining reaction for the estrogen and progesterone receptor\n(with regular external and internal control reaction).\n\n \n\n**Critical Findings:**\n\nResected mammary segment with paracentral, max. 1.6 cm necrotic zone\nwith foreign body reaction, chronic resorptive. Chronic resorptive\ninflammation, fibrosis, and hemorrhage remnants (primarily corresponding\nto the pre-biopsy site), and surrounding portions of ductal carcinoma in\nsitu. Ductal carcinoma in situ, solid and rib-shaped growth type with\ncomedonecrosis, WHO grade 3, nuclear grade 3. The resection was locally\ncomplete with the following Safety margins: ventral 0.15 cm, caudal 0.2\ncm, dorsal 0.4 cm, and the remaining sedimentation margins more than 0.5\ncm.\n\nTNM classification (8th edition 2017): pTis (DCIS), R0, G3.\n\n[Hormone receptor status:]{.underline}\n\n- Estrogen receptor: negative (0%).\n\n- Progesterone receptor: negative (0%).\n\n \n\n \n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient treatment on 27/09/2019.\n\n**Diagnoses**: Left breast carcinoma; iT1c; iN0; MX; ER:12/12; PR:2/12;\nHer-2: neg; Ki67:15%, BRCA 2 mutation.\n\n**Other Diagnoses**:\n\n- Hailey-Hailey disease - currently regressing under prednisolone.\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 due to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage (Abrasio) in 2004\n\n- Hysterectomy in 2005\n\n**Allergies**: Hay fever\n\n**Imaging**:\n\n- CT revealed a cystic lesion in the liver, not suspicious for\n metastasis. Granulomatous, post-inflammatory changes in the lung.\n\n- An MRI of the left breast showed a unifocal lesion on the outer left\n side with a 2.4 cm extension.\n\n**Histology: **Gene score of 6.5, indicating a high-risk profile (pT2 or\npN1) if BRCA negative.\n\n**Recommendation**: If BRCA negative, SE left mamma after ultrasound-FNM\nwith correlation in Mx and SLNB on the left.\n\n**Current Presentation**: Mrs. Linda Mayer presented for pre-operative\nevaluation for left mastectomy. BRCA testing confirmed a BRCA2 mutation,\nwarranting bilateral subcutaneous mastectomy and SLNB on the left.\nReconstruction with implants and mesh is planned, along with a breast\nlift as requested by the patient.\n\n**Macroscopy:**\n\n**Left Subcutaneous Mastectomy (Blue/Ventral, Green/Cranial):**\n\n- Specimen Size: 17 x 15 x 6 cm (Height x Width x Depth), Weight: 410\n g\n\n- Description: Dual filament-labeled subcutaneous mastectomy specimen\n\n- Specimen Workup: 27 lamellae from lateral to medial\n\n- Tumor-Suspect Area (Lamellae 17-21): Max. 1.6 cm, white dermal,\n partly blurred\n\n- Margins from Tumor Area: Ventral 0.1 cm, Caudal 1 cm, Dorsal 1.2 cm,\n Cranial \\> 5 cm, Lateral \\> 5 cm, Medial \\> 2 cm\n\n- Remaining Mammary Parenchyma: Predominantly yellowish lipomatous\n with focal nodular appearance\n\n- Ink Markings: Cranial/Green, Caudal/Yellow, Ventral/Blue,\n Dorsal/Black\n\n - A: Lamella 17 - Covers dorsal and caudal\n\n - B: Lamella 18 - Covers ventral\n\n - C: Lamella 19 - Covers ventral\n\n - D: Blade 21 - Covers ventral\n\n - E: Lamella 20 - Reference cranial\n\n - F: Lamella 16 - Immediately laterally following mammary\n parenchyma\n\n - G: Blade 22 - Reference immediately medial following mammary\n tissue\n\n - H: Lamella 12 - Central section\n\n - I: Lamella 8 - Documented section top/outside\n\n - J: Lamella 3 - Vestigial section below/outside\n\n - K: Lamella 21 - White-nodular imposing area\n\n - L: Lamella 8 - Further section below/outside with nodular area\n\n - M: Lateral border lamella perpendicularly\n\n - N: Medial border lamella perpendicular (Exemplary)\n\n**Second Sentinel Lymph Node on the Left:**\n\n- Specimen: Maximum of 6 cm of fat tissue resectate with 1 to 2 cm of\n lymph nodes and smaller nodular indurations.\n\n- A, B: One lymph node each divided\n\n- C: Further nodular indurations\n\n**Palpable Lymph Nodes Level I:**\n\n- Specimen: One max. 4.5 cm large fat resectate with nodular\n indurations up to 1.5 cm in size\n\n- A: One nodular induration divided\n\n- B: Further nodular indurated portions\n\n**Right Subcutaneous Mastectomy:**\n\n- Specimen: Double thread-labeled 450 g subcutaneous mastectomy\n specimen\n\n- Assumed Suture Markings: Blue (Ventral) and Green (Cranial)\n\n- Dorsal Fascia Intact\n\n- [Specimen Preparation:]{.underline} 16 lamellae from medial to\n lateral\n\n- Predominantly yellowish lobulated with streaky, beige, impinging\n strands of tissue\n\n- Isolated hemorrhages in the parenchyma\n\n- Ink Markings: Green = Cranial, Yellow = Caudal, Blue = Ventral,\n Black = Dorsal\n\n<!-- -->\n\n- A: Medial border lamella perpendicular (Exemplary)\n\n- B: Lamella 5 with reference ventrally (below inside)\n\n- C: Lamella 8 with reference ventrally (below inside)\n\n- D: Lamella 6 with ventral and dorsal reference (upper inside)\n\n- E: Blade 8 with ventral and dorsal cover (top inside)\n\n- F: Blade 11 with cover dorsal and caudal (bottom outside)\n\n- G: Blade 13 with dorsal cover (bottom outside)\n\n- H: Blade 10 with ventral and dorsal cover (top outside)\n\n- I: Lamella 14 with reference cranial and dorsal and bleeding in\n (upper outer)\n\n- J: Lateral border lamella perpendicular (Exemplary)\n\n**Microscopy:**\n\n1\\) In the tumor-suspicious area, a blurred large fibrosis zone with\nstar-shaped extensions is visible. Intercalated are single-cell and\nstranded epithelial cells with a high nuclear-cytoplasmic ratio. The\nnuclei are monomorphic with finely dispersed chromatin, at most, very\nisolated mitoses. Adjacent distended glandular ducts with a discohesive\ncell proliferate with the same cytomorphology. Sporadically, preexistent\nglandular ducts are sheared disc-like by the infiltrative tumor cells.\nSamples from the nodular area of lamella 21 show areas of cell-poor\nhyaline sclerosis with partly ectatically dilated glandular ducts.\n\n2\\) Second lymph node with partial infiltrates of the neoplasia described\nabove. The cells here are relatively densely packed. Somewhat increased\nmitoses. In the lymph nodes, iron deposition is also in the sinus\nhistiocytes.\n\n3\\) Lymph nodes with partly sparse iron deposition. No epithelial foreign\ninfiltrates.\n\n4\\) Regular mammary gland parenchyma. No tumor infiltrates. Part of the\nglandular ducts are slightly cystically dilated.\n\n**Preliminary Critical Findings Report: **\n\nLeft breast carcinoma measuring max 1.6 cm diagnosed as moderately\ndifferentiated invasive lobular carcinoma, B.R.E. score 6 (3+2+1, G2).\nPresence of tumor-associated and peritumoral lobular carcinoma in situ.\nResection status indicates locally complete excision of both invasive\nand non-invasive carcinoma; minimal margins as follows: ventral \\<0.1\ncm, caudal 0.2 cm, dorsal 0.8 cm, remaining margins ≥0.5 cm. Nodal\nstatus reveals max 0.25 cm metastasis in 1/5 nodes, 0/2 additional\nnodes, without extracapsular spread. Right mammary gland from\nsubcutaneous mastectomy shows tumor-free parenchyma.\n\n**TNM classification (8th ed. 2017):** pT1c, pTis (LCIS), pN1a, G2, L0,\nV0, Pn0, R0. Investigations to determine tumor biology were initiated.\nAddendum follows.\n\n**Supplementary findings on 10/07/2019**\n\nEditing: immunohistochemistry:** **\n\nEstrogen receptor, Progesterone receptor, Her2neu, MIB-1 (block 1D).\n\n**Critical Findings Report:** Breast carcinoma on the left with a 1.6 cm\ninvasive lobular carcinoma, moderately differentiated, with a B.R.E.\nscore of 6 (3+2+1, G2). Additionally, tumor-associated and peritumoral\nlobular carcinoma in situ are noted. Resection status confirms locally\ncomplete excision of both invasive and non-invasive carcinomas; minimal\nresection margins are ventral \\<0.1 cm, caudal (LCIS) 0.2 cm, dorsal 0.8\ncm, and all other margins ≥0.5 cm. Nodal assessment reveals a single\nmetastasis with a maximum dimension of 0.25 cm among 7 lymph nodes,\nspecifically found in 1/5 nodes, with no additional metastasis in 0/2\nnodes and no extracapsular extension. Contralateral right mammary gland\nfrom subcutaneous mastectomy is tumor-free.\n\nTumor biology of the invasive carcinoma demonstrates strong positive\nestrogen receptor expression in 100% of tumor cells, strong positive\nprogesterone receptor expression in 1% of tumor cells, negative HER2/neu\nstatus (Score 1+), and a Ki67 (MIB-1) proliferation index of 25%.\n\n**TNM classification (8th Edition 2017):** pT1c, pTis (LCIS), pN1a (1/7\nECE-, sn), G2, L0, V0, Pn0, R0.\n\n**Surgery Report (Vac Change + Irrigation)**: Indication for VAC change.\nAfter a detailed explanation of the procedure, its risks, and\nalternatives, the patient agrees to the proposed procedure.\n\nThe course of surgery: Proper positioning in a supine position. Removal\nof the VAC sponge. A foul odor appears from the wound cavity. Careful\ndisinfection of the surgical area. Sterile draping. Detailed inspection\nof the wound conditions. Wound debridement with removal of fibrin\ncoatings and freshening of the wound. Resection of necrotic material in\nplaces with sharp spoon. Followed by extensive Irrigation of the entire\nwound bed and wound edges using 1 l Polyhexanide solution. Renewed VAC\nsponge application according to standard.\n\n**Postoperative procedure**: Pain medication, thrombosis prophylaxis,\ncontinuation of antibiotic therapy. In the case of abundant\nStaphylococcus aureus and isolated Pseudomosas in the smear and still\nclinical suspected infection, extension of antibiotic treatment to\nMeropenem.\n\n**Surgery Report: Implant Placement**\n\n**Type of Surgery:** Implant placement and wound closure.\n\n**Report:** After infection and VAC therapy, clean smears and planning\nof reinsertion. Informed consent. Intraoperative consults: Anesthesia.\n\n**Course of Surgery:** Team time out. Removal VAC sponge. Disinfection\nand covering. Irrigation of the wound cavity with Serasept. Blust\nirrigation. Fixation cranially and laterally with 4 fixation sutures\nwith Vircryl 2-0. Choice of trial implant. Temporary insertion. Control\nin sitting and lying positions. Choice of the implant. Repeated\ndisinfection. Change of gloves. Insertion of the implant into the\npocket. Careful hemostasis. Insertion of a Blake drain into the wound\ncavity. Suturing of the drainage. Subcutaneous sutures with Monocryl\n3-0.\n\n**Type of Surgery:** Prophylactic open Laparoscopy, extensive\nadhesiolysis\n\n**Type of Anesthesia:** ITN\n\n**Report:** Patient presented for prophylactic right adnexectomy in the\ncourse of hysterectomy and left adnexectomy due to genetic burden.\nIntraoperatively, secondary wound closure was to be performed in the\ncase of a right mammary wound weeping more than one year\npostoperatively. The patient agreed to the planned procedure in writing\nafter receiving detailed information about the extent, the risks, and\nthe alternatives.\n\n**Course of the Operation:** Team time out with anesthesia colleagues.\nFlat lithotomy positioning, disinfection, and sterile draping. Placement\nof permanent transurethral catheter. Subumbilical incision and\ndissection onto the fascia. Opening of the fascia and suturing of the\nsame. Exposure of the peritoneum and opening of the same. Insertion of\nthe 10-mm optic trocar. Insertion of three additional trocars into the\nlower abdomen (left and center right, each 5mm; right 10mm). The\nfollowing situation is seen: when the camera is inserted from the\numbilical region, an extensive adhesion is seen. Only by changing the\ncamera to the right lower bay is extensive adhesiolysis possible. The\nomentum is fused with the peritoneum and the serosa of the uterus. Upper\nabdomen as far as visible inconspicuous.\n\nAfter hysterectomy and adnexectomy on the left side, adnexa on the right\nside atrophic and inconspicuous. The peritoneum is smooth as far as can\nbe seen.\n\nVisualization of the right adnexa and the suspensory ligament of ovary.\n\nCoagulation of the suspensory ligament of ovary ligament after\nvisualization of the ureter on the same side. Stepwise dissection of the\nadnexa from the pelvic wall.\n\nRecovery via endobag. Hemostasis. Inspection of the situs.\n\nRemoval of instrumentation under vision and draining of\npneumoperitoneum.\n\nClosure of the abdominal fascia at the umbilicus and right lower\nabdomen. Suturing of the skin with Monocryl 3/0. Compression bandage at\neach trocar insertion site. Inspection of the right mamma. In the area\nof the surgical scar laterally/externally, 2-3 small epithelium-lined\npore-like openings are visible; here, on pressure, discharge of rather\nviscous/sebaceous, non-odorous, or purulent fluid. No dehiscence is\nvisible, suspected. fistula ducts to the implant cavity. After\nconsultation with the mamma surgeon, a two-stage procedure was planned\nfor the treatment of the fistula tracts. Correct positioning and\ninconspicuous anesthesiological course. Instrumentation, swabs, and\ncloths complete according to the operating room nurse. Postoperative\nprocedures include analgesia, mobilization, thrombosis prophylaxis, and\nwaiting for histology.\n\n**Internal Histopathological Report** \n\n[Clinical information/question]{.underline}: Fistula formation mammary\nright. Dignity?\n\n[Macroscopy]{.underline}**:** Skin spindle from scar mammary right: fix.\na 2.4 cm long, stranded skin-subcutaneous excidate. Lamellation and\ncomplete embedding.\n\n[Processing]{.underline}**:** 1 block, HE\n\n[Microscopy]{.underline}**:** Histologic skin/subcutaneous\ncross-sections with overlay by a multilayered keratinizing squamous\nepithelium. The dermis with few inset regular skin adnexal structures,\nsparse to moderately dense mononuclear-dominated inflammatory\ninfiltrates, and proliferation of cell-poor, fiber-rich collagenous\nconnective tissue.\n\n**Critical Findings Report:** \n\nSkin spindle on scar mamma right: skin/subcutaneous resectate with\nfibrosis and chronic inflammation. To ensure that all findings are\nrecorded, the material will be further processed. A follow-up report\nwill follow.\n\n[Microscopy]{.underline}**:** In the meantime, the material was further\nprocessed as announced. The van Gieson stain showed extensive\nproliferation of collagenous and, in some places elastic fibers. Also in\nthe additional immunohistochemical staining against no evidence of\natypical epithelial infiltrates.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n CRP 7.8 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 11.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 3.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to provide an update on Mrs. Linda Mayer, born on\n01/12/1948, who received inpatient care at our facility from 01/01/2021\nto 01/14/2021.\n\n**Diagnosis:** Hailey-Hailey disease.\n\n- Upon admission, the patient was under treatment with Acitretin 25mg.\n\n**Other Diagnoses**:\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 die to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage in 2004\n\n- Hysterectomy in 2005\n\n**Medical History:** Mrs. Linda Mayer was referred to our hospital for\nthe management of Hailey-Hailey disease after assessment in our\noutpatient clinic. She reported a worsening of painful skin erosions on\nher neck and inner thighs over a span of approximately 3 weeks.\nItchiness was not reported. Prior attempts at treatment, including the\ntopical use of Fucicort, Prednisolone with Octenidine, and Polidocanol\ngel, had provided limited relief. She denied any other physical\ncomplaints, dyspnea, B symptoms, infections, or irregularities in stool\nand micturition.\n\nHer history revealed the initial onset of Hailey-Hailey disease,\ninitially presenting as itching followed by skin erosions, which\nsubsequently healed with scarring. The diagnosis was established at the\nFairview Clinic. Previous therapeutic interventions included systemic\ncortisone shock therapy, as-needed application of Fucicort ointment, and\naxillary laser therapy.\n\n**Family History:**\n\n- Father: Hailey-Hailey Disease (M. Hailey-Hailey)\n\n- Mother and Sister: Breast carcinoma\n\n**Psychosocial History:** Socially, Ms. Linda Mayer is described as a\nretiree, having previously worked as a nurse.\n\n**Physical Examination on Admission:**\n\nHeight: 16 cm, Body Weight: 80.0 kg, BMI: 29.7\n\n**Physical Examination Findings:**\n\nGenerally stable condition with increased nutritional status. Her\nconsciousness was unremarkable, and cranial mobility was free. Ocular\nmobility was regular, with prompt pupillary reflexes to accommodation\nand light. She exhibited a normal heart rate, and cardiac and pulmonary\nexaminations were unremarkable. No heart murmurs were detected. Renal\nbed and spine were not palpable. Further internal and orienting\nneurological examinations revealed no pathological findings.\n\n**Skin Findings on Admission:** Sharp erosions, approximately 10x10 cm\nin size, with a livid-erythematous base, partly crusty, were observed on\nthe neck and proximal inner thighs.\n\nIn the axillary regions on both sides, there were marginal,\nlivid-erythematous, well-demarcated plaques interspersed with scarring\nstrands, more pronounced on the right side.\n\nSkin type II.\n\nMucous membranes appeared normal. Dermographism was noted to be ruber.\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------ ------------ -------------------------------\n Prednisolone (Deltasone) 5 mg 1.5-0-0-0-0-0\n Aspirin (Bayer) 100 mg 0-1-0-0-0-0\n Simvastatin (Zocor) 40 mg 0-0-0-0-1\n Pantoprazole (Protonix) 45.1 mg 1-0-0-0-0\n Acitretin (Soriatane) 25 mg 1-0-0-0-0\n Tetrabenazine (Xenazine) 111 mg 0.25-0.25-0.25-0.25-0.25-0.25\n Letrozole (Femara) 2.5 mg 0-0-1-0\n Risedronate Sodium (Actonel) 35 mg 1-0-0-0-0\n Acetaminophen (Tylenol) 500 mg 0-1-0-1\n Naloxone (Narcan) 8.8 mg 1-0-1-0\n Eszopiclone (Lunesta) 7.5 mg 0-0-1-0\n\n**Other Findings:** MRSA Smears:\n\n- Nasal Smear: Normal flora, no MRSA.\n\n- Throat Swab: Normal flora, no MRSA.\n\n- Non-lesional Skin Smear: Normal flora.\n\n- Lesional Skin Swab: Abundant Pseudomonas aeruginosa, abundant\n Klebsiella oxytoca, and abundant Serratia sp., sensitive to\n piperacillin-tazobactam.\n\n**Therapy and Progression:** Mrs. Linda Mayer was admitted on 01/01/2021\nas an inpatient for a refractory exacerbation of previously diagnosed\nHailey-Hailey disease. On admission, both bacteriological and\nmycological smears were conducted, which indicated abundant levels of\nPseudomonas aeruginosa, Klebsiella oxytoca, and Serratia sp. Lab tests\nshowed a CRP level of 2.83 mg/dL and a leukocyte count of 8.8 G/L.\n\nInitial topical therapy consisted of Zinc oxide ointment, Clotrimazole\npaste, and Triamcinolone Acetonide shake lotion. Treatment was modified\non 01/04/2021 to include Clotrimazole (Lotrimin) paste in the mornings\nand methylprednisolone emulsion in the evenings. Starting on 01/08,\neosin aqueous solution was introduced for application on the thighs,\nserving antiseptic and drying purposes. A hydrophilic prednicarbate\ncream at 0.25% concentration, combined with octenidine at 0.1%, was\napplied to the neck and thighs twice daily, also starting on 01/08. For\nshowering, octenidine-based wash lotion was utilized. Additionally, Mrs.\nLinda Mayer received an emulsifying ointment as part of her treatment.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are providing an update on our patient Mrs. Linda Mayer, born on\n01/12/1948, who presented to our outpatient clinic on 09/22/2021.\n\n**Diagnoses:** M. Hailey-Hailey\n\n**Medical History:**\n\n- Diagnosis of M. Hailey-Hailey at the Fairview Clinic\n\n<!-- -->\n\n- Treatment involved systemic steroid shock therapy, laser therapy,\n and the initiation of Acitretin in October 2021, with no observed\n improvement.\n\n<!-- -->\n\n- A dermabrasion procedure was scheduled on 03/18/2021, during a\n previous inpatient admission.\n\n- Acitretin 25mg has been administered daily, with favorable outcomes\n noted when using Triamcinolone/Triclosan or Prednisolone +\n Octenidine.\n\n- A history of mastectomy with Vacuum-Assisted Closure (VAC) has\n resulted in breast erosion.\n\n**Skin Findings:**\n\n- Erythematous and partially mottled lesions have been identified in\n the axillary and inguinal regions, with some scarring observed in\n the axillary area.\n\n- On 04/28/2021, somewhat erosive plaques were noted in the inguinal\n regions.\n\n- As of 05/05/2021 discrete erosions are currently present on both\n forearms.\n\n**Current Recommendations:**\n\n- Inpatient admission is scheduled for September 2021.\n\n- The prescribed treatment plan includes topical prednicarbate\n (Dermatop) 0.25% with Octenidine 0.1%, per NRF 11.145, in a 50g\n container, to be applied once daily for 1-2 weeks.\n\n- Hydrocortisone 5% in a suitable base, 200g, is to be applied daily.\n\n- The regimen also includes prednicarbate (Dermatop) combined with\n Octenidine.\n\n- Acitretin will be continued temporarily.\n\n- A follow-up appointment in the outpatient clinic is scheduled for\n three months from now.\n\n- Discontinuation of Acitretin.\n\n- It is recommended to avoid the use of compresses on the erosions to\n prevent constant trauma.\n\n- Topical therapy with petrolatum-based wound ointment and sterile\n compresses.\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are writing to provide an update on the examination results of our\npatient Mrs. Hilary Sanders, born on 08/24/1976, who presented to our\noutpatient clinic on 10/09/2016.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n human immunoglobulin\n\n**Medical History:** Mrs. Sanders presented with suspected previously\nundiagnosed immunodeficiency. There were no reports of frequent\ninfections during childhood and adolescence. No increased herpes\ninfections. No history of pneumonia, meningitis, or other serious\ninfections.\n\n**Current Presentation:** Mrs. Sanders has experienced recurrent\nrespiratory infections (bronchitis, pharyngitis) for about 3 years.\n\n**Physical Examination:** She reported joint pain in the left knee and\nnumbness below the shoulder blade. A tendency to bruise easily. No\nmucosal lesions, recurrent axillary lymph node swelling. No recurrent\nfevers. No B-symptoms. No resting dyspnea, no subjective heart rhythm\ndisturbances, no syncope, no peripheral edema, or other signs of\ncardiopulmonary decompensation.\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all IgG\n subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and NK-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B-cells.\n\n- Monocytic HLA-DR expression (immune competence marker) within the\n normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n- T-cell function after 24h polyvalent ConA stimulation: TNF-alpha,\n IFN-gamma, IL-2, IL-4 unremarkable\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells.\n\nFurther cellular immune status, including the complement system and\nsoluble mediators, showed no significant abnormalities except for an\nelevated soluble IL-2 receptor. Given the unremarkable monocytic\nTNF-alpha secretion after LPS stimulation, a significant Toll-like\nReceptor 4 defect is unlikely. An antibody response to Tetanus Toxoid\nwas demonstrated in a vaccine titer test. Protective\npneumococcal-specific antibodies could not be detected. There were no\nabnormalities in autoimmune diagnostics.\n\nImmunofixation showed no evidence of monoclonal gammopathy.\nHypogammaglobulinemia due to enteral or renal protein loss is unlikely\nin the presence of normal albumin.\n\nOverall, the picture is consistent with Common Variable\nImmunodeficiency. Formally, CVID is defined by a reduction in the major\nimmunoglobulin class IgG, with accompanying reduction in IgA and/or IgM,\nin the absence of normal or impaired vaccine response. Due to very low\nimmunoglobulin levels and planned travel, determination of vaccine\nresponse was currently omitted in the absence of therapeutic\nconsequence. After stable substitution, specific vaccine antibody levels\ncan be determined before or after vaccination, with the assumption that\nstable antibody concentrations exist due to continuous immunoglobulin\nsubstitution.\n\nAccording to B-cell differentiation, it corresponds to Type Ib according\nto the Freiburg Classification and Type B+smB-CD21lo according to the\nEuro Classification. The classification is clinically relevant, as Type\nIa is associated with increased immunocytopenias (especially ITP and\nAIH) and splenomegaly. In CVID with a high proportion (\\>10%) of CD-21\nlow B-cells, increased granulomatous diseases and splenomegaly have also\nbeen observed.\n\nThe indication for immunoglobulin substitution therapy exists because of\nrecurrent infections. The form of substitution therapy (intravenous. vs.\nsubcutaneous) is primarily based on patient preferences, but also on\nmedical conditions (concomitant diseases such as thrombocytopenia,\nconvenience, insurance, etc.).\n\n**Current Recommendations:**\n\nWe propose to initiate immunoglobulin substitution therapy with Hizentra\n20% (subcutaneous) at a dose of 200 ml once a week on Tuesdays. Further\ninformation and training on subcutaneous immunoglobulin substitution\ntherapy will be provided by a home care nursing service.\n\nMrs. Sanders will remain under regular medical supervision with close\nmonitoring of clinical symptoms, laboratory parameters, and the\neffectiveness of immunoglobulin substitution therapy. Any unexpected\nside effects or changes in her condition should be reported immediately.\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n --------------------------------------- --------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Calcium 2.41 mg/dL 2.15-2.50 mg/dL\n Inorganic Phosphate 1.00 mg/dL 0.87-1.45 mg/dL\n Selenium 0.79 µmol/L 0.60-1.50 µmol/L\n Zinc 10.1 µmol/L 9.0-22.0 µmol/L\n Creatinine 0.75 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 mL/min \\>90 mL/min\n Total Bilirubin 0.37 mg/dL \\< 1.20 mg/dL\n Albumin 4.55 g/dL 3.50-5.20 g/dL\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n A2-Globulin in Serum 10.7% 7.1-11.8%\n ß-Globulin in Serum 9.2% 8.4-13.1%\n Gamma-Globulin in Serum 3.2% 11.1-18.8%\n Immunoglobulin G 514 mg/dL 700-1600 mg/dL\n Immunoglobulin A 14 mg/dL 70-400 mg/dL\n Immunoglobulin M 19 mg/dL 40-230 mg/dL\n Immunoglobulin E 90 kU/L 0.0-100.0 kU/L\n IgG 1 299.5 mg/dL 280-800 mg/dL\n IgG 2 162.7 mg/dL 115-570 mg/dL\n IgG 3 49.1 mg/dL 24-125 mg/dL\n IgG 4 4.0 mg/dL 5.2-125 mg/dL\n Serum Immunofixation \n CRP 4.8 mg/L \\< 5.0 mg/L\n C3 Complement 980 mg/L 900-1800 mg/L\n C4 Complement 120 mg/L 100-400 mg/L\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n HBs Antigen Negative \n HBc Antibody Negative \n HBs Antibody Negative \n Ferritin 56 µg/L 13-140 µg/L\n ALT (GPT) 33 U/L \\< 31 U/L\n AST (GOT) 29 U/L \\< 35 U/L\n Alkaline Phosphatase 84 U/L 35-105 U/L\n Creatine Kinase 90 U/L \\< 167 U/L\n CK-MB 8.3 U/L \\< 24.0 U/L\n Gamma-GT 40 U/L 5-36 U/L\n LDH 204 U/L 135-214 U/L\n Lipase 50 U/L 13-60 U/L\n Cortisol 306.6 nmol/L 64.0-327.0 nmol/L\n 25-OH-Vitamin D3 65.3 nmol/L 50.0-150.0 nmol/L\n 1.25-OH-Vitamin D3 134 pmol/L 18.0-155.0 pmol/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Vitamin B12 770 pg/mL 191-663 pg/mL\n Folic Acid 14.6 ng/mL 4.6-18.7 ng/mL\n Hemoglobin 13.9 g/dL 12.0-15.6 g/dL\n Hematocrit 41.0% 35.5-45.5%\n Erythrocytes 5.2 M/uL 3.9-5.2 M/uL\n Leukocytes 4.13 K/uL 3.90-10.50 K/uL\n Platelets 174 K/uL 150-370 K/uL\n MCV 80.0 fL 80.0-99.0 fL\n MCH 26.7 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n RDW-CV 13.7% 11.5-15.0%\n Absolute Neutrophils 2.87 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.010 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.71 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.42 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.03 K/uL 0.00-0.20 K/uL\n HbA1c 4.9% \\< 6.0%\n HbA1c (IFCC) 30.1 mmol/mol \\< 42.0\n HBV Serology Result Negative \n HIV1/2 Antibodies, P24 Antigen Negative \n Hepatitis C Virus Antibodies in Serum Negative \n\n**Dear colleague,**\n\nWe report the examination results of Mrs. Hilary Sanders, born on\n08/24/1976 who presented at our outpatient clinic on 03/04/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all\n IgG-Subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and natural killer-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B cells.\n\n- Monocytic HLA-DR expression within the normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells. The further cellular immune\nstatus, including the complement system and soluble mediators, showed no\nsignificant abnormalities except for an elevated soluble IL-2 receptor.\n\n**Current Presentation:** Mrs. Sanders was again provided with detailed\ninformation about her condition and the planned course of action. We\nscheduled an appointment to initiate regular subcutaneous immunoglobulin\ntherapy.\n\n**Medical History:** Mrs. Sanders received her first dose of Hizentra\n20% subcutaneously as immunoglobulin substitution therapy for CVID. The\nadministration was well-tolerated initially, with no evidence of\nsignificant local or systemic side effects. Mrs. Sanders was once again\ninformed about possible risks (especially hypersensitivity reactions)\nand advised to contact us immediately in case of questions,\nuncertainties, or any abnormalities. The dosing for the first four weeks\nwas 3x20mL Hizentra 20% subcutaneously, and from the fifth week onward,\nit was changed to either 1x40mL or 2x20mL Hizentra 20% subcutaneously\nper week.\n\nIn the past days, Mrs. Sanders has been experiencing a cold: runny nose,\ncough (green-yellow), difficulty clearing mucus, slight fever, sinus\ninflammation, sore throat, difficulty speaking, and swallowing problems.\nThere was no improvement.\n\n**Physical Examination:** Reddened throat, no exudates, non-swollen\ncervical lymph nodes, lung examination showed bronchitis-like breathing\nsounds, no rales.\n\n**Therapy and Progression**: Today\\'s CRP is not elevated. IgGs are\nstill below normal. We recommended increasing immunoglobulin\nsubstitution during the infection. The patient had difficulty finding a\nsuitable injection site on her abdomen. However, she reported that the\nsecretions were gradually becoming lighter, so she decided to wait with\nthe antibiotic and only use it if there was no improvement.\n\nThe patient has been receiving 3x20mL Hizentra 20% per week since her\nlast visit. She complained of developing skin hardening at the injection\nsites, so a slower infusion time was discussed. She has been\nexperiencing a strong cough for several weeks without fever. No rales or\nsigns of pleuritis were detected on auscultation. No abnormalities were\nobserved on the chest X-ray. Laboratory results now show normal IgG\nlevels, so the dose was reduced to 2x20mL per week. A CT scan of the\nthorax and abdominal ultrasound were requested.\n\n**Chest X-ray in two planes from 03/04/2017:**\n\n[Findings/Assessment:]{.underline} No previous images are available for\ncomparison. Upper mediastinum and heart appear normal, with no central\ncongestion. No pneumothorax, effusions, confluent infiltrates, or\nsignificant focal lesions.\n\n**Abdominal ultrasound on 03/04/2017:**\n\nHepatosplenomegaly and retroperitoneal lymphadenopathy up to 26mm.\n\n**CT Chest/Abdomen/ from 03/04/2017:**\n\n[Methodology]{.underline}: Digital overview radiographs. After\nintravenous injection of contrast agent a 16-row CT scan of the thorax\nand entire abdomen was performed in the venous contrast phase, with\nprimary data set reconstruction at a thickness of 1.25 mm. Multiplanar\nreconstructions were created.\n\n[Findings]{.underline}: A conventional radiographic pre-image from\n11/18/2014 is available for comparison.\n\n[Thorax]{.underline}: Normal lung parenchyma with normal vascular\nmarkings. Small, sometimes hazy, sometimes nodular densities measuring\nup to 4mm in both lower lobes and the left upper lobe. Small\npleura-adjacent density in the right lower lobe. No evidence of\nconfluent infiltrates. No pleural effusion or pneumothorax. Normal heart\nsize and configuration. Normal diameter of the thoracic aorta and\npulmonary trunk. Increased number and enlarged retroclavicular lymph\nnodes on the right and left, axillary on both sides measuring up to 30mm\nin diameter. Trachea and esophagus displayed normally. No hiatus hernia.\nThyroid and neck soft tissues were unremarkable, as far as depicted.\nNormal thoracic soft tissue mantle. No soft tissue emphysema.\n\n[Abdomen]{.underline}: Hepatomegaly with morphologically normal liver\nparenchyma. No portal vein thrombosis. Gallbladder is unremarkable with\nno calculi. Intrahepatic and extrahepatic bile ducts are not dilated.\nPancreas is normally lobulated and structured, with no dilation of the\npancreatic duct. Splenomegaly. Accessory spleen measuring approximately\n20 mm in diameter. Splenic parenchyma is homogeneously contrasted in the\nvenous phase. Kidneys are orthotopically positioned, normal size with no\nside differences, and contrasted equally on both sides. Two regularly\nconfigured hypodense lesions in the left kidney, suggestive of\nuncomplicated renal cysts. No dilation of the urinary tract, and no\nevidence of stones. Adrenal glands are not visualized. Increased and\nenlarged mesenteric, pararaortic, parailiacal, and inguinal lymph nodes\nup to 30 mm in size. Gastrointestinal tract is displayed normally, as\nfar as assessable. Normal representation of major abdominal vessels. No\nfree intraperitoneal fluid or air.\n\n[Osseous structures:]{.underline} No evidence of suspicious osseous\ndestruction. Normal soft tissue mantle.\n\n[Assessment:]{.underline} Intrapulmonary multifocal, sometimes hazy,\nsometimes nodular densities, differential diagnosis includes atypical\npneumonia. Thoracoabdominal lymphadenopathy. Hepatosplenomegaly without\nsuspicious lesions.\n\n**Current Recommendations:**\n\n- Outpatient follow-up for discussion of findings\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% 2x20mL/week\n\n- Lung function test\n\n- Gastroscopy\n\n- In case of acute infection: increase immunoglobulin administration\n\n- Abdominal ultrasound: annually\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually Seasonal influenza vaccination: annually\n\n**Lab results upon discharge:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n Gamma-Globulin 3.2% 11.1-18.8%\n Immunoglobulin G 188 mg/dL 700-1600 mg/dL\n Immunoglobulin A 11 mg/dL 70-400 mg/dL\n Immunoglobulin M 12 mg/dL 40-230 mg/dL\n IgG Subclass 1 113 mg/dL 280-800 mg/dL\n IgG Subclass 2 49.1 mg/dL 115-570 mg/dL\n IgG Subclass 4 \\<0.0 mg/dL 5.2-125 mg/dL\n aPCP-IgG 7.32 mg/dL 10.00-191.20 mg/dL\n aPCP-IgG2 2.74 mg/dL 4.70-89.40 mg/dL\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n LDH 224 U/L 135-214 U/L\n Vitamin B12 708 pg/mL 191-663 pg/mL\n Erythrocytes 5.3 M/uL 3.9-5.2 M/uL\n Platelets 129 K/uL 150-370 K/uL\n MCV 78.0 fL 80.0-99.0 fL\n MCH 25.1 pg 27.0-33.5 pg\n Absolute Lymphocytes 0.91 K/uL 1.10-4.50 K/uL\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on Mrs. Hilary Sanders, born on 08/24/1976, who\npresented to our Immunodeficiency Clinic on 10/06/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Hepatosplenomegaly\n\n- Thoracoabdominal, inguinal, and axillary lymphadenopathy\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** Mrs. Sanders first presented herself to our clinic,\nwith suspected undiagnosed immunodeficiency. Regular subcutaneous\nimmunoglobulin therapy with Hizentra 20% (2x20mL/week) has been\nwell-tolerated. Initially, there were frequent upper respiratory tract\ninfections with sore throat and cough. In the absence of fever, a\none-time course of Cotrim was prescribed for 7 days due to sinusitis. We\ndiscussed Mrs. Sanders' medical history in detail, including the recent\nCT findings. She has been informed about the necessity of vigilance in\ncase of unclear and especially persistent lymph node swellings.\nRegarding the inguinal and axillary lymph nodes measuring up to 30mm in\ndiameter found on CT, we recommend an observational approach with\nregular sonographic monitoring. There have been no significant changes\nin laboratory parameters, with good IgG levels during ongoing\nsubstitution therapy and known moderate leukopenia and lymphopenia.\nDuring the next appointment, an additional lung function test, including\ndiffusion measurement, will be conducted\n\n**Current Recommendations:**\n\n- Outpatient follow-up, including lung function test\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% (2x20mL/week).\n\n- Current gastroscopy.\n\n<!-- -->\n\n- In case of acute infection: increase immunoglobulin administration.\n\n- Administer targeted, sufficiently long, and high-dose antibiotic\n therapy if bacterial infections require treatment.\n\n- Ideally, obtain material for microbiological diagnostics.\n\n- In case of increasing diarrhea, consider outpatient stool\n examinations, including Giardia lamblia and Cryptosporidium.\n\n- Abdominal ultrasound: annually.\n\n- Lung function test, including diffusion measurement: annually.\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually.\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings or H. pylori testing\n\n- Chest X-ray or CT thorax: if clinical symptoms or lung function\n abnormalities are observed.\n\n- Seasonal influenza vaccination: annually.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.1 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffé) 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n Immunoglobulin G 1025 mg/dL 700-1600 mg/dL\n Immunoglobulin A 16 mg/dL 70-400 mg/dL\n Immunoglobulin M 28 mg/dL 40-230 mg/dL\n Free Lambda Light Chains 5.86 5.70-26.30\n Free Kappa Light Chains 6.05 3.30-19.40\n Kappa/Lambda Ratio 1.03 0.26-1.65\n IgG Subclass 1 580.9 mg/dL 280-800 mg/dL\n IgG Subclass 2 340.7 mg/dL 115-570 mg/dL\n IgG Subclass 3 50.9 mg/dL 24-125 mg/dL\n IgG Subclass 4 5.7 mg/dL 5.2-125 mg/dL\n CRP 7.3 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 13.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 5.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n**Abdominal Ultrasound on 10/06/2017:**\n\n[Liver]{.underline}: Measures 19 cm in the MCL, homogeneous parenchyma,\nno focal lesions.\n\n[Gallbladder/Biliary Tract:]{.underline} No evidence of calculi, no\nsigns of inflammation, no congestion.\n\n[Spleen]{.underline}: Measures 14 cm in diameter, homogeneous. Accessory\nspleen measures 16 mm at the hilus.\n\n[Pancreas]{.underline}: Morphologically unremarkable, as far as visible\ndue to intestinal gas overlay, no evidence of space-occupying processes.\n\nRetroperitoneum: No signs of aneurysms. Enlarged retroperitoneal and\niliac lymph nodes, measuring up to approximately 2.5 cm in diameter.\n\n[Kidneys]{.underline}: Both kidneys are of normal size (right 4.3 x 11.8\ncm, left 4.6 cm x 11.9 cm). No congestion, no evidence of calculi\n(stones), no evidence of space-occupying processes.\n\n[Bladder]{.underline}: Smoothly defined and normally configured.\nMinimally filled.\n\n[Uterus]{.underline}: Size within the normal range, homogeneous.\n\nNo ascites.\n\n[Assessment:]{.underline} Evidence of enlarged lymph nodes up to 2.5 cm\nretroperitoneal and iliac. Compared to previous findings, a slight\ndecrease in splenomegaly.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on the examination results of our patient, Mrs. Hilary\nSanders, born on 08/24/1976, who presented herself in our\nImmunodeficiency Clinic on 02/10/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Ongoing diarrhea in the morning, often\nrecurring in the afternoon. No melena, no fresh blood. Resolving\nrespiratory infection, positive influenza.\n\nCurrently, IgG levels remain within the target range. An increased need\nfor immunoglobulins is expected, especially in the third trimester of\npregnancy. Therefore, we recommend close monitoring with us during\npregnancy. Ferritin levels have further declined, indicating the need\nfor iron substitution. Anamnestically, there is an intolerance to oral\niron preparations.\n\n**Recommendations:**\n\n- Outpatient follow-up\n\n- Early follow-up in case of infections or persistent diarrhea\n\n- Continue regular subcutaneous immunoglobulin therapy, currently with\n Hizentra 20% 2x20mL/week\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n04/12/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infection with symptoms for 3-4\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance.\n\nIgG levels remain within the target range; therefore, we recommend\ncontinuing the current treatment unchanged.\n\nSince the last visit, mild upper respiratory tract infections. No fever\n(except for one episode of sinusitis), no antibiotics. SCIG treatment\nunchanged with 3x20mL/week of Hizentra ®.\n\nMrs. Sanders continues to experience watery diarrhea about 5-7 times\ndaily. No blood in stools, no pain, no vomiting, no nausea. There has\nbeen no clear association with specific foods observed. Current weight:\n69kg.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori testing: e.g., breath test or Helicobacter\n pylori antigen in stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and Helicobacter pylori testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n02/18/2019.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infections with symptoms for 7\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance. Continued diarrhea, approximately 6 times a\nday, without weight loss. IgG levels remain within the target range;\ntherefore, we recommend continuing the current treatment unchanged.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue treatment as is\n\n- External upper gastrointestinal endoscopy (and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are writing to provide summary on the clinical course of Mrs. Hilary\nSanders, born on 08/24/1976, who presented at our outpatient\nImmunodeficiency Clinic.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n- Iron-deficiency anemia\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Overall stable condition. No longer\nexperiencing cough. Persistent fatigue. Upcoming appointment with the\nGastroenterology department next week. There is again an indication for\niron substitution.\n\n**Update on 11/15/2019: Laboratory results from 11/15/2019:**\nTransaminase elevation, Protein 18, markedly elevated BNP. However, IgA\nis at 0.5 (otherwise not detectable), IgG subclasses within normal\nrange. Findings do not align. Patient informed by phone, returning for\nfurther evaluation today; also screening for Hepatitis A, B, C, and E,\nEBV, CMV, TSH, coagulation. No shortness of breath, no edema, no\nabdominal enlargement, stable weight at 69 kg. In case of worsening\nsymptoms, shortness of breath, or fever, immediate referral to the\nemergency department recommended.\n\n**02/12/2020:** The patient is doing reasonably well. She has had a mild\ncold for about 2 weeks, no fever, but nasal congestion and\nyellowish-green sputum. No other infections. No antibiotics prescribed.\nShe has adapted to her gastrointestinal issues. An appointment with the\nGastroenterology department. She is currently working from home.\nMedication: no new medications, only Cuvitru 20mL 3x weekly. Weight\nremains stable at 67 kg. The last lung function test was in the summer\nof this year and was within normal limits. Imaging has not been\nperformed recently. Gastroscopy and colonoscopy have not been conducted\nfor some time.\n\n**04/14/2020:** Referral to Gastroenterology at is recommended for\npersistent abdominal symptoms.\n\n**10/24/2020:** The patient has mostly avoided social contacts due to\nthe pandemic. She continues to experience digestive problems (food\nintolerances, diarrhea, flatulence). She has less stamina. Few\ninfections in the past year, at most a minor cold. No significant\ninfections. Hizentra injections remain unchanged at 20 mL 3 times a\nweek.\n\n**03/22/2021:** Constant colds since December 2020. One-time antibiotic\ntreatment in October 2019. Subcutaneous Immunoglobulin therapy remains\nunchanged at 20 mL 3 times weekly.\n\n**09/19/2021:** She feels disoriented and very tired, more so than\nusual. Difficulty maintaining a steady gaze. No steroid therapy was\nadministered. CT showed enlarged lymph nodes. Diarrhea, especially in\nthe morning, 3-4 times a day, additional bowel movements with meals,\nsometimes watery. No fever, no infections. Hizentra injections continued\nunchanged.\n\n**Summary**: IgG levels are currently within the target range, so we\nrecommend continuing immunoglobulin substitution therapy without\nchanges. The antibody response (SARS-CoV-2 (S-Ag) IgG ELISA) to the\nCovid-19 vaccination is, as expected, negative. However, there is a\npositive detection of SARS-CoV-2 (N-Ag) IgG ELISA, as expected in the\ncase of viral contact (not vaccination). We consider this to be an\nunspecific reaction and recommend further monitoring at the next\nfollow-up appointment. With a platelet count currently at 55 K/uL, we\nrecommend a short-term blood count check with us or your primary care\nphysician.\n\nDue to the immunodeficiency, a lack of antibody response to vaccination\nwas expected. In the medium term, passive protection through\nimmunoglobulin substitution therapy will play a role. This is contingent\non a significant portion of plasma donors having antibodies against\nSARS-CoV2. There is a multi-month delay from the time of donation to the\nrelease of the preparations, so we anticipate that meaningful protection\nthrough immunoglobulin products will not be expected. An exact prognosis\nin this regard is not possible.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Consultation with Gastroenterology\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are providing you with an update regarding our patient Mrs. Hilary\nSanders, born on 08/24/1976. She was under our inpatient care from\n03/29/2023 to 04/05/2023.\n\n**Diagnoses:**\n\n- Suspected CVID-Associated enteropathy\n\n- Known hepatosplenomegaly with a borderline enlarged portal vein, no\n significant portocaval shunts. Multiple liver lesions, possibly\n hemangiomas further evaluation if not already done.\n\n- Known retroperitoneal and iliac lymphadenopathy, likely related to\n the underlying condition.\n\n- Known changes in the lower lung bases, likely associated with the\n underlying condition, e.g., ILD. Refer to previous examinations.\n\n- Capsule endoscopy: Incomplete capsule enteroscopy with no evidence\n of inflammatory changes. Some hyperemia and blurry vascular pattern\n observed in the visible colon.\n\n- CVID-Associated Hepatopathy in the Form of Nodular Regenerative\n Hyperplasia\n\n**Other Diagnoses:** Common Variable Immunodeficiency Syndrome (CVID)\nwith:\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n Hizentra 20%\n\n- Infectious manifestations: Frequent respiratory tract infections\n\n- Non-Infectious manifestations:\n\n - ITP (Immune Thrombocytopenia)\n\n - Hepatosplenomegaly\n\n - Lymphadenopathy in supraclavicular, infraclavicular,\n thoracoabdominal, inguinal, and axillary regions\n\n - Suspected Granulomatous-Lymphocytic Interstitial Lung Disease in\n CVID\n\n<!-- -->\n\n- Iron-deficiency anemia\n\n**Pysical Examination:** Patient in normal general condition and\nnutritional status (175 cm, 65.8 kg. No resting dyspnea.\n\n[Neuro (grossly orienting):]{.underline} awake, oriented to\ntime/place/person/situation, No evidence of focal neurological deficit.\nNo meningism.\n\n[Head/neck]{.underline}: pharynx non-irritable. Moist, rosy mucous\nmembranes. Tongue occupied.\n\n[Skin]{.underline}: intact, turgor normal, no icterus, no cyanosis.\n\n[Thorax]{.underline}: normal configuration, no spinal palpitation, renal\nbed clear.\n\n[Lung]{.underline}: vesicular breath sound bds, no accessory sounds,\nsonorous tapping sound bds.\n\n[Cor]{.underline}: Cardiac action pure, rhythmic, no vitia typical\nmurmurs.\n\n[Abdomen]{.underline}: regular bowel sounds, soft abdominal wall, no\ntenderness, no resistances, no hepatosplenomegaly.\n\n[Extremities]{.underline}: no edema. Feet warm. Dorsalis pedis +/+ and\nposterior tibial artery +/+.\n\n**Current Presentation:** The patient was admitted for further\nevaluation of suspected CVID-associated enteropathy, as she had been\nexperiencing chronic diarrhea for the past three years. On admission,\nthe patient reported an overall good general and nutritional condition.\nShe described her current subjective well-being as good but mentioned\nhaving chronic diarrhea for the past three years, with up to 7 bowel\nmovements per day. The stools were watery without any signs of blood.\nThere were no indications of infection, such as fever, chills, dysuria,\nhematuria, cough, sputum, or dyspnea. She also experienced intermittent\nleft-sided upper abdominal pain, primarily postprandially. She had a\ngood appetite.\n\nOn the day of admission, an esophagogastroduodenoscopy was performed,\nwhich revealed erythematous antral gastritis. Additionally, there was an\napproximately 1 cm irregular mucosal area at the corpus-antrum junction\non the greater curvature side. A magnetic resonance imaging scan showed\nno evidence of inflamed bowel loops, ruling out chronic inflammatory\nbowel disease or celiac disease. To further investigate, a capsule\nendoscopy was performed, with results pending at the time of discharge.\nHypovitaminosis B12 and folate deficiency were ruled out. However,\niron-deficiency anemia was confirmed, and the patient had already\nscheduled an outpatient appointment for iron substitution. Serum levels\nof vitamin B6 and zinc were pending at discharge.\n\nDue to a moderate increase in transaminases and evidence of\nhepatosplenomegaly, we decided, after detailed explanation and with the\npatient\\'s consent, to perform a sonographically guided liver biopsy in\naddition to the planned endoscopy. The differential diagnosis included\nCVID-associated hepatopathy. The biopsy was successfully conducted ,\nwithout any post-interventional bleeding. Histology revealed mild acute\nhepatitis and nodular regenerative hyperplasia.This finding could be\nconsistent with changes in CVID-associated hepatopathy. Granulomas were\nnot observed. With only slightly elevated liver values, a trial therapy\nwith budesonide was initiated, and clinical (diarrhea?) and laboratory\n(transaminases?) follow-up will be performed in the outpatient setting.\n\nWe discharged Mrs. Sanders in a cardiopulmonarily stable condition.\n\n[Current Recommendations:]{.underline}\n\n- Follow-up in the gastroenterological outpatient clinic\n\n**Esophagogastroduodenoscopy (EGD) on 04/01/2023:** Introduction of the\ngastroscope in a left lateral position. Visualized up to the descending\npart of the duodenum. Unremarkable upper esophageal sphincter. Normal\nmotility and mucosa in the upper, middle, and distal esophagus. The\nZ-line is sharply demarcated in the hiatus. The cardia closes\nsufficiently. The stomach expands normally in all parts under air\ninsufflation. Multiple glandular cysts \\< 8 mm in size in the fundus and\ncorpus. Approximately 1 cm irregular mucosal area at the corpus-antrum\njunction on the greater curvature side. Streaky redness of the mucosa in\nthe antrum. Unremarkable mucosa in the bulb. Unremarkable mucosa in the\ndescending part of the duodenum. Step biopsies performed.\n\n[Summary]{.underline}: Erythematous antral gastritis. Approximately 1 cm\nirregular mucosal area at the corpus-antrum junction on the greater\ncurvature side, suggestive of inflammation. Multiple glandular cysts\nobserved in the fundus and corpus.\n\n[Abdominal MRI on 04/02/2023:]{.underline}\n\n[Clinical information, questions, and justification for the\nexam]{.underline}: Chronic diarrhea, suspected CVID-associated\nenteropathy, differential diagnosis of celiac disease, and inflammatory\nbowel disease (IBD). Assessment of malignancy.\n\nTechnique: After oral administration of mannitol solution and injection\nof 40 mg Buscopan, a 3-Tesla abdominal MRI was performed.\n\n[Findings]{.underline}: Multiple nodular consolidations and opacities\ndetected in the lower basal lung segments, measuring 7 x 4 mm, for\nexample, in the right lateral lower lobe (Series 18, Image 3).\nAdditionally, streaky-reticular changes observed. Left diaphragmatic\nelevation. Liver globally enlarged and smooth-bordered with several\nlesions showing mild to moderately hyperintense signals in T2-weighted\nimages and hypointense signals in T1-weighted images. These lesions\ndemonstrated increased enhancement in the early contrast phases,\nespecially those at the periphery, and more diffuse enhancement in the\nlate phases. For example, a lesion measuring 12 x 11 mm in Segment 2, a\nlesion measuring 8 mm in Segment 8 and a lesion measuring 21 x 13 mm in\nSegment 7. The portal vein measures borderline wide, up to 15 mm in\ndiameter. Gallbladder is unremarkable without evidence of stones. Intra-\nand extrahepatic bile ducts are not dilated. Spleen significantly\nenlarged, measuring 14 cm in pole-to-pole distance and 7.2 cm in\ntransverse diameter, homogeneous enhancement in native phases and late\ncontrast phase. Large accessory spleen located hilarly. Bilateral\nadrenal glands appear slender. Pancreas displays typical appearance with\nno ductal dilatation. Both kidneys are in orthotopic position, with\nunremarkable cortical cysts on the right side. No signs of urinary\nobstruction. The urinary bladder is moderately filled. No free fluid.\nAdequate dilation of small bowel loops. No evidence of significant bowel\nobstruction. No thickened bowel walls or increased post-contrast signal\nin the bowel loops. Cystic lesion in the right ovary measuring 17 x 11\nmm consistent with a corpus luteum cyst. Multiple enlarged\nretroperitoneal lymph nodes observed, for example, paracaval node with a\nshort-axis diameter of 14 mm and right iliacoexternal node with a\nshort-axis diameter of 14.5 mm No evidence of enlarged mesenteric or\ninguinal lymph nodes.\n\n\n\n\nHere is the query:\nPlease select the correct chronological order of radiological imaging studies Mrs. Sanders received: \n\nChoose the correct answer from the following options:\nA. Chest X-ray < Abdominal Ultrasound < CT Scan of Chest/Abdomen/Pelvis < Abdominal Ultrasound < Abdominal MRI\nB. Chest X-ray < Abdominal Ultrasound < CT Scan of Chest/Abdomen/Pelvis < CT Chest < Abdominal Ultrasound < Abdominal MRI\nC. Chest X-ray < Abdominal Ultrasound < CT Scan of Chest/Abdomen/Pelvis < Abdominal MRI < CT chest < Chest X-ray\nD. Chest X-ray < Abdominal Ultrasound < Gastrointestinal endoscopy and colonoscopy < CT Scan of Chest/Abdomen/Pelvis < Abdominal MRI < CT chest < Chest X-ray\nE. CT chest scan < Abdominal Ultrasound < CT Scan of Chest/Abdomen/Pelvis < Abdominal MRI < Gastroscopy: < Abdominal Ultrasound < CT chest\n\n\nYour response:\n", "role": "user" }, { "content": "Chest X-ray < Abdominal Ultrasound < CT Scan of Chest/Abdomen/Pelvis < Abdominal Ultrasound < Abdominal MRI", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are writing to provide an update on the examination results of our\npatient Mrs. Hilary Sanders, born on 08/24/1976, who presented to our\noutpatient clinic on 10/09/2016.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n human immunoglobulin\n\n**Medical History:** Mrs. Sanders presented with suspected previously\nundiagnosed immunodeficiency. There were no reports of frequent\ninfections during childhood and adolescence. No increased herpes\ninfections. No history of pneumonia, meningitis, or other serious\ninfections.\n\n**Current Presentation:** Mrs. Sanders has experienced recurrent\nrespiratory infections (bronchitis, pharyngitis) for about 3 years.\n\n**Physical Examination:** She reported joint pain in the left knee and\nnumbness below the shoulder blade. A tendency to bruise easily. No\nmucosal lesions, recurrent axillary lymph node swelling. No recurrent\nfevers. No B-symptoms. No resting dyspnea, no subjective heart rhythm\ndisturbances, no syncope, no peripheral edema, or other signs of\ncardiopulmonary decompensation.\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all IgG\n subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and NK-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B-cells.\n\n- Monocytic HLA-DR expression (immune competence marker) within the\n normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n- T-cell function after 24h polyvalent ConA stimulation: TNF-alpha,\n IFN-gamma, IL-2, IL-4 unremarkable\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells.\n\nFurther cellular immune status, including the complement system and\nsoluble mediators, showed no significant abnormalities except for an\nelevated soluble IL-2 receptor. Given the unremarkable monocytic\nTNF-alpha secretion after LPS stimulation, a significant Toll-like\nReceptor 4 defect is unlikely. An antibody response to Tetanus Toxoid\nwas demonstrated in a vaccine titer test. Protective\npneumococcal-specific antibodies could not be detected. There were no\nabnormalities in autoimmune diagnostics.\n\nImmunofixation showed no evidence of monoclonal gammopathy.\nHypogammaglobulinemia due to enteral or renal protein loss is unlikely\nin the presence of normal albumin.\n\nOverall, the picture is consistent with Common Variable\nImmunodeficiency. Formally, CVID is defined by a reduction in the major\nimmunoglobulin class IgG, with accompanying reduction in IgA and/or IgM,\nin the absence of normal or impaired vaccine response. Due to very low\nimmunoglobulin levels and planned travel, determination of vaccine\nresponse was currently omitted in the absence of therapeutic\nconsequence. After stable substitution, specific vaccine antibody levels\ncan be determined before or after vaccination, with the assumption that\nstable antibody concentrations exist due to continuous immunoglobulin\nsubstitution.\n\nAccording to B-cell differentiation, it corresponds to Type Ib according\nto the Freiburg Classification and Type B+smB-CD21lo according to the\nEuro Classification. The classification is clinically relevant, as Type\nIa is associated with increased immunocytopenias (especially ITP and\nAIH) and splenomegaly. In CVID with a high proportion (\\>10%) of CD-21\nlow B-cells, increased granulomatous diseases and splenomegaly have also\nbeen observed.\n\nThe indication for immunoglobulin substitution therapy exists because of\nrecurrent infections. The form of substitution therapy (intravenous. vs.\nsubcutaneous) is primarily based on patient preferences, but also on\nmedical conditions (concomitant diseases such as thrombocytopenia,\nconvenience, insurance, etc.).\n\n**Current Recommendations:**\n\nWe propose to initiate immunoglobulin substitution therapy with Hizentra\n20% (subcutaneous) at a dose of 200 ml once a week on Tuesdays. Further\ninformation and training on subcutaneous immunoglobulin substitution\ntherapy will be provided by a home care nursing service.\n\nMrs. Sanders will remain under regular medical supervision with close\nmonitoring of clinical symptoms, laboratory parameters, and the\neffectiveness of immunoglobulin substitution therapy. Any unexpected\nside effects or changes in her condition should be reported immediately.\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n --------------------------------------- --------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Calcium 2.41 mg/dL 2.15-2.50 mg/dL\n Inorganic Phosphate 1.00 mg/dL 0.87-1.45 mg/dL\n Selenium 0.79 µmol/L 0.60-1.50 µmol/L\n Zinc 10.1 µmol/L 9.0-22.0 µmol/L\n Creatinine 0.75 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 mL/min \\>90 mL/min\n Total Bilirubin 0.37 mg/dL \\< 1.20 mg/dL\n Albumin 4.55 g/dL 3.50-5.20 g/dL\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n A2-Globulin in Serum 10.7% 7.1-11.8%\n ß-Globulin in Serum 9.2% 8.4-13.1%\n Gamma-Globulin in Serum 3.2% 11.1-18.8%\n Immunoglobulin G 514 mg/dL 700-1600 mg/dL\n Immunoglobulin A 14 mg/dL 70-400 mg/dL\n Immunoglobulin M 19 mg/dL 40-230 mg/dL\n Immunoglobulin E 90 kU/L 0.0-100.0 kU/L\n IgG 1 299.5 mg/dL 280-800 mg/dL\n IgG 2 162.7 mg/dL 115-570 mg/dL\n IgG 3 49.1 mg/dL 24-125 mg/dL\n IgG 4 4.0 mg/dL 5.2-125 mg/dL\n Serum Immunofixation \n CRP 4.8 mg/L \\< 5.0 mg/L\n C3 Complement 980 mg/L 900-1800 mg/L\n C4 Complement 120 mg/L 100-400 mg/L\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n HBs Antigen Negative \n HBc Antibody Negative \n HBs Antibody Negative \n Ferritin 56 µg/L 13-140 µg/L\n ALT (GPT) 33 U/L \\< 31 U/L\n AST (GOT) 29 U/L \\< 35 U/L\n Alkaline Phosphatase 84 U/L 35-105 U/L\n Creatine Kinase 90 U/L \\< 167 U/L\n CK-MB 8.3 U/L \\< 24.0 U/L\n Gamma-GT 40 U/L 5-36 U/L\n LDH 204 U/L 135-214 U/L\n Lipase 50 U/L 13-60 U/L\n Cortisol 306.6 nmol/L 64.0-327.0 nmol/L\n 25-OH-Vitamin D3 65.3 nmol/L 50.0-150.0 nmol/L\n 1.25-OH-Vitamin D3 134 pmol/L 18.0-155.0 pmol/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Vitamin B12 770 pg/mL 191-663 pg/mL\n Folic Acid 14.6 ng/mL 4.6-18.7 ng/mL\n Hemoglobin 13.9 g/dL 12.0-15.6 g/dL\n Hematocrit 41.0% 35.5-45.5%\n Erythrocytes 5.2 M/uL 3.9-5.2 M/uL\n Leukocytes 4.13 K/uL 3.90-10.50 K/uL\n Platelets 174 K/uL 150-370 K/uL\n MCV 80.0 fL 80.0-99.0 fL\n MCH 26.7 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n RDW-CV 13.7% 11.5-15.0%\n Absolute Neutrophils 2.87 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.010 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.71 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.42 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.03 K/uL 0.00-0.20 K/uL\n HbA1c 4.9% \\< 6.0%\n HbA1c (IFCC) 30.1 mmol/mol \\< 42.0\n HBV Serology Result Negative \n HIV1/2 Antibodies, P24 Antigen Negative \n Hepatitis C Virus Antibodies in Serum Negative \n\n**Dear colleague,**\n\nWe report the examination results of Mrs. Hilary Sanders, born on\n08/24/1976 who presented at our outpatient clinic on 03/04/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all\n IgG-Subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and natural killer-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B cells.\n\n- Monocytic HLA-DR expression within the normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells. The further cellular immune\nstatus, including the complement system and soluble mediators, showed no\nsignificant abnormalities except for an elevated soluble IL-2 receptor.\n\n**Current Presentation:** Mrs. Sanders was again provided with detailed\ninformation about her condition and the planned course of action. We\nscheduled an appointment to initiate regular subcutaneous immunoglobulin\ntherapy.\n\n**Medical History:** Mrs. Sanders received her first dose of Hizentra\n20% subcutaneously as immunoglobulin substitution therapy for CVID. The\nadministration was well-tolerated initially, with no evidence of\nsignificant local or systemic side effects. Mrs. Sanders was once again\ninformed about possible risks (especially hypersensitivity reactions)\nand advised to contact us immediately in case of questions,\nuncertainties, or any abnormalities. The dosing for the first four weeks\nwas 3x20mL Hizentra 20% subcutaneously, and from the fifth week onward,\nit was changed to either 1x40mL or 2x20mL Hizentra 20% subcutaneously\nper week.\n\nIn the past days, Mrs. Sanders has been experiencing a cold: runny nose,\ncough (green-yellow), difficulty clearing mucus, slight fever, sinus\ninflammation, sore throat, difficulty speaking, and swallowing problems.\nThere was no improvement.\n\n**Physical Examination:** Reddened throat, no exudates, non-swollen\ncervical lymph nodes, lung examination showed bronchitis-like breathing\nsounds, no rales.\n\n**Therapy and Progression**: Today\\'s CRP is not elevated. IgGs are\nstill below normal. We recommended increasing immunoglobulin\nsubstitution during the infection. The patient had difficulty finding a\nsuitable injection site on her abdomen. However, she reported that the\nsecretions were gradually becoming lighter, so she decided to wait with\nthe antibiotic and only use it if there was no improvement.\n\nThe patient has been receiving 3x20mL Hizentra 20% per week since her\nlast visit. She complained of developing skin hardening at the injection\nsites, so a slower infusion time was discussed. She has been\nexperiencing a strong cough for several weeks without fever. No rales or\nsigns of pleuritis were detected on auscultation. No abnormalities were\nobserved on the chest X-ray. Laboratory results now show normal IgG\nlevels, so the dose was reduced to 2x20mL per week. A CT scan of the\nthorax and abdominal ultrasound were requested.\n\n**Chest X-ray in two planes from 03/04/2017:**\n\n[Findings/Assessment:]{.underline} No previous images are available for\ncomparison. Upper mediastinum and heart appear normal, with no central\ncongestion. No pneumothorax, effusions, confluent infiltrates, or\nsignificant focal lesions.\n\n**Abdominal ultrasound on 03/04/2017:**\n\nHepatosplenomegaly and retroperitoneal lymphadenopathy up to 26mm.\n\n**CT Chest/Abdomen/ from 03/04/2017:**\n\n[Methodology]{.underline}: Digital overview radiographs. After\nintravenous injection of contrast agent a 16-row CT scan of the thorax\nand entire abdomen was performed in the venous contrast phase, with\nprimary data set reconstruction at a thickness of 1.25 mm. Multiplanar\nreconstructions were created.\n\n[Findings]{.underline}: A conventional radiographic pre-image from\n11/18/2014 is available for comparison.\n\n[Thorax]{.underline}: Normal lung parenchyma with normal vascular\nmarkings. Small, sometimes hazy, sometimes nodular densities measuring\nup to 4mm in both lower lobes and the left upper lobe. Small\npleura-adjacent density in the right lower lobe. No evidence of\nconfluent infiltrates. No pleural effusion or pneumothorax. Normal heart\nsize and configuration. Normal diameter of the thoracic aorta and\npulmonary trunk. Increased number and enlarged retroclavicular lymph\nnodes on the right and left, axillary on both sides measuring up to 30mm\nin diameter. Trachea and esophagus displayed normally. No hiatus hernia.\nThyroid and neck soft tissues were unremarkable, as far as depicted.\nNormal thoracic soft tissue mantle. No soft tissue emphysema.\n\n[Abdomen]{.underline}: Hepatomegaly with morphologically normal liver\nparenchyma. No portal vein thrombosis. Gallbladder is unremarkable with\nno calculi. Intrahepatic and extrahepatic bile ducts are not dilated.\nPancreas is normally lobulated and structured, with no dilation of the\npancreatic duct. Splenomegaly. Accessory spleen measuring approximately\n20 mm in diameter. Splenic parenchyma is homogeneously contrasted in the\nvenous phase. Kidneys are orthotopically positioned, normal size with no\nside differences, and contrasted equally on both sides. Two regularly\nconfigured hypodense lesions in the left kidney, suggestive of\nuncomplicated renal cysts. No dilation of the urinary tract, and no\nevidence of stones. Adrenal glands are not visualized. Increased and\nenlarged mesenteric, pararaortic, parailiacal, and inguinal lymph nodes\nup to 30 mm in size. Gastrointestinal tract is displayed normally, as\nfar as assessable. Normal representation of major abdominal vessels. No\nfree intraperitoneal fluid or air.\n\n[Osseous structures:]{.underline} No evidence of suspicious osseous\ndestruction. Normal soft tissue mantle.\n\n[Assessment:]{.underline} Intrapulmonary multifocal, sometimes hazy,\nsometimes nodular densities, differential diagnosis includes atypical\npneumonia. Thoracoabdominal lymphadenopathy. Hepatosplenomegaly without\nsuspicious lesions.\n\n**Current Recommendations:**\n\n- Outpatient follow-up for discussion of findings\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% 2x20mL/week\n\n- Lung function test\n\n- Gastroscopy\n\n- In case of acute infection: increase immunoglobulin administration\n\n- Abdominal ultrasound: annually\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually Seasonal influenza vaccination: annually\n\n**Lab results upon discharge:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n Gamma-Globulin 3.2% 11.1-18.8%\n Immunoglobulin G 188 mg/dL 700-1600 mg/dL\n Immunoglobulin A 11 mg/dL 70-400 mg/dL\n Immunoglobulin M 12 mg/dL 40-230 mg/dL\n IgG Subclass 1 113 mg/dL 280-800 mg/dL\n IgG Subclass 2 49.1 mg/dL 115-570 mg/dL\n IgG Subclass 4 \\<0.0 mg/dL 5.2-125 mg/dL\n aPCP-IgG 7.32 mg/dL 10.00-191.20 mg/dL\n aPCP-IgG2 2.74 mg/dL 4.70-89.40 mg/dL\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n LDH 224 U/L 135-214 U/L\n Vitamin B12 708 pg/mL 191-663 pg/mL\n Erythrocytes 5.3 M/uL 3.9-5.2 M/uL\n Platelets 129 K/uL 150-370 K/uL\n MCV 78.0 fL 80.0-99.0 fL\n MCH 25.1 pg 27.0-33.5 pg\n Absolute Lymphocytes 0.91 K/uL 1.10-4.50 K/uL\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mrs. Hilary Sanders, born on 08/24/1976, who\npresented to our Immunodeficiency Clinic on 10/06/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Hepatosplenomegaly\n\n- Thoracoabdominal, inguinal, and axillary lymphadenopathy\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** Mrs. Sanders first presented herself to our clinic,\nwith suspected undiagnosed immunodeficiency. Regular subcutaneous\nimmunoglobulin therapy with Hizentra 20% (2x20mL/week) has been\nwell-tolerated. Initially, there were frequent upper respiratory tract\ninfections with sore throat and cough. In the absence of fever, a\none-time course of Cotrim was prescribed for 7 days due to sinusitis. We\ndiscussed Mrs. Sanders' medical history in detail, including the recent\nCT findings. She has been informed about the necessity of vigilance in\ncase of unclear and especially persistent lymph node swellings.\nRegarding the inguinal and axillary lymph nodes measuring up to 30mm in\ndiameter found on CT, we recommend an observational approach with\nregular sonographic monitoring. There have been no significant changes\nin laboratory parameters, with good IgG levels during ongoing\nsubstitution therapy and known moderate leukopenia and lymphopenia.\nDuring the next appointment, an additional lung function test, including\ndiffusion measurement, will be conducted\n\n**Current Recommendations:**\n\n- Outpatient follow-up, including lung function test\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% (2x20mL/week).\n\n- Current gastroscopy.\n\n<!-- -->\n\n- In case of acute infection: increase immunoglobulin administration.\n\n- Administer targeted, sufficiently long, and high-dose antibiotic\n therapy if bacterial infections require treatment.\n\n- Ideally, obtain material for microbiological diagnostics.\n\n- In case of increasing diarrhea, consider outpatient stool\n examinations, including Giardia lamblia and Cryptosporidium.\n\n- Abdominal ultrasound: annually.\n\n- Lung function test, including diffusion measurement: annually.\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually.\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings or H. pylori testing\n\n- Chest X-ray or CT thorax: if clinical symptoms or lung function\n abnormalities are observed.\n\n- Seasonal influenza vaccination: annually.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.1 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffé) 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n Immunoglobulin G 1025 mg/dL 700-1600 mg/dL\n Immunoglobulin A 16 mg/dL 70-400 mg/dL\n Immunoglobulin M 28 mg/dL 40-230 mg/dL\n Free Lambda Light Chains 5.86 5.70-26.30\n Free Kappa Light Chains 6.05 3.30-19.40\n Kappa/Lambda Ratio 1.03 0.26-1.65\n IgG Subclass 1 580.9 mg/dL 280-800 mg/dL\n IgG Subclass 2 340.7 mg/dL 115-570 mg/dL\n IgG Subclass 3 50.9 mg/dL 24-125 mg/dL\n IgG Subclass 4 5.7 mg/dL 5.2-125 mg/dL\n CRP 7.3 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 13.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 5.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n**Abdominal Ultrasound on 10/06/2017:**\n\n[Liver]{.underline}: Measures 19 cm in the MCL, homogeneous parenchyma,\nno focal lesions.\n\n[Gallbladder/Biliary Tract:]{.underline} No evidence of calculi, no\nsigns of inflammation, no congestion.\n\n[Spleen]{.underline}: Measures 14 cm in diameter, homogeneous. Accessory\nspleen measures 16 mm at the hilus.\n\n[Pancreas]{.underline}: Morphologically unremarkable, as far as visible\ndue to intestinal gas overlay, no evidence of space-occupying processes.\n\nRetroperitoneum: No signs of aneurysms. Enlarged retroperitoneal and\niliac lymph nodes, measuring up to approximately 2.5 cm in diameter.\n\n[Kidneys]{.underline}: Both kidneys are of normal size (right 4.3 x 11.8\ncm, left 4.6 cm x 11.9 cm). No congestion, no evidence of calculi\n(stones), no evidence of space-occupying processes.\n\n[Bladder]{.underline}: Smoothly defined and normally configured.\nMinimally filled.\n\n[Uterus]{.underline}: Size within the normal range, homogeneous.\n\nNo ascites.\n\n[Assessment:]{.underline} Evidence of enlarged lymph nodes up to 2.5 cm\nretroperitoneal and iliac. Compared to previous findings, a slight\ndecrease in splenomegaly.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination results of our patient, Mrs. Hilary\nSanders, born on 08/24/1976, who presented herself in our\nImmunodeficiency Clinic on 02/10/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Ongoing diarrhea in the morning, often\nrecurring in the afternoon. No melena, no fresh blood. Resolving\nrespiratory infection, positive influenza.\n\nCurrently, IgG levels remain within the target range. An increased need\nfor immunoglobulins is expected, especially in the third trimester of\npregnancy. Therefore, we recommend close monitoring with us during\npregnancy. Ferritin levels have further declined, indicating the need\nfor iron substitution. Anamnestically, there is an intolerance to oral\niron preparations.\n\n**Recommendations:**\n\n- Outpatient follow-up\n\n- Early follow-up in case of infections or persistent diarrhea\n\n- Continue regular subcutaneous immunoglobulin therapy, currently with\n Hizentra 20% 2x20mL/week\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n04/12/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infection with symptoms for 3-4\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance.\n\nIgG levels remain within the target range; therefore, we recommend\ncontinuing the current treatment unchanged.\n\nSince the last visit, mild upper respiratory tract infections. No fever\n(except for one episode of sinusitis), no antibiotics. SCIG treatment\nunchanged with 3x20mL/week of Hizentra ®.\n\nMrs. Sanders continues to experience watery diarrhea about 5-7 times\ndaily. No blood in stools, no pain, no vomiting, no nausea. There has\nbeen no clear association with specific foods observed. Current weight:\n69kg.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori testing: e.g., breath test or Helicobacter\n pylori antigen in stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and Helicobacter pylori testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n02/18/2019.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infections with symptoms for 7\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance. Continued diarrhea, approximately 6 times a\nday, without weight loss. IgG levels remain within the target range;\ntherefore, we recommend continuing the current treatment unchanged.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue treatment as is\n\n- External upper gastrointestinal endoscopy (and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are writing to provide summary on the clinical course of Mrs. Hilary\nSanders, born on 08/24/1976, who presented at our outpatient\nImmunodeficiency Clinic.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n- Iron-deficiency anemia\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Overall stable condition. No longer\nexperiencing cough. Persistent fatigue. Upcoming appointment with the\nGastroenterology department next week. There is again an indication for\niron substitution.\n\n**Update on 11/15/2019: Laboratory results from 11/15/2019:**\nTransaminase elevation, Protein 18, markedly elevated BNP. However, IgA\nis at 0.5 (otherwise not detectable), IgG subclasses within normal\nrange. Findings do not align. Patient informed by phone, returning for\nfurther evaluation today; also screening for Hepatitis A, B, C, and E,\nEBV, CMV, TSH, coagulation. No shortness of breath, no edema, no\nabdominal enlargement, stable weight at 69 kg. In case of worsening\nsymptoms, shortness of breath, or fever, immediate referral to the\nemergency department recommended.\n\n**02/12/2020:** The patient is doing reasonably well. She has had a mild\ncold for about 2 weeks, no fever, but nasal congestion and\nyellowish-green sputum. No other infections. No antibiotics prescribed.\nShe has adapted to her gastrointestinal issues. An appointment with the\nGastroenterology department. She is currently working from home.\nMedication: no new medications, only Cuvitru 20mL 3x weekly. Weight\nremains stable at 67 kg. The last lung function test was in the summer\nof this year and was within normal limits. Imaging has not been\nperformed recently. Gastroscopy and colonoscopy have not been conducted\nfor some time.\n\n**04/14/2020:** Referral to Gastroenterology at is recommended for\npersistent abdominal symptoms.\n\n**10/24/2020:** The patient has mostly avoided social contacts due to\nthe pandemic. She continues to experience digestive problems (food\nintolerances, diarrhea, flatulence). She has less stamina. Few\ninfections in the past year, at most a minor cold. No significant\ninfections. Hizentra injections remain unchanged at 20 mL 3 times a\nweek.\n\n**03/22/2021:** Constant colds since December 2020. One-time antibiotic\ntreatment in October 2019. Subcutaneous Immunoglobulin therapy remains\nunchanged at 20 mL 3 times weekly.\n\n**09/19/2021:** She feels disoriented and very tired, more so than\nusual. Difficulty maintaining a steady gaze. No steroid therapy was\nadministered. CT showed enlarged lymph nodes. Diarrhea, especially in\nthe morning, 3-4 times a day, additional bowel movements with meals,\nsometimes watery. No fever, no infections. Hizentra injections continued\nunchanged.\n\n**Summary**: IgG levels are currently within the target range, so we\nrecommend continuing immunoglobulin substitution therapy without\nchanges. The antibody response (SARS-CoV-2 (S-Ag) IgG ELISA) to the\nCovid-19 vaccination is, as expected, negative. However, there is a\npositive detection of SARS-CoV-2 (N-Ag) IgG ELISA, as expected in the\ncase of viral contact (not vaccination). We consider this to be an\nunspecific reaction and recommend further monitoring at the next\nfollow-up appointment. With a platelet count currently at 55 K/uL, we\nrecommend a short-term blood count check with us or your primary care\nphysician.\n\nDue to the immunodeficiency, a lack of antibody response to vaccination\nwas expected. In the medium term, passive protection through\nimmunoglobulin substitution therapy will play a role. This is contingent\non a significant portion of plasma donors having antibodies against\nSARS-CoV2. There is a multi-month delay from the time of donation to the\nrelease of the preparations, so we anticipate that meaningful protection\nthrough immunoglobulin products will not be expected. An exact prognosis\nin this regard is not possible.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Consultation with Gastroenterology\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update regarding our patient Mrs. Hilary\nSanders, born on 08/24/1976. She was under our inpatient care from\n03/29/2023 to 04/05/2023.\n\n**Diagnoses:**\n\n- Suspected CVID-Associated enteropathy\n\n- Known hepatosplenomegaly with a borderline enlarged portal vein, no\n significant portocaval shunts. Multiple liver lesions, possibly\n hemangiomas further evaluation if not already done.\n\n- Known retroperitoneal and iliac lymphadenopathy, likely related to\n the underlying condition.\n\n- Known changes in the lower lung bases, likely associated with the\n underlying condition, e.g., ILD. Refer to previous examinations.\n\n- Capsule endoscopy: Incomplete capsule enteroscopy with no evidence\n of inflammatory changes. Some hyperemia and blurry vascular pattern\n observed in the visible colon.\n\n- CVID-Associated Hepatopathy in the Form of Nodular Regenerative\n Hyperplasia\n\n**Other Diagnoses:** Common Variable Immunodeficiency Syndrome (CVID)\nwith:\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n Hizentra 20%\n\n- Infectious manifestations: Frequent respiratory tract infections\n\n- Non-Infectious manifestations:\n\n - ITP (Immune Thrombocytopenia)\n\n - Hepatosplenomegaly\n\n - Lymphadenopathy in supraclavicular, infraclavicular,\n thoracoabdominal, inguinal, and axillary regions\n\n - Suspected Granulomatous-Lymphocytic Interstitial Lung Disease in\n CVID\n\n<!-- -->\n\n- Iron-deficiency anemia\n\n**Pysical Examination:** Patient in normal general condition and\nnutritional status (175 cm, 65.8 kg. No resting dyspnea.\n\n[Neuro (grossly orienting):]{.underline} awake, oriented to\ntime/place/person/situation, No evidence of focal neurological deficit.\nNo meningism.\n\n[Head/neck]{.underline}: pharynx non-irritable. Moist, rosy mucous\nmembranes. Tongue occupied.\n\n[Skin]{.underline}: intact, turgor normal, no icterus, no cyanosis.\n\n[Thorax]{.underline}: normal configuration, no spinal palpitation, renal\nbed clear.\n\n[Lung]{.underline}: vesicular breath sound bds, no accessory sounds,\nsonorous tapping sound bds.\n\n[Cor]{.underline}: Cardiac action pure, rhythmic, no vitia typical\nmurmurs.\n\n[Abdomen]{.underline}: regular bowel sounds, soft abdominal wall, no\ntenderness, no resistances, no hepatosplenomegaly.\n\n[Extremities]{.underline}: no edema. Feet warm. Dorsalis pedis +/+ and\nposterior tibial artery +/+.\n\n**Current Presentation:** The patient was admitted for further\nevaluation of suspected CVID-associated enteropathy, as she had been\nexperiencing chronic diarrhea for the past three years. On admission,\nthe patient reported an overall good general and nutritional condition.\nShe described her current subjective well-being as good but mentioned\nhaving chronic diarrhea for the past three years, with up to 7 bowel\nmovements per day. The stools were watery without any signs of blood.\nThere were no indications of infection, such as fever, chills, dysuria,\nhematuria, cough, sputum, or dyspnea. She also experienced intermittent\nleft-sided upper abdominal pain, primarily postprandially. She had a\ngood appetite.\n\nOn the day of admission, an esophagogastroduodenoscopy was performed,\nwhich revealed erythematous antral gastritis. Additionally, there was an\napproximately 1 cm irregular mucosal area at the corpus-antrum junction\non the greater curvature side. A magnetic resonance imaging scan showed\nno evidence of inflamed bowel loops, ruling out chronic inflammatory\nbowel disease or celiac disease. To further investigate, a capsule\nendoscopy was performed, with results pending at the time of discharge.\nHypovitaminosis B12 and folate deficiency were ruled out. However,\niron-deficiency anemia was confirmed, and the patient had already\nscheduled an outpatient appointment for iron substitution. Serum levels\nof vitamin B6 and zinc were pending at discharge.\n\nDue to a moderate increase in transaminases and evidence of\nhepatosplenomegaly, we decided, after detailed explanation and with the\npatient\\'s consent, to perform a sonographically guided liver biopsy in\naddition to the planned endoscopy. The differential diagnosis included\nCVID-associated hepatopathy. The biopsy was successfully conducted ,\nwithout any post-interventional bleeding. Histology revealed mild acute\nhepatitis and nodular regenerative hyperplasia.This finding could be\nconsistent with changes in CVID-associated hepatopathy. Granulomas were\nnot observed. With only slightly elevated liver values, a trial therapy\nwith budesonide was initiated, and clinical (diarrhea?) and laboratory\n(transaminases?) follow-up will be performed in the outpatient setting.\n\nWe discharged Mrs. Sanders in a cardiopulmonarily stable condition.\n\n[Current Recommendations:]{.underline}\n\n- Follow-up in the gastroenterological outpatient clinic\n\n**Esophagogastroduodenoscopy (EGD) on 04/01/2023:** Introduction of the\ngastroscope in a left lateral position. Visualized up to the descending\npart of the duodenum. Unremarkable upper esophageal sphincter. Normal\nmotility and mucosa in the upper, middle, and distal esophagus. The\nZ-line is sharply demarcated in the hiatus. The cardia closes\nsufficiently. The stomach expands normally in all parts under air\ninsufflation. Multiple glandular cysts \\< 8 mm in size in the fundus and\ncorpus. Approximately 1 cm irregular mucosal area at the corpus-antrum\njunction on the greater curvature side. Streaky redness of the mucosa in\nthe antrum. Unremarkable mucosa in the bulb. Unremarkable mucosa in the\ndescending part of the duodenum. Step biopsies performed.\n\n[Summary]{.underline}: Erythematous antral gastritis. Approximately 1 cm\nirregular mucosal area at the corpus-antrum junction on the greater\ncurvature side, suggestive of inflammation. Multiple glandular cysts\nobserved in the fundus and corpus.\n\n[Abdominal MRI on 04/02/2023:]{.underline}\n\n[Clinical information, questions, and justification for the\nexam]{.underline}: Chronic diarrhea, suspected CVID-associated\nenteropathy, differential diagnosis of celiac disease, and inflammatory\nbowel disease (IBD). Assessment of malignancy.\n\nTechnique: After oral administration of mannitol solution and injection\nof 40 mg Buscopan, a 3-Tesla abdominal MRI was performed.\n\n[Findings]{.underline}: Multiple nodular consolidations and opacities\ndetected in the lower basal lung segments, measuring 7 x 4 mm, for\nexample, in the right lateral lower lobe (Series 18, Image 3).\nAdditionally, streaky-reticular changes observed. Left diaphragmatic\nelevation. Liver globally enlarged and smooth-bordered with several\nlesions showing mild to moderately hyperintense signals in T2-weighted\nimages and hypointense signals in T1-weighted images. These lesions\ndemonstrated increased enhancement in the early contrast phases,\nespecially those at the periphery, and more diffuse enhancement in the\nlate phases. For example, a lesion measuring 12 x 11 mm in Segment 2, a\nlesion measuring 8 mm in Segment 8 and a lesion measuring 21 x 13 mm in\nSegment 7. The portal vein measures borderline wide, up to 15 mm in\ndiameter. Gallbladder is unremarkable without evidence of stones. Intra-\nand extrahepatic bile ducts are not dilated. Spleen significantly\nenlarged, measuring 14 cm in pole-to-pole distance and 7.2 cm in\ntransverse diameter, homogeneous enhancement in native phases and late\ncontrast phase. Large accessory spleen located hilarly. Bilateral\nadrenal glands appear slender. Pancreas displays typical appearance with\nno ductal dilatation. Both kidneys are in orthotopic position, with\nunremarkable cortical cysts on the right side. No signs of urinary\nobstruction. The urinary bladder is moderately filled. No free fluid.\nAdequate dilation of small bowel loops. No evidence of significant bowel\nobstruction. No thickened bowel walls or increased post-contrast signal\nin the bowel loops. Cystic lesion in the right ovary measuring 17 x 11\nmm consistent with a corpus luteum cyst. Multiple enlarged\nretroperitoneal lymph nodes observed, for example, paracaval node with a\nshort-axis diameter of 14 mm and right iliacoexternal node with a\nshort-axis diameter of 14.5 mm No evidence of enlarged mesenteric or\ninguinal lymph nodes.\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n\n\n\n\nHere is the query:\nWhich medication was NOT part of Mr. Chapman's regimen post-transfer?\n\nChoose the correct answer from the following options:\nA. Bisoprolol\nB. Diazepam\nC. Ciprofloxacin\nD. Meropenem\nE. Aspirin\n\n\nYour response:\n", "role": "user" }, { "content": "Diazepam", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n\n\n\n\nHere is the query:\nComparing the laboratory results of Mr. John Chapman between 2018 and 2019, which of the following statements is correct?\n\n\nChoose the correct answer from the following options:\nA. The creatinine level normalized from a previously low value to within the reference range.\nB. Hemoglobin levels decreased further outside the reference range.\nC. White blood cell count showed a significant increase from 2018 to 2019.\nD. Platelet count remained consistently above the reference range in both years.\nE. The patient's RDW-CV (Red Cell Distribution Width-Coefficient of Variation) levels decreased from 2018 to 2019.\n\n\nYour response:\n", "role": "user" }, { "content": "The creatinine level normalized from a previously low value to within the reference range.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, ****Dear colleague, **\n\n \n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who was treated in our clinic from 05/28/14 to 06/20/14.\n\n \n\n**Diagnoses: **\n\n- pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left\n midline tongue carcinoma\n\n- Arterial hypertension\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Idiopathic thrombocytopenia\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Hypothyroidism\n\n- Nicotine abuse\n\n<!-- -->\n\n- Panendoscopy with sampling on 04/14/2014 and 04/26/2014\n\n \n\n**Current Presentation**: With histologically confirmed carcinoma in the\nregion of the base of the tongue on the left side, Mr. Doe presents for\nsurgical treatment of the findings. In accordance with the tumor board\ndecision, resection is performed via a lateral pharyngotomy and neck\ndissection on both sides.\n\n \n\n**Physical Examination:** Patient in stable general condition (85 kg,\n188 cm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I° (L-thyroxine increased to 150 μg 1-0-0), hoarseness\n0°, hearing loss 0° (subjectively reduced), dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\nA tumorous mass can be inspected at the base of the left tongue. Tongue\nmobility is unremarkable.\n\n**CT chest, abdomen, pelvis on 05/28/14:**\n\nEmphasized mediastinal as well as abdominal lymph\nnodes.** **Vasosclerosis. Otherwise, there is no evidence for the\npresence of distant metastases with a suspected base of tongue\ncarcinoma. Liver cirrhosis.\n\n \n\n**CT neck on 06/11/14:**\n\nSuspected left tongue base carcinoma crossing midline with extension\ninto the left vallecula and compression of the left piriform sinus with\nsuspected lymph node metastases in levels I-III ipsilateral.\nContralateral prominent but not certainly suspicious lymph nodes. The\nprominent structure on the left supraclavicular side can also be\ninterpreted as circumscribed cystiform ectasia of the thoracic duct.\n\n \n\n**Ultrasound abdomen on 06/15/14:**\n\nImage of liver cirrhosis status post cholecystectomy.\nHepatosplenomegaly. Moderate aortic sclerosis.\n\n \n\n**X-ray pap swallow on 06/17/14:**\n\nClear tracheal aspiration in the absence of epiglottis envelope. The\ncough reflex is preserved. Otherwise, essentially unremarkable\nswallowing act. \n\n \n\n**Histology**: Invasive, moderately differentiated, squamous cell\ncarcinoma with keratinization of the medial left base of the tongue,\nmaximum extent 1.0 cm. Carcinoma- and dysplasia-free biopsies of the\nleft tonsil, the oropharyngeal tumor/tongue base on the left, deep\nresection of the tumor, lower tonsillar pole transition on the left\ntongue base, tongue base on the left and medial left tongue base, as\nwell as median tongue base.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** pT1. pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n \n\n**Therapy and Progression**: After the usual clinical and laboratory\npreparations, we performed the above-mentioned therapy on 05/29/14 in\nintubation anesthesia without complications. For perioperative infection\nprophylaxis, the patient received intravenous antibiotic therapy with\nAmpicillin and Sulbactam 3g three times daily for the duration of his\nhospital stay.\n\nDuring this procedure, the left lingual artery was interrupted\nprophylactically. No postoperative bleeding and no wound healing\ndisturbances occurred.\n\nA porridge swallow examination showed no evidence of a fistula. On the\nfollowing day, the patient was decannulated in consultation with the\ncolleagues of the speech therapy. After this, a food build-up was\ncarried out in cooperation with speech therapists. At the time of\ndischarge, the patient was receiving regular oral nutrition. The stoma\ncontinued to shrink. The patient was monitored, and if necessary, the\ntracheostoma was closed with local anesthesia. Histological findings\nwere pT1. Due to an RX status, adjuvant radiotherapy will be performed\nas decided by the tumor board. A prophylactic presentation at the\ncolleagues of the MKG as a preparatory measure for the upcoming\nradiotherapy. We asked for a control re-presentation in our outpatient\nclinic on 06/26/14 at 3:00 PM. Further controls take place at the half\nand at the end of the radiotherapy and further in 4-6 weeks rhythm. In\ncase of acute complaints, an immediate re-presentation is possible at\nany time.\n\n \n\n**Type of surgery**: Lateral pharyngotomy with resection of the base of\nthe tongue on the left as well as selective neck dissection on both\nsides level II-IV with ligature of the lingual artery on the left side,\ncreation of a stable tracheostoma and tonsillectomy on the left side.\n\n**Surgery report: **First, tracheotomy in a typical manner. A horizontal\nincision was made on the skin, positioned approximately two transverse\nfinger widths above the jugulum. Subsequently, the subcutaneous tissue\nand the platysma colli were incised. To facilitate access to the\ntrachea, the laryngeal muscles were carefully displaced to the side. The\nthyroid isthmus was undermined and clamped bilaterally. A precise\ntransection of the thyroid isthmus followed, with both halves of the\nthyroid gland being meticulously sutured using 0- Vicryl. The thyroid\nhalves were repositioned to expose the trachea. A visceral tracheotomy\nwas performed, and re-intubation was achieved utilizing a U-tube. The\nsurgical procedure then transitioned to a neck dissection on the left\nside. This phase began with an incision along the anterior edge of the\nsternocleidomastoid muscle. The subcutaneous tissue and platysma colli\nwere carefully cut, with due respect to the auricularis magnus nerve.\nDissection continued dorsally along the sternocleidomastoid muscle to\nreach the anterior border of the trapezius muscle. Further exposure\ninvolved the accessorius nerve in a cranialward direction, with\npreservation of this neural structure. Dissection proceeded along the\ncervical vascular sheath, revealing the common carotid artery, internal\njugular vein, and vagus nerve up to the digastric muscle. Below this\nlevel, exposure of the hypoglossal nerve was achieved.\n\nSuccessive dissection involved the lymph node fat package, progressing\nfrom level II to level IV in a cranial to caudal and ventral to dorsal\ndirection. Throughout this process, careful attention was paid to\nsparing the aforementioned neural and vascular structures. Subsequently,\naccess to the lateral pharyngectomy area was gained, allowing\nvisualization of the external carotid artery along with its branches,\nincluding the superior thyroid artery, superior laryngeal artery, and\nlingual artery. Notably, the lingual artery was interrupted during this\nstage.\n\nFurther exploration revealed the superior laryngeal nerve and\nhypoglossal nerve intersecting in a loop above the internal carotid\nartery and externally below the external jugular vein. Additional\ndissection in a ventral direction followed. The hypoglossal nerve was\nprepared meticulously. Exposure of the hyoid bone was achieved, with a\nposterior resection of half of the hyoid bone. Importantly, the\nhypoglossal nerve was spared during this procedure. Subsequent to these\nsteps, the lateral pharynx wall was opened, exposing the base of the\nhyoid. The next phase of the procedure involved enoral tumor\ntonsillectomy on the left side. Starting from the left side, the\nsurgical team identified the tonsil capsule at the anterior palatal arch\nusing a Henke spatula. The upper tonsillar pole was then dislodged and\ndissected with the Rosenblatt instrument, proceeding from cranial to\ncaudal. Hemostasis was meticulously achieved through swab pressure and\nelectrocautery. The excised tonsil tissue was sent for frozen section\nexamination for further analysis.\n\n**Frozen Section Report: **No evidence of malignancy was found. The\nresection was carried out at the junction of the caudal tonsillar pole\nand the base of the tongue. At this location, tissue from the base of\nthe tongue was resected and sent for a frozen section examination, which\nrevealed no indication of malignancy. Subsequently, a medial resection\nof the base of the tongue was performed, confirming the presence of\nsquamous cell carcinoma in the frozen section analysis. Mucosal suturing\nwith inverting sutures was then conducted. On the left side, a neck\ndissection procedure was performed. The dissection extended along the\nsternocleidomastoid muscle, reaching dorsally to the anterior border of\nthe trapezius muscle. This approach allowed for cranial exposure of the\naccessorius nerve while sparing the same. Dissection continued along the\ncervical vascular sheath, exposing the common carotid artery, internal\njugular vein, and the vagus nerve up to the digastric muscle. Below\nthis, the hypoglossal nerve was exposed. Subsequently, the lymph node\nfat package was dissected systematically from level II to level IV,\nprogressing from cranial to caudal and ventral to dorsal, while\ncarefully preserving the mentioned structures. The surgical procedure\nconcluded with the placement of a drain, subcutaneous suturing, and skin\nsuturing.\n\n**Frozen section report:** Invasive squamous cell carcinoma.\n\n \n\n**Microscopy:**\n\nEven after paraffin embedding, mucosal cross-sections show a covering of\nstratified, non-keratinizing squamous epithelium with occasional\nsignificant stratification disturbances extending into superficial cell\nlayers. This transitions into invasive growth with solid clusters of\npolygonal tumor cells, some of which exhibit identifiable intercellular\nbridges. The cell nuclei are enlarged, round to oval, with occasional\nsmall nucleoli and mild to moderate nuclear pleomorphism. Dyskeratosis\nis observed in some areas.\n\n**Lab results upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- ----------------------- -----------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.0 mg/dL 0.7 - 1.3 mg/dL\n Calcium 9.04 mg/dL 8.8 - 10.6 mg/dL\n GFR (MDRD) \\> 60 mL/min/1.73m\\^2 \\> 60 mL/min/1.73m\\^2\n GFR (CKD-EPI,CREA) 80 mL/min/1.73m\\^2 \\> 90 mL/min/1.73m\\^2\n C-reactive protein 1.0 mg/dL \\< 0.5 mg/dL\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who presented to our outpatient clinic on 09/14/2014.\n\n**Diagnosis: **Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21)\nL0 V0 Pn0 G2 RX\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n- Since 03/2014: Odynophagia\n\n<!-- -->\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Histology:**\n\nInvasive, moderately differentiated, squamous cell carcinoma with\nkeratinization of the medial left base of the tongue, maximum extent 1.0\ncm. Carcinoma- and dysplasia-free biopsies of the left tonsil, the\noropharyngeal tumor/tongue base on the left, deep resection of the\ntumor, lower tonsillar pole transition on the left tongue base, tongue\nbase on the left and medial left tongue base, as well as median tongue\nbase.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** min pT1, pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n**Current Radiotherapy:**\n\n**Indication**: According to the decision made by the interdisciplinary\ntumor board for head and neck tumors, it was determined by our medical\nteam that, in the postoperative condition following the resection of a\ntongue base carcinoma with an unclear resection status, there is an\nindication for radiation therapy of the former tumor site.\n\n**Technique:** Percutaneous radiotherapy of the former primary tumor\nregion with 6-MeVPhotons, in Rapid-Arc technique, with a single dose of\n2 Gy up to a total dose of 60 Gy.\n\n**Radiotherapy 07/27/2014 - 09/06/2014:**\n\nDuring the course of radiotherapy, the patient experienced enoral\nmucositis (grade II according to CTCAE) leading to subsequent\nodynophagia and dysphagia. We managed these symptoms with oral rinses\nand initiated pain management using Acetaminophen, resulting in an\nacceptable reduction of pain over time. At the end of the therapy, the\npatient\\'s general condition remained stable (ECOG performance status:\n70%). Second-degree mucositis enoral persisted, causing ongoing\ndysphagia and odynophagia. Additionally, the patient exhibited localized\nradiodermatitis (grade II according to CTCAE) within the radiation\nfield. The patient did not report xerostomia or dysgeusia.\n\n**Current Recommendations:**\n\nThe patient received comprehensive instructions on continued skincare\nand side-effect management. An initial follow-up appointment with the\nradio-oncology team has been scheduled in our outpatient clinic. We\nkindly request the patient to provide a renewed referral for\nradiotherapy on the day of the appointment.\n\nThe ongoing oncological treatment plan will be determined by the\npatient\\'s Ear, Nose, and Throat specialists. Regular follow-up\nexaminations are strongly recommended. Additionally, for patients who\nhave completed radiation therapy in the ENT region, we advise lifelong\nadherence to fluoride prophylaxis and antibiotic therapy during any\ndental procedures.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965, who presented\nto our outpatient clinic for phoniatrics and pedaudiology on 10/10/2014.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Medical History: **We may kindly assume the detailed history as known.\n\n**Phoniatrics: Fiberoptic endoscopic swallow examination:**\n\nTongue motor function is well preserved, sensitivity of lip and tongue\nlaterally equal,\n\nMucous membranes non-irritant on all sides. Tracheal mucosa\nnon-irritant, no evidence of saliva intratracheal. Neopharynx\ninconspicuous, air bubbles visible above Provox outlet on pressing\nattempt. Tongue retraction slightly limited. Velopharyngeal closure\ngood.\n\n**Therapy and Course:** After completion of the adjuvant radiotherapy\napproximately 6 weeks ago, phonation via the Provox voice prosthesis was\nno longer possible after this had initially worked after the operation.\nAdditionally, there were issues with regurgitation of ingested\nsubstances, regardless of their consistency. In some cases, nasal\npenetration with fluids occurred. There were no indications of\naspiration. A self-assessment, involving the use of blue-colored liquid,\nrevealed no signs of leakage from the Provox device.\n\n**Current Recommendations:** Oncological follow-up in 12 months.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965 who presented\nat our outpatient clinic for radio-oncological follow-up on 10/09/2020.\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n \n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for a radio-oncological follow-up on 10/09/2020 in the\npresence of his wife.\n\n**Physical Examination**: Patient in stable general condition (85 kg,188\ncm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I°, hoarseness 0°, hearing loss 0° (subjectively\nreduced), dyspnea: 0°, pneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\n**MRI scan of the neck from 10/09/2020:** \n\nClear post-therapeutic changes in the resection and radiation area after\nadjuvant RTx following tumor resection with laryngectomy for extensive\nrecurrence of oropharyngeal cancer. \n\nSize constant, but still clearly accentuated lymph nodes in level Ib/IIa\non the left. Regredience of seroma formation under the left\nsternocleidomastoid muscle.\n\n**Current Recommendations: **Primary oncological care and follow-up,\nincluding imaging, will be provided by the ENT clinic according to the\nguidelines. A re-appointment for a further radio-oncological follow-up\nat the follow-up appointment at the Radiation Therapy Tumor Therapy\nCenter has been scheduled. After head and neck radiation therapy,\nregular fluoridation of the teeth and guideline-based antibiotic\nprophylaxis is required prior to major dental procedures. We also\nrecommend temporomandibular joint opening exercises to prevent\ntemporomandibular joint fibrosis and consecutive temporomandibular joint\nopening obstruction. We also refer to regular control of thyroid\nfunction parameters and, if necessary, initiation of substitution\ntherapy after radiotherapy to the neck.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe hereby report on our patient Mr. Paul Doe, born 08/08/1965 for\nradio-oncological follow-up on 09/24/2021.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for radio-oncological follow-up on 09/24/2021. \n\n**Physical Examination: **Patient in reduced general condition (KPS 60%,\n86 kg,188 cm). Weight loss 0°, MUST score: 0, pain VAS 1-2/10, fatigue\nI°, dysphagia I° with solid food (liquids occasionally flow out of the\nnose again when swallowing), aspiration 0°, ulcer 0°, trismus 0°, taste\ndisorder I° (present in approx. 80%), xerostomia I°, osteonecrosis 0°,\nhypothyroidism II°, hoarseness II°, hearing loss, I°, dyspnea: 0°,\npneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**MR neck plain + contrast agent on 09/24/2021**:\n\n[Technique]{.underline}: STIR triplanar, T1 ax -/+ contrast agent, T1\nmDixon cor after\n\ncontrast agent.\n\n[Findings]{.underline}: Known status post tumor resection with\nlaryngectomy for extensive recurrence of oropharyngeal Carcinoma;\nFollow-up after RTx. Somewhat increasing swelling of nasopharynx to\noropharynx. From the uvula the swelling is stable. As far as can be\nassessed, no clear recurrence-specific tissue proliferation or contrast\nuptake. Unchanged accentuated lymph nodes in level Ib/IIa on the left\n(one exemplary measured lymph node borderline large, idem to preliminary\nexamination). Mastoid cells minimally displaced on the left. Moderate\ndegenerative changes of the cervical spine. Assessment. Increasing\nswelling of the naso- to oropharynx. Neopharynx unchanged swollen. No\nevidence of malignancy-suspicious lymph nodes.\n\n**CT scan of the thorax on 09/24/2021**:\n\nSize-constant visualization of interlobar oval compaction in the left\nupper lobe corresponding to an interlobar lymph node. New to the\nprevious examination, two small nodular condensations appear, basal in\nthe right and in the left lower lobe, differentially inflammatory;\nfollow-up is recommended. Unchanged the prominent mediastinal lymph\nnodes, constant in size and number.\n\n**Current Recommendations:**\n\nPrimary oncologic care and follow-up including imaging will take place\nvia the ENT clinic on 01/14/22 at 11:00 AM. A re-appointment for the\nnext radio-oncological follow-up has been arranged for 01/14/2022 at\n1:00 PM in our radiotherapy outpatient clinic in the Tumor Therapy\nCenter.\n\n**Lab results upon Discharge:**\n\n**Hematology**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- -----------------------\n WBC 6,900 /μL 4,500 - 11,000 /μL\n RBC 2.7M /μL 4.5M - 5.9M /μL\n Hemoglobin 8.2 g/dL 14 - 18 g/dL\n Hematocrit 25.1 % 40 - 48 %\n MCH 31.27 pg 27 - 33 pg\n MCV 94 fL 82 - 92 fL\n MCHC 32.7 g/dL 32 - 36 g/dL\n Platelets 638,000 /μL 150,000 - 450,000 /μL\n\n**Serum chemistry**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ -----------------\n Sodium 144 mEq/L 135 - 145 mEq/L\n Potassium 4.8 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.3 mg/dL 0.7 - 1.3 mg/dL\n ALT 21 U/L 10 - 50 U/L\n eGFR 55 mL/min \\> 90 mL/min\n CRP 2.9 mg/dL \\< 0.5 mg/dL\n\n**Coagulation**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ ---------------\n PT 93 % 70 - 120 %\n INR 1.1 0.8 - 1.2\n aPTT 31 sec 26 - 37 sec\n\n**Thyroid hormones**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- ------------------\n TSH 1.16 μIU/mL 0.4 - 4.2 μIU/mL\n fT3 2.38 pg/mL 2.3 - 4.2 pg/mL\n fT4 1.70 ng/dL 0.9 - 1.7 ng/dL\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who was admitted\nto our hospital from 01/10/2022 to 01/27/2022.\n\n**Diagnosis**: Metachronous pulmonary metastatic squamous cell carcinoma\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014 Odynophagia\n\n- 05/14/2014 Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014 Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Planned Surgical Procedure:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Medical History**: Mr. Paul Doe initially presented with a diagnosis\nof pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left midline\ntongue carcinoma. Panendoscopy with specimen collection on 04/14/2014\nand 04/26/2014 confirmed carcinoma.\n\nSurgical resection was performed via lateral pharyngotomy and neck\ndissection. Histology confirmed squamous cell carcinoma. He subsequently\nreceived radiotherapy.\n\nDuring a follow-up CT examination, a suspicious lesion was identified in\nthe lung, which raised concerns regarding the possibility of metastasis\noriginating from the previously diagnosed left midline tongue carcinoma\n(pT1, pN0, G2, RX).\n\n**Current Presentation:** Mr. Doe was admitted for further examination\nand treatment to assess the behavior and extent of the lesion.\nClinically, Mr. Doe was in stable general condition and had no symptoms\nsuggestive of B symptoms.\n\n**Therapy and Progression**: The above-mentioned procedure was performed\nwithout complications on 01/10/2022. Histologically, the final resection\nspecimen confirmed the presence of a 2.9 cm squamous cell carcinoma,\nconsistent with a metastatic recurrence of the previously known\nhypopharyngeal carcinoma. The dissected lymph nodes were free of tumor.\nThe postoperative course was uneventful. In the absence of any\ncomplications, surgical sutures were removed on day 10 after surgery. A\ncurrent chest X-ray showed a regular postoperative outcome with\nsufficient expansion of the left lobe. Further monitoring is recommended\nby the treating colleagues in this regard. Mr. Doe is also connected to\nthe radiation therapy team for ongoing follow-up.\n\nIf there are any complications or questions, please contact the relevant\nward or reach out to our Central Patient Management. Outside regular\nworking hours, you can contact the on-call colleague in the Abdominal\nSurgery department for assistance.\n\nFor further information on the patient\\'s discharge management, treating\nproviders are available for inquiries from Monday to Friday, 9 AM to 7\nPM, as well as on weekends and holidays from 10 AM to 2 PM.\n\nMr. Doe was discharged from the hospital on 01/27/2022.\n\n**Addition:**\n\n**Histology Report:** Resected left upper lobe specimen with a 2.9 cm\nsolid carcinoma. The histological picture is consistent with a\nmetastasis from the previously diagnosed non-keratinizing squamous cell\ncarcinoma. There were focal vascular invasions. No pleural invasion was\nobserved. The resection was complete, with all dissected lymph nodes\nshowing no tumor involvement.\n\n**Chest X-ray, anterior-posterior view from 01/21/2022**:\n\n[Clinical Information:]{.underline} History of VATS with wedge\nresection, yesterday\\'s drain removal\n\n[Question:]{.underline} Follow-up, pneumothorax after drain removal?\nInfiltrates? Atelectasis?\n\n[Findings:]{.underline} Left chest drainage tube has been removed. Left\napical pneumothorax line, measuring approximately 2.3 cm. Continued\nextensive shadowing of the left upper field, most likely postoperative,\ninfiltrate cannot be definitively ruled out. Slightly hypotransparent\nleft lung in comparison, most likely due to residual postoperative\nreduced ventilation. No effusion. Widened cardiac silhouette. Regression\nof dystelectasis in the right lower field. No acute signs of pulmonary\nvenous congestion. Trachea is mid-positioned and not stenosed.\nLeft-sided port catheter still in place.\n\n[Summary]{.underline}: Left apical corax with a width of 2.3 cm.\nContinued extensive shadowing of the left upper field, most likely\npostoperative, with infiltrate not definitively excluded. Residual\npostoperative reduced ventilation on the left side. Regression of\ndystelectasis in the right lower field. No effusion. No acute signs of\npulmonary venous congestion. Follow-up recommended.\n\n**Examinations Chest X-ray, anterior-posterior view from 01/23/2022:**\n\n[Question]{.underline}**:** Follow-up.\n\n[Findings]{.underline}: Left apical pneumothorax, measuring\napproximately 1.4 cm. Extensive shadowing in projection onto the left\nupper lobe, differentials include postoperative changes, incipient\ninfiltrate not excluded. Dystelectasis of the right lower field. No\nevidence of pleural effusion or acute pulmonary venous congestion.\nCardiomegaly. Indwelling chest drainage with the catheter tip projecting\nonto the left upper lobe. Well-positioned port catheter tip projecting\nonto the right atrial entrance plane. No evidence of pleural effusion.\nAssessment Left apical pneumothorax, measuring approximately 1.4 cm,\nwith indwelling left chest drainage. Extensive shadowing in projection\nonto the left upper lobe, differentials include postoperative changes,\nincipient infiltrate not excluded. Dystelectasis of the right lower\nfield. No significant pleural effusion. No acute pulmonary venous\ncongestion. Cardiomegaly.\n\n**Chest X-ray, anterior-posterior view from 01/25/2022**\n\n[Previous Examinations]{.underline}: Appearance of a diffuse\npostoperative shadow in the left upper field. No evidence of pleural\neffusion, inflammatory infiltrate, or pulmonary venous congestion.\n\n[Findings]{.underline}: Left-sided chest port with the tip projecting\nonto the superior vena cava. The upper mediastinum is narrow, the\ntrachea is mid-positioned and patent.\n\n[Assessment]{.underline}: The pneumothorax appears to be largely\nresolved.\n\n**Urinanalysis**:\n\nMaterial: Urine, midstream sample collected on 01/11/2022\n\n- Antimicrobial inhibitors negative\n\n- No evidence of growth-inhibiting substances in the sample material.\n\n- Colony Count (CFU) / mL \\<1,000, Assessment: A low colony count\n typically does not support a urinary tract infection.\n\n- Epithelial cells (microscopic) \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic) \\<20 leukocytes/μL\n\n- Microorganisms (microscopic) 20-100 microorganisms/μL Pathogen\n Enterococci\n\n**Lab values upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- --------------------- ---------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n Calcium 10.4 mg/dL 8.8 - 10.6 mg/dL\n eGFR (MDRD) \\> 60 mL/min/1.73m² \\> 60 mL/min/1.73m²\n eGFR (CKD-EPI) 85 mL/min/1.73m² \\> 90 mL/min/1.73m²\n C-Reactive Protein 5.0 mg/dL \\< 0.5 mg/dL\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgical Procedure from 01/11/2022:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015: radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n- OSAS with CPAP incompliance\n\n<!-- -->\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for postoperative follow-up\nafter his left-sided videothoracoscopic upper lobe resection due to\npreviously diagnosed pulmonary metastatic hypopharyngeal carcinoma.\n\n**Medical History:** The patient\\'s general condition is good. He is\ncurrently on intermittent as-needed analgesia with Acetaminophen. The\nfinal resection specimen histologically confirmed the presence of a 2.9\ncm squamous cell carcinoma, consistent with a metastatic recurrence of\nthe previously known hypopharyngeal carcinoma. The dissected lymph nodes\nwere free of tumor.\n\n**Therapy and Progression**: During the follow-up appointment, Mr. Doe\nunderwent a clinical examination and a chest X-ray to assess his\npostoperative condition. The examination revealed no new concerning\nfindings, and Mr. Doe continued to remain in stable general condition.\nHis surgical incision site was inspected, showing signs of satisfactory\nhealing without any signs of infection or complications.\n\nFurthermore, Mr. Doe\\'s lung function was evaluated through spirometry,\nwhich indicated adequate pulmonary function post-surgery. He was also\nprovided with personalized recommendations for respiratory exercises to\noptimize his lung function during the recovery period.\n\n**Current Recommendations:**\n\n- Mr. Doe is connected to the radiation therapy team for ongoing\n follow-up.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgery on 01/11/2022:**\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015 Radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n**Other Diagnoses:**\n\n- OSAS with CPAP incompliance\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for routine follow-up.\nClinically, he remains in stable general condition, with no signs of\nB-symptoms.\n\n**Medical History**: The surgical procedure performed on 01/11/2022\ninvolved perioperative bronchoscopy, left VATS, pleurolysis, anatomical\nupper lobe resection, systematic mediastinal, hilar, and interlobar\nlymph node dissection, as well as the placement of double chest drains.\nHistologically, the final resection specimen confirmed a 2.9 cm solid\ncarcinoma, consistent with metastasis from the previously diagnosed\nsquamous cell carcinoma. Lymph nodes dissected during the procedure were\ntumor-free. Mr. Doe\\'s postoperative course was uneventful, and surgical\nsutures were removed on day 10 after surgery.\n\n**Physical Examination:** Patient in good general condition. Weight loss\n0°, MUST score: 0, pain VAS 1-2/10, fatigue I°, dysphagia I° with solid\nfood (liquids occasionally flow out of the nose again when swallowing),\naspiration 0°, ulcer 0°, trismus 0°, taste disorder I° (present in\napprox. 80%), xerostomia I°, osteonecrosis 0°, hypothyroidism II°,\nhoarseness II°, hearing loss, I°, dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**Current Recommendations:** Mr. Doe is advised to continue his\nfollow-up appointments.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------- ---------------------\n Neutrophils 72.2 % 42.0-77.0 %\n Lymphocytes 8.6 % 20.0-44.0 %\n Monocytes 11.6 % 2.0-9.5 %\n Basophils 1.4 % 0.0-1.8 %\n Eosinophils 6.0 % 0.5-5.5 %\n Immature Granulocytes 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 9.24 mg/dL 8.8-10.2 mg/dL\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n CRP 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n GGT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5 % 37.0-49.0 %\n RBC 3.3 M/µL 4.0-5.6 M/µL\n WBC 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Absolute Neutrophils 3.59 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.010 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.43 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.58 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.30 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94 % 0.50-2.00 %\n Ret-Hb 33.9 pg 28.5-34.5 pg\n PT 112 % \\> 78 %\n INR 0.95 \\< 1.25\n aPTT 30.2 sec. 25.0-38.0 sec.\n\n\n\n\nHere is the query:\nRegarding Paul Doe, what was the histological size of the metastatic recurrence from the previously known hypopharyngeal carcinoma?\n\nChoose the correct answer from the following options:\nA. 1.9 cm\nB. 3.9 cm\nC. 2.4 cm\nD. 2.9 cm\nE. 2.2 cm\n\n\nYour response:\n", "role": "user" }, { "content": "2.9 cm", "role": "assistant" } ]

[ { "content": "**Dear colleague, ****Dear colleague, **\n\n \n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who was treated in our clinic from 05/28/14 to 06/20/14.\n\n \n\n**Diagnoses: **\n\n- pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left\n midline tongue carcinoma\n\n- Arterial hypertension\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Idiopathic thrombocytopenia\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Hypothyroidism\n\n- Nicotine abuse\n\n<!-- -->\n\n- Panendoscopy with sampling on 04/14/2014 and 04/26/2014\n\n \n\n**Current Presentation**: With histologically confirmed carcinoma in the\nregion of the base of the tongue on the left side, Mr. Doe presents for\nsurgical treatment of the findings. In accordance with the tumor board\ndecision, resection is performed via a lateral pharyngotomy and neck\ndissection on both sides.\n\n \n\n**Physical Examination:** Patient in stable general condition (85 kg,\n188 cm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I° (L-thyroxine increased to 150 μg 1-0-0), hoarseness\n0°, hearing loss 0° (subjectively reduced), dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\nA tumorous mass can be inspected at the base of the left tongue. Tongue\nmobility is unremarkable.\n\n**CT chest, abdomen, pelvis on 05/28/14:**\n\nEmphasized mediastinal as well as abdominal lymph\nnodes.** **Vasosclerosis. Otherwise, there is no evidence for the\npresence of distant metastases with a suspected base of tongue\ncarcinoma. Liver cirrhosis.\n\n \n\n**CT neck on 06/11/14:**\n\nSuspected left tongue base carcinoma crossing midline with extension\ninto the left vallecula and compression of the left piriform sinus with\nsuspected lymph node metastases in levels I-III ipsilateral.\nContralateral prominent but not certainly suspicious lymph nodes. The\nprominent structure on the left supraclavicular side can also be\ninterpreted as circumscribed cystiform ectasia of the thoracic duct.\n\n \n\n**Ultrasound abdomen on 06/15/14:**\n\nImage of liver cirrhosis status post cholecystectomy.\nHepatosplenomegaly. Moderate aortic sclerosis.\n\n \n\n**X-ray pap swallow on 06/17/14:**\n\nClear tracheal aspiration in the absence of epiglottis envelope. The\ncough reflex is preserved. Otherwise, essentially unremarkable\nswallowing act. \n\n \n\n**Histology**: Invasive, moderately differentiated, squamous cell\ncarcinoma with keratinization of the medial left base of the tongue,\nmaximum extent 1.0 cm. Carcinoma- and dysplasia-free biopsies of the\nleft tonsil, the oropharyngeal tumor/tongue base on the left, deep\nresection of the tumor, lower tonsillar pole transition on the left\ntongue base, tongue base on the left and medial left tongue base, as\nwell as median tongue base.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** pT1. pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n \n\n**Therapy and Progression**: After the usual clinical and laboratory\npreparations, we performed the above-mentioned therapy on 05/29/14 in\nintubation anesthesia without complications. For perioperative infection\nprophylaxis, the patient received intravenous antibiotic therapy with\nAmpicillin and Sulbactam 3g three times daily for the duration of his\nhospital stay.\n\nDuring this procedure, the left lingual artery was interrupted\nprophylactically. No postoperative bleeding and no wound healing\ndisturbances occurred.\n\nA porridge swallow examination showed no evidence of a fistula. On the\nfollowing day, the patient was decannulated in consultation with the\ncolleagues of the speech therapy. After this, a food build-up was\ncarried out in cooperation with speech therapists. At the time of\ndischarge, the patient was receiving regular oral nutrition. The stoma\ncontinued to shrink. The patient was monitored, and if necessary, the\ntracheostoma was closed with local anesthesia. Histological findings\nwere pT1. Due to an RX status, adjuvant radiotherapy will be performed\nas decided by the tumor board. A prophylactic presentation at the\ncolleagues of the MKG as a preparatory measure for the upcoming\nradiotherapy. We asked for a control re-presentation in our outpatient\nclinic on 06/26/14 at 3:00 PM. Further controls take place at the half\nand at the end of the radiotherapy and further in 4-6 weeks rhythm. In\ncase of acute complaints, an immediate re-presentation is possible at\nany time.\n\n \n\n**Type of surgery**: Lateral pharyngotomy with resection of the base of\nthe tongue on the left as well as selective neck dissection on both\nsides level II-IV with ligature of the lingual artery on the left side,\ncreation of a stable tracheostoma and tonsillectomy on the left side.\n\n**Surgery report: **First, tracheotomy in a typical manner. A horizontal\nincision was made on the skin, positioned approximately two transverse\nfinger widths above the jugulum. Subsequently, the subcutaneous tissue\nand the platysma colli were incised. To facilitate access to the\ntrachea, the laryngeal muscles were carefully displaced to the side. The\nthyroid isthmus was undermined and clamped bilaterally. A precise\ntransection of the thyroid isthmus followed, with both halves of the\nthyroid gland being meticulously sutured using 0- Vicryl. The thyroid\nhalves were repositioned to expose the trachea. A visceral tracheotomy\nwas performed, and re-intubation was achieved utilizing a U-tube. The\nsurgical procedure then transitioned to a neck dissection on the left\nside. This phase began with an incision along the anterior edge of the\nsternocleidomastoid muscle. The subcutaneous tissue and platysma colli\nwere carefully cut, with due respect to the auricularis magnus nerve.\nDissection continued dorsally along the sternocleidomastoid muscle to\nreach the anterior border of the trapezius muscle. Further exposure\ninvolved the accessorius nerve in a cranialward direction, with\npreservation of this neural structure. Dissection proceeded along the\ncervical vascular sheath, revealing the common carotid artery, internal\njugular vein, and vagus nerve up to the digastric muscle. Below this\nlevel, exposure of the hypoglossal nerve was achieved.\n\nSuccessive dissection involved the lymph node fat package, progressing\nfrom level II to level IV in a cranial to caudal and ventral to dorsal\ndirection. Throughout this process, careful attention was paid to\nsparing the aforementioned neural and vascular structures. Subsequently,\naccess to the lateral pharyngectomy area was gained, allowing\nvisualization of the external carotid artery along with its branches,\nincluding the superior thyroid artery, superior laryngeal artery, and\nlingual artery. Notably, the lingual artery was interrupted during this\nstage.\n\nFurther exploration revealed the superior laryngeal nerve and\nhypoglossal nerve intersecting in a loop above the internal carotid\nartery and externally below the external jugular vein. Additional\ndissection in a ventral direction followed. The hypoglossal nerve was\nprepared meticulously. Exposure of the hyoid bone was achieved, with a\nposterior resection of half of the hyoid bone. Importantly, the\nhypoglossal nerve was spared during this procedure. Subsequent to these\nsteps, the lateral pharynx wall was opened, exposing the base of the\nhyoid. The next phase of the procedure involved enoral tumor\ntonsillectomy on the left side. Starting from the left side, the\nsurgical team identified the tonsil capsule at the anterior palatal arch\nusing a Henke spatula. The upper tonsillar pole was then dislodged and\ndissected with the Rosenblatt instrument, proceeding from cranial to\ncaudal. Hemostasis was meticulously achieved through swab pressure and\nelectrocautery. The excised tonsil tissue was sent for frozen section\nexamination for further analysis.\n\n**Frozen Section Report: **No evidence of malignancy was found. The\nresection was carried out at the junction of the caudal tonsillar pole\nand the base of the tongue. At this location, tissue from the base of\nthe tongue was resected and sent for a frozen section examination, which\nrevealed no indication of malignancy. Subsequently, a medial resection\nof the base of the tongue was performed, confirming the presence of\nsquamous cell carcinoma in the frozen section analysis. Mucosal suturing\nwith inverting sutures was then conducted. On the left side, a neck\ndissection procedure was performed. The dissection extended along the\nsternocleidomastoid muscle, reaching dorsally to the anterior border of\nthe trapezius muscle. This approach allowed for cranial exposure of the\naccessorius nerve while sparing the same. Dissection continued along the\ncervical vascular sheath, exposing the common carotid artery, internal\njugular vein, and the vagus nerve up to the digastric muscle. Below\nthis, the hypoglossal nerve was exposed. Subsequently, the lymph node\nfat package was dissected systematically from level II to level IV,\nprogressing from cranial to caudal and ventral to dorsal, while\ncarefully preserving the mentioned structures. The surgical procedure\nconcluded with the placement of a drain, subcutaneous suturing, and skin\nsuturing.\n\n**Frozen section report:** Invasive squamous cell carcinoma.\n\n \n\n**Microscopy:**\n\nEven after paraffin embedding, mucosal cross-sections show a covering of\nstratified, non-keratinizing squamous epithelium with occasional\nsignificant stratification disturbances extending into superficial cell\nlayers. This transitions into invasive growth with solid clusters of\npolygonal tumor cells, some of which exhibit identifiable intercellular\nbridges. The cell nuclei are enlarged, round to oval, with occasional\nsmall nucleoli and mild to moderate nuclear pleomorphism. Dyskeratosis\nis observed in some areas.\n\n**Lab results upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- ----------------------- -----------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.0 mg/dL 0.7 - 1.3 mg/dL\n Calcium 9.04 mg/dL 8.8 - 10.6 mg/dL\n GFR (MDRD) \\> 60 mL/min/1.73m\\^2 \\> 60 mL/min/1.73m\\^2\n GFR (CKD-EPI,CREA) 80 mL/min/1.73m\\^2 \\> 90 mL/min/1.73m\\^2\n C-reactive protein 1.0 mg/dL \\< 0.5 mg/dL\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who presented to our outpatient clinic on 09/14/2014.\n\n**Diagnosis: **Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21)\nL0 V0 Pn0 G2 RX\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n- Since 03/2014: Odynophagia\n\n<!-- -->\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Histology:**\n\nInvasive, moderately differentiated, squamous cell carcinoma with\nkeratinization of the medial left base of the tongue, maximum extent 1.0\ncm. Carcinoma- and dysplasia-free biopsies of the left tonsil, the\noropharyngeal tumor/tongue base on the left, deep resection of the\ntumor, lower tonsillar pole transition on the left tongue base, tongue\nbase on the left and medial left tongue base, as well as median tongue\nbase.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** min pT1, pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n**Current Radiotherapy:**\n\n**Indication**: According to the decision made by the interdisciplinary\ntumor board for head and neck tumors, it was determined by our medical\nteam that, in the postoperative condition following the resection of a\ntongue base carcinoma with an unclear resection status, there is an\nindication for radiation therapy of the former tumor site.\n\n**Technique:** Percutaneous radiotherapy of the former primary tumor\nregion with 6-MeVPhotons, in Rapid-Arc technique, with a single dose of\n2 Gy up to a total dose of 60 Gy.\n\n**Radiotherapy 07/27/2014 - 09/06/2014:**\n\nDuring the course of radiotherapy, the patient experienced enoral\nmucositis (grade II according to CTCAE) leading to subsequent\nodynophagia and dysphagia. We managed these symptoms with oral rinses\nand initiated pain management using Acetaminophen, resulting in an\nacceptable reduction of pain over time. At the end of the therapy, the\npatient\\'s general condition remained stable (ECOG performance status:\n70%). Second-degree mucositis enoral persisted, causing ongoing\ndysphagia and odynophagia. Additionally, the patient exhibited localized\nradiodermatitis (grade II according to CTCAE) within the radiation\nfield. The patient did not report xerostomia or dysgeusia.\n\n**Current Recommendations:**\n\nThe patient received comprehensive instructions on continued skincare\nand side-effect management. An initial follow-up appointment with the\nradio-oncology team has been scheduled in our outpatient clinic. We\nkindly request the patient to provide a renewed referral for\nradiotherapy on the day of the appointment.\n\nThe ongoing oncological treatment plan will be determined by the\npatient\\'s Ear, Nose, and Throat specialists. Regular follow-up\nexaminations are strongly recommended. Additionally, for patients who\nhave completed radiation therapy in the ENT region, we advise lifelong\nadherence to fluoride prophylaxis and antibiotic therapy during any\ndental procedures.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965, who presented\nto our outpatient clinic for phoniatrics and pedaudiology on 10/10/2014.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Medical History: **We may kindly assume the detailed history as known.\n\n**Phoniatrics: Fiberoptic endoscopic swallow examination:**\n\nTongue motor function is well preserved, sensitivity of lip and tongue\nlaterally equal,\n\nMucous membranes non-irritant on all sides. Tracheal mucosa\nnon-irritant, no evidence of saliva intratracheal. Neopharynx\ninconspicuous, air bubbles visible above Provox outlet on pressing\nattempt. Tongue retraction slightly limited. Velopharyngeal closure\ngood.\n\n**Therapy and Course:** After completion of the adjuvant radiotherapy\napproximately 6 weeks ago, phonation via the Provox voice prosthesis was\nno longer possible after this had initially worked after the operation.\nAdditionally, there were issues with regurgitation of ingested\nsubstances, regardless of their consistency. In some cases, nasal\npenetration with fluids occurred. There were no indications of\naspiration. A self-assessment, involving the use of blue-colored liquid,\nrevealed no signs of leakage from the Provox device.\n\n**Current Recommendations:** Oncological follow-up in 12 months.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965 who presented\nat our outpatient clinic for radio-oncological follow-up on 10/09/2020.\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n \n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for a radio-oncological follow-up on 10/09/2020 in the\npresence of his wife.\n\n**Physical Examination**: Patient in stable general condition (85 kg,188\ncm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I°, hoarseness 0°, hearing loss 0° (subjectively\nreduced), dyspnea: 0°, pneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\n**MRI scan of the neck from 10/09/2020:** \n\nClear post-therapeutic changes in the resection and radiation area after\nadjuvant RTx following tumor resection with laryngectomy for extensive\nrecurrence of oropharyngeal cancer. \n\nSize constant, but still clearly accentuated lymph nodes in level Ib/IIa\non the left. Regredience of seroma formation under the left\nsternocleidomastoid muscle.\n\n**Current Recommendations: **Primary oncological care and follow-up,\nincluding imaging, will be provided by the ENT clinic according to the\nguidelines. A re-appointment for a further radio-oncological follow-up\nat the follow-up appointment at the Radiation Therapy Tumor Therapy\nCenter has been scheduled. After head and neck radiation therapy,\nregular fluoridation of the teeth and guideline-based antibiotic\nprophylaxis is required prior to major dental procedures. We also\nrecommend temporomandibular joint opening exercises to prevent\ntemporomandibular joint fibrosis and consecutive temporomandibular joint\nopening obstruction. We also refer to regular control of thyroid\nfunction parameters and, if necessary, initiation of substitution\ntherapy after radiotherapy to the neck.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe hereby report on our patient Mr. Paul Doe, born 08/08/1965 for\nradio-oncological follow-up on 09/24/2021.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for radio-oncological follow-up on 09/24/2021. \n\n**Physical Examination: **Patient in reduced general condition (KPS 60%,\n86 kg,188 cm). Weight loss 0°, MUST score: 0, pain VAS 1-2/10, fatigue\nI°, dysphagia I° with solid food (liquids occasionally flow out of the\nnose again when swallowing), aspiration 0°, ulcer 0°, trismus 0°, taste\ndisorder I° (present in approx. 80%), xerostomia I°, osteonecrosis 0°,\nhypothyroidism II°, hoarseness II°, hearing loss, I°, dyspnea: 0°,\npneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**MR neck plain + contrast agent on 09/24/2021**:\n\n[Technique]{.underline}: STIR triplanar, T1 ax -/+ contrast agent, T1\nmDixon cor after\n\ncontrast agent.\n\n[Findings]{.underline}: Known status post tumor resection with\nlaryngectomy for extensive recurrence of oropharyngeal Carcinoma;\nFollow-up after RTx. Somewhat increasing swelling of nasopharynx to\noropharynx. From the uvula the swelling is stable. As far as can be\nassessed, no clear recurrence-specific tissue proliferation or contrast\nuptake. Unchanged accentuated lymph nodes in level Ib/IIa on the left\n(one exemplary measured lymph node borderline large, idem to preliminary\nexamination). Mastoid cells minimally displaced on the left. Moderate\ndegenerative changes of the cervical spine. Assessment. Increasing\nswelling of the naso- to oropharynx. Neopharynx unchanged swollen. No\nevidence of malignancy-suspicious lymph nodes.\n\n**CT scan of the thorax on 09/24/2021**:\n\nSize-constant visualization of interlobar oval compaction in the left\nupper lobe corresponding to an interlobar lymph node. New to the\nprevious examination, two small nodular condensations appear, basal in\nthe right and in the left lower lobe, differentially inflammatory;\nfollow-up is recommended. Unchanged the prominent mediastinal lymph\nnodes, constant in size and number.\n\n**Current Recommendations:**\n\nPrimary oncologic care and follow-up including imaging will take place\nvia the ENT clinic on 01/14/22 at 11:00 AM. A re-appointment for the\nnext radio-oncological follow-up has been arranged for 01/14/2022 at\n1:00 PM in our radiotherapy outpatient clinic in the Tumor Therapy\nCenter.\n\n**Lab results upon Discharge:**\n\n**Hematology**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- -----------------------\n WBC 6,900 /μL 4,500 - 11,000 /μL\n RBC 2.7M /μL 4.5M - 5.9M /μL\n Hemoglobin 8.2 g/dL 14 - 18 g/dL\n Hematocrit 25.1 % 40 - 48 %\n MCH 31.27 pg 27 - 33 pg\n MCV 94 fL 82 - 92 fL\n MCHC 32.7 g/dL 32 - 36 g/dL\n Platelets 638,000 /μL 150,000 - 450,000 /μL\n\n**Serum chemistry**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ -----------------\n Sodium 144 mEq/L 135 - 145 mEq/L\n Potassium 4.8 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.3 mg/dL 0.7 - 1.3 mg/dL\n ALT 21 U/L 10 - 50 U/L\n eGFR 55 mL/min \\> 90 mL/min\n CRP 2.9 mg/dL \\< 0.5 mg/dL\n\n**Coagulation**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ ---------------\n PT 93 % 70 - 120 %\n INR 1.1 0.8 - 1.2\n aPTT 31 sec 26 - 37 sec\n\n**Thyroid hormones**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- ------------------\n TSH 1.16 μIU/mL 0.4 - 4.2 μIU/mL\n fT3 2.38 pg/mL 2.3 - 4.2 pg/mL\n fT4 1.70 ng/dL 0.9 - 1.7 ng/dL\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who was admitted\nto our hospital from 01/10/2022 to 01/27/2022.\n\n**Diagnosis**: Metachronous pulmonary metastatic squamous cell carcinoma\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014 Odynophagia\n\n- 05/14/2014 Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014 Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Planned Surgical Procedure:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Medical History**: Mr. Paul Doe initially presented with a diagnosis\nof pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left midline\ntongue carcinoma. Panendoscopy with specimen collection on 04/14/2014\nand 04/26/2014 confirmed carcinoma.\n\nSurgical resection was performed via lateral pharyngotomy and neck\ndissection. Histology confirmed squamous cell carcinoma. He subsequently\nreceived radiotherapy.\n\nDuring a follow-up CT examination, a suspicious lesion was identified in\nthe lung, which raised concerns regarding the possibility of metastasis\noriginating from the previously diagnosed left midline tongue carcinoma\n(pT1, pN0, G2, RX).\n\n**Current Presentation:** Mr. Doe was admitted for further examination\nand treatment to assess the behavior and extent of the lesion.\nClinically, Mr. Doe was in stable general condition and had no symptoms\nsuggestive of B symptoms.\n\n**Therapy and Progression**: The above-mentioned procedure was performed\nwithout complications on 01/10/2022. Histologically, the final resection\nspecimen confirmed the presence of a 2.9 cm squamous cell carcinoma,\nconsistent with a metastatic recurrence of the previously known\nhypopharyngeal carcinoma. The dissected lymph nodes were free of tumor.\nThe postoperative course was uneventful. In the absence of any\ncomplications, surgical sutures were removed on day 10 after surgery. A\ncurrent chest X-ray showed a regular postoperative outcome with\nsufficient expansion of the left lobe. Further monitoring is recommended\nby the treating colleagues in this regard. Mr. Doe is also connected to\nthe radiation therapy team for ongoing follow-up.\n\nIf there are any complications or questions, please contact the relevant\nward or reach out to our Central Patient Management. Outside regular\nworking hours, you can contact the on-call colleague in the Abdominal\nSurgery department for assistance.\n\nFor further information on the patient\\'s discharge management, treating\nproviders are available for inquiries from Monday to Friday, 9 AM to 7\nPM, as well as on weekends and holidays from 10 AM to 2 PM.\n\nMr. Doe was discharged from the hospital on 01/27/2022.\n\n**Addition:**\n\n**Histology Report:** Resected left upper lobe specimen with a 2.9 cm\nsolid carcinoma. The histological picture is consistent with a\nmetastasis from the previously diagnosed non-keratinizing squamous cell\ncarcinoma. There were focal vascular invasions. No pleural invasion was\nobserved. The resection was complete, with all dissected lymph nodes\nshowing no tumor involvement.\n\n**Chest X-ray, anterior-posterior view from 01/21/2022**:\n\n[Clinical Information:]{.underline} History of VATS with wedge\nresection, yesterday\\'s drain removal\n\n[Question:]{.underline} Follow-up, pneumothorax after drain removal?\nInfiltrates? Atelectasis?\n\n[Findings:]{.underline} Left chest drainage tube has been removed. Left\napical pneumothorax line, measuring approximately 2.3 cm. Continued\nextensive shadowing of the left upper field, most likely postoperative,\ninfiltrate cannot be definitively ruled out. Slightly hypotransparent\nleft lung in comparison, most likely due to residual postoperative\nreduced ventilation. No effusion. Widened cardiac silhouette. Regression\nof dystelectasis in the right lower field. No acute signs of pulmonary\nvenous congestion. Trachea is mid-positioned and not stenosed.\nLeft-sided port catheter still in place.\n\n[Summary]{.underline}: Left apical corax with a width of 2.3 cm.\nContinued extensive shadowing of the left upper field, most likely\npostoperative, with infiltrate not definitively excluded. Residual\npostoperative reduced ventilation on the left side. Regression of\ndystelectasis in the right lower field. No effusion. No acute signs of\npulmonary venous congestion. Follow-up recommended.\n\n**Examinations Chest X-ray, anterior-posterior view from 01/23/2022:**\n\n[Question]{.underline}**:** Follow-up.\n\n[Findings]{.underline}: Left apical pneumothorax, measuring\napproximately 1.4 cm. Extensive shadowing in projection onto the left\nupper lobe, differentials include postoperative changes, incipient\ninfiltrate not excluded. Dystelectasis of the right lower field. No\nevidence of pleural effusion or acute pulmonary venous congestion.\nCardiomegaly. Indwelling chest drainage with the catheter tip projecting\nonto the left upper lobe. Well-positioned port catheter tip projecting\nonto the right atrial entrance plane. No evidence of pleural effusion.\nAssessment Left apical pneumothorax, measuring approximately 1.4 cm,\nwith indwelling left chest drainage. Extensive shadowing in projection\nonto the left upper lobe, differentials include postoperative changes,\nincipient infiltrate not excluded. Dystelectasis of the right lower\nfield. No significant pleural effusion. No acute pulmonary venous\ncongestion. Cardiomegaly.\n\n**Chest X-ray, anterior-posterior view from 01/25/2022**\n\n[Previous Examinations]{.underline}: Appearance of a diffuse\npostoperative shadow in the left upper field. No evidence of pleural\neffusion, inflammatory infiltrate, or pulmonary venous congestion.\n\n[Findings]{.underline}: Left-sided chest port with the tip projecting\nonto the superior vena cava. The upper mediastinum is narrow, the\ntrachea is mid-positioned and patent.\n\n[Assessment]{.underline}: The pneumothorax appears to be largely\nresolved.\n\n**Urinanalysis**:\n\nMaterial: Urine, midstream sample collected on 01/11/2022\n\n- Antimicrobial inhibitors negative\n\n- No evidence of growth-inhibiting substances in the sample material.\n\n- Colony Count (CFU) / mL \\<1,000, Assessment: A low colony count\n typically does not support a urinary tract infection.\n\n- Epithelial cells (microscopic) \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic) \\<20 leukocytes/μL\n\n- Microorganisms (microscopic) 20-100 microorganisms/μL Pathogen\n Enterococci\n\n**Lab values upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- --------------------- ---------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n Calcium 10.4 mg/dL 8.8 - 10.6 mg/dL\n eGFR (MDRD) \\> 60 mL/min/1.73m² \\> 60 mL/min/1.73m²\n eGFR (CKD-EPI) 85 mL/min/1.73m² \\> 90 mL/min/1.73m²\n C-Reactive Protein 5.0 mg/dL \\< 0.5 mg/dL\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgical Procedure from 01/11/2022:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015: radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n- OSAS with CPAP incompliance\n\n<!-- -->\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for postoperative follow-up\nafter his left-sided videothoracoscopic upper lobe resection due to\npreviously diagnosed pulmonary metastatic hypopharyngeal carcinoma.\n\n**Medical History:** The patient\\'s general condition is good. He is\ncurrently on intermittent as-needed analgesia with Acetaminophen. The\nfinal resection specimen histologically confirmed the presence of a 2.9\ncm squamous cell carcinoma, consistent with a metastatic recurrence of\nthe previously known hypopharyngeal carcinoma. The dissected lymph nodes\nwere free of tumor.\n\n**Therapy and Progression**: During the follow-up appointment, Mr. Doe\nunderwent a clinical examination and a chest X-ray to assess his\npostoperative condition. The examination revealed no new concerning\nfindings, and Mr. Doe continued to remain in stable general condition.\nHis surgical incision site was inspected, showing signs of satisfactory\nhealing without any signs of infection or complications.\n\nFurthermore, Mr. Doe\\'s lung function was evaluated through spirometry,\nwhich indicated adequate pulmonary function post-surgery. He was also\nprovided with personalized recommendations for respiratory exercises to\noptimize his lung function during the recovery period.\n\n**Current Recommendations:**\n\n- Mr. Doe is connected to the radiation therapy team for ongoing\n follow-up.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgery on 01/11/2022:**\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015 Radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n**Other Diagnoses:**\n\n- OSAS with CPAP incompliance\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for routine follow-up.\nClinically, he remains in stable general condition, with no signs of\nB-symptoms.\n\n**Medical History**: The surgical procedure performed on 01/11/2022\ninvolved perioperative bronchoscopy, left VATS, pleurolysis, anatomical\nupper lobe resection, systematic mediastinal, hilar, and interlobar\nlymph node dissection, as well as the placement of double chest drains.\nHistologically, the final resection specimen confirmed a 2.9 cm solid\ncarcinoma, consistent with metastasis from the previously diagnosed\nsquamous cell carcinoma. Lymph nodes dissected during the procedure were\ntumor-free. Mr. Doe\\'s postoperative course was uneventful, and surgical\nsutures were removed on day 10 after surgery.\n\n**Physical Examination:** Patient in good general condition. Weight loss\n0°, MUST score: 0, pain VAS 1-2/10, fatigue I°, dysphagia I° with solid\nfood (liquids occasionally flow out of the nose again when swallowing),\naspiration 0°, ulcer 0°, trismus 0°, taste disorder I° (present in\napprox. 80%), xerostomia I°, osteonecrosis 0°, hypothyroidism II°,\nhoarseness II°, hearing loss, I°, dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**Current Recommendations:** Mr. Doe is advised to continue his\nfollow-up appointments.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------- ---------------------\n Neutrophils 72.2 % 42.0-77.0 %\n Lymphocytes 8.6 % 20.0-44.0 %\n Monocytes 11.6 % 2.0-9.5 %\n Basophils 1.4 % 0.0-1.8 %\n Eosinophils 6.0 % 0.5-5.5 %\n Immature Granulocytes 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 9.24 mg/dL 8.8-10.2 mg/dL\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n CRP 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n GGT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5 % 37.0-49.0 %\n RBC 3.3 M/µL 4.0-5.6 M/µL\n WBC 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Absolute Neutrophils 3.59 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.010 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.43 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.58 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.30 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94 % 0.50-2.00 %\n Ret-Hb 33.9 pg 28.5-34.5 pg\n PT 112 % \\> 78 %\n INR 0.95 \\< 1.25\n aPTT 30.2 sec. 25.0-38.0 sec.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953, who\nreceived an MRI of the right proximal thigh for further clarification of\na potential tumor.\n\n**MRI of the right thigh, plain and with contrast agent, on\n02/19/2017:**\n\n[Technique]{.underline}: Surface coil, localization scan, coronal T1 SE,\ntransverse, coronal, sagittal T2 TSE with fat suppression. After\nintravenous contrast administration, T1-TSE transverse and T1-TSE FS\n(coronal, T2 TSE FS coronal as an additional fat-saturated sequence in\nthe same section level for exploring relevant edema).\n\n[Findings]{.underline}: Normal bone marrow signal consistent with age.\nNo signs of fractures. Coexistence of moderate degenerative changes in\nthe hip joints, more pronounced on the right than on the left. Mild\nactivation of the muscles in the left proximal adductor region. Ventral\nto the gracilis muscle and dorsal to the sartorius muscle at the level\nof the middle third of the right thigh is a subfascial intermuscular\noval mass lesion with a high-signal appearance on T2-weighted images and\na low-signal appearance on T1-weighted images. It is partially septated,\nwell-demarcated, and shows strong contrast enhancement. No evidence of\nblood degradation products. Dimensions are 35 x 45 x 40 mm. No evidence\nof suspiciously enlarged lymph nodes. Other assessed soft tissues are\nunremarkable for the patient\\'s age.\n\n[Assessment]{.underline}: Overall, a high suspicion of a mucinous mass\nlesion in the region of the right adductor compartment. Differential\nDiagnosis: Mucinous liposarcoma. Further histological evaluation is\nstrongly recommended.\n\n**Current Recommendations:** Presentation at the clinic for surgery for\nfurther differential diagnostic clarification.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953. He was\nunder our inpatient care from 03/10/2017 to 03/12/2017.\n\n**Diagnosis:** Soft tissue tumor of the right proximal thigh\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Treatment**: Incisional biopsy on 03/10/2017\n\n**Histology:**\n\n[Microscopy]{.underline}: (Hematoxylin and Eosin staining):\nHistologically, an infiltrate of a mesenchymal neoplasm is evident in a\nsection prepared by us and stained with HE. There are areas with an\nestimated tumor percentage of approximately 90% that were selected and\nlabeled for molecular pathology analysis.\n\n[Molecular Pathology]{.underline}: After macrodissection of labeled\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused next-generation sequencing technology. The\nanalysis was performed using FusioPlex Sarcoma v2 assays, allowing\ndetection of fusions in 63 genes.\n\n**Medical History:** We may kindly assume that you are familiar with Mr.\nHavers's medical history. The patient presented to our surgery clinic\ndue to a mass in the right proximal thigh. The swelling was first\nnoticed approximately 3 months ago and has shown significant enlargement\nsince. The patient subsequently consulted a general surgeon, who\nreferred him to our center after performing an MRI, suspecting an\nintramuscular liposarcoma. After presenting the case to our\ninterdisciplinary tumor board, the decision was made to perform an\nincisional biopsy. The patient was admitted for the above procedure on\n03/10/2017.\n\n**Physical Examination:** On clinical examination, a patient in slightly\nreduced general and nutritional status was observed. Approximately 6 x 7\nx 4 cm-sized tumor in the right proximal thigh, well mobile,\nintramuscular. Numbness in both legs at L5/S1.\n\nNo change in skin color. No fluctuation or redness. The rest of the\nclinical examination was unremarkable.\n\n**Treatment and Progression:** Following routine preoperative\npreparations and informed consent, the above-mentioned procedure was\nperformed under general anesthesia on 03/10/2017. The intraoperative and\npostoperative courses were uncomplicated.\n\nInitial mild swelling regressed over time. The inserted drainage was\nremoved on the second postoperative day. The patient mobilized\nindependently on the ward. Pain management was provided as needed.\n\nWith the patient\\'s subjective well-being and inconspicuous wound\nconditions, we were able to discharge Mr. Havers on 03/12/2017 for\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- Suture material to be shortened on the 14th postoperative day.\n\n- Follow-up appointments in our outpatient clinic\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin Calcium (Lipitor) 21.7 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole Sodium (Protonix) 22.6 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Urea 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Complete Blood Count \\- \\-\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n Erythrocytes 5.2 M/µL 4.3-5.8 M/µL\n Leukocytes 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n INR 0.94 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n\n**Addition: Histology Report:**\n\n[Microscopy:]{.underline} (Hematoxylin and Eosin staining):\nHistologically, infiltrates of a mesenchymal neoplasm can be seen in a\nsection we prepared. Below this are areas estimated to contain 90%\ntumor, which have been selected and labeled for molecular pathological\nanalysis.\n\n[Molecular Pathology:]{.underline} After macrodissection of the marked\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused Next-Generation Sequencing technology. The\nexamination was performed using the FusioPlex Sarcoma v2 Assays, that\nallows for the detection of fusions involving 63 genes.\n\n[Diagnosis:]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma, Grade 1 according to\n FNCLCC (Sum score 2 + 0 + 1 = 3), with the detection of a FUS: DDIT3\n fusion transcript (right adductor compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue.\n\n- In addition to previous reports, myxoid neoplasm is characterized by\n minimal cell density/round cell areas, here less than 25%, according\n to FNCLCC (=2 points for tumor differentiation).\n\n- No evidence of necrosis (=0 points).\n\n- 2 mitotic figures in 10 high-power fields (=1 point).\n\n- Total score is 2 + 0 + 1 = 3, corresponding to Grade 1 according to\n FNCLCC.\n\n[Diagnosis]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma (right adductor\n compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue\n (subcutaneous).\n\n[Comment]{.underline}: The present biopsy material corresponds to Grade\n1 according to FNCLCC. A supplementary report follows.\n\n**Supplementary Report from: 03/29/2017:**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh. Encapsulated subfascial tumor, palpably indurated.\nAdipose tissue adjacent to the tumor, macroscopically lighter and finer\nthan the subcutaneous adipose tissue towards the skin.\n\n[Material]{.underline}: Microscopy and Molecular Pathology Interphase\nFISH analysis using a two-color break-apart probe to examine a\nchromosomal break in the FUS gene (chromosome 16p11.2) and in the DDIT3\ngene (chromosome 12q13.3-q14.1).\n\nInterphase FISH analysis reveals a specific break event in the FUS gene\n(FUS-FISH positive). This indicates the presence of a FUS translocation.\nSimilarly, in interphase FISH analysis, a specific break event is\ndetectable in the DDIT3 gene (DDIT3-FISH positive), indicating the\npresence of a DDIT3 translocation.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n[Comment]{.underline}: The cytogenetic findings are indicative of a\nmyxoid liposarcoma. Technical validation by RNA sequencing will be\nprovided in a supplemental report. This does not affect the above\ndiagnosis.\n\n**Supplementary Report from: 03/18/2017:**\n\n[Microscopy: MDM2, S100:]{.underline} Partial weak expression of S100\nprotein by the lesional cells, occasionally including pre-existing\nadipocytes. No abnormal expression of MDM2. No abnormal expression of\nMDM2 in mature adipose tissue.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n**Main Report from: 03/18/2017**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh, as per MRI 02/19/2017. Encapsulated subfascial tumor,\npalpably indurated located in the right adductor compartment. Adipose\ntissue adjacent to the tumor, macroscopically lighter and finer than the\nsubcutaneous adipose tissue towards the skin.\n\n[Macroscopy:]{.underline}\n\nTumor: Brown, nodular piece of tissue, 20 x 14 x 10 mm, with smooth and\nrough surface. Cut surface shiny and mottled, sometimes gray, sometimes\nbrown.\n\nSubcutaneous adipose tissue: A piece of adipose tissue, 25 x 20 x 5 mm.\n\n[Microscopy:]{.underline}\n\nModerately cell dense mesenchymal proliferation with a myxoid matrix.\nPredominantly round nuclei, moderately dense nuclear chromatin, slight\npleomorphism. Occasional adipocytic cells with univacuolar cytoplasm.\n\nPartially dense, ribbon-like connective tissue as well as mature\nunivacuolar adipose tissue.\n\n[Diagnosis:]{.underline}\n\nIncisional biopsy suspected of a myxoid liposarcoma. Predominantly\nmature fatty tissue as well as fascial tissue.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe would like to inform you about our patient Mr. John Havers, born on\n05/29/1953, who was admitted to our hospital from 03/29/2017 to\n04/05/2017.\n\n**Diagnoses**:\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n- Incisional biopsy on 03/10/2017\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Current Presentation**: Neoplasm of uncertain or unknown behavior.\n\n**Treatment**: On 04/01/2017, en bloc tumor excision with removal of the\nold biopsy scar, partial resection of the M. gracilis, fibers of the M.\nsartorius and M. adductor longus, and ligation of the V. saphena magna\nwas performed.\n\n**Histology from 04/11/2017**\n\nClinical Information: Myxoid liposarcoma, localized in the right thigh.\n\n[Macroscopy Tumor, right thigh]{.underline}: A triple surgical resection\nwas performed, removing skin and subcutaneous tissue and the underlying\nsoft tissue and muscle. The size of the excised skin spindle was 130 x\n45 mm with a resection depth of up to 48 mm. A wound 25 mm long and 6 mm\nwide was noted on the skin surface. The muscle attached\nlaterally/dorsally measured 75 x 25 x 6 mm. Two nodules were noted on\nthe cut surface. The larger nodule, located in the subcutaneous tissue,\nmeasured 33 mm (proximal/distal) x 36 mm (anterior/dorsal) x 30 mm. Its\ndistance from the proximal preparation cap was 26 mm, from the distal\npreparation cap more than 60 mm, from the ventral soft tissue 20 mm, and\nfrom the dorsal soft tissue 3 mm, with less than 1 mm basal extension.\nSuperficially, it was surrounded by a delicate capsule. A separate\nnodule measuring 20 mm (proximal/distal) x 24 mm (ventral/dorsal) x 20\nmm was found immediately ventro-distal to the first nodule. This nodule\nwas located more than 40 mm from the proximal preparation cap, more than\n50 mm from the distal preparation cap, 12 mm ventrally, 11 mm dorsally,\nand 5 mm basally. Consequently, the maximum size of the tumor from\nproximal to distal was 53 mm. No macroscopic necrotic areas were evident\non the cut surface of the nodule. However, partial necrosis of the\nsubcutaneous fatty tissue in the vicinity of the described wound was\nobserved.\n\n[Microscopy HE, PAS:]{.underline} Histomorphologically, there is a\nmoderately cell-dense proliferation with a significant myxoid matrix in\nthe area of the two confluent nodules, with a maximum diameter of 53 mm.\nThere are also areas with relative cell poverty. Within the myxoid\nmatrix, there are blood vessels with a distinct growth pattern referred\nto as the \\\"chicken wire pattern.\\\" No clear tumor necroses are evident.\nThe tumor cell nuclei have a round configuration with moderately dense\nchromatin. Apoptotic figures are increased. The number of mitoses is\nlow.The lesion was completely removed with a minimal margin of 0.5 mm\nfrom the posterior resection edge. In the superficial subcutaneous\ntissue, there is a band-like necrosis directly related to superficial\ngranulation tissue. The included skin spindle shows regular epidermal\ncovering and a largely unremarkable dermis.\n\n[Diagnosis]{.underline}: Skin/subcutaneous excision with a maximum 53 mm\nmyxoid liposarcoma that was completely removed (minimum distance to\nposterior cutoff plane 0.5 mm).\n\n[Comment]{.underline}: In view of the present morphology and knowledge\nof the molecular pathological examination results with proven break\nevents in the FUS gene and DDIT3 gene as part of interphase FISH\nanalysis, the diagnosed condition is myxoid liposarcoma.\n\nAccording to the FNCLCC grading scheme, this corresponds to grade 1:\nHistological type: 2 points + mitotic index 1 point + necrosis index 0\npoints = 3 points.\n\nICD-O-3 tumor classification: Myxoid liposarcoma TNM (8th edition): pT2\npNX L0 V0 Pn0 G1 R0\n\n**Medical History:** We assume that you are familiar with Mr. Havers's\nmedical history, and we refer to our previous correspondence.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds.\n\nHeart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys.\n\nNormal peripheral pulses; joints freely movable. Strength, motor\nfunction, and sensation are unremarkable.\n\n**Therapy and Progression**: The patient presented to our surgical\nclinic because of a mass in the right proximal thigh. The swelling was\nfirst noticed about 3 months ago and has increased significantly in size\nsince then. MRI findings raised suspicion of a liposarcoma. After\nconsultation in the interdisciplinary tumor board, the indication for\nincisional biopsy was performed on 03/10/2017. The histopathological\nexamination confirmed the presence of a myxoid liposarcoma, leading to\nthe decision for en bloc excision. The patient was extensively informed\nabout the procedure and the risks and gave his consent. The patient was\nadmitted for the procedure on 03/29/2017.\n\nUpon clinical examination, a patient in good general and nutritional\ncondition was noted. Other general clinical findings were unremarkable.\nA wound healing disorder of 2 cm was observed in the area of the wound\nafter incisional biopsy.\n\n**Sarcoma Tumor Board Recommendation dated 03/11/2017:** R0 G1 finding,\nstandard sarcoma follow-up.\n\n**Procedure**: Following standard preoperative preparations and informed\nconsent, the aforementioned procedure was performed on 03/01/2017 under\ngeneral anesthesia. The intraoperative and postoperative course was\nuneventful.\n\nOn the first postoperative day, there was slight swelling in the\naffected area, which gradually subsided. Analgesia was sufficient with\nAcetaminophen as needed. Thrombosis prophylaxis was administered with\nsubcutaneous Enoxaparin 0.4 mL. The patient mobilized independently on\nthe ward. The inserted drainage could not be removed so far due to\nexcessive drainage output. During the hospital stay, a staging CT of the\nchest and abdomen was performed. No thoracoabdominal metastases were\ndetected.\n\n**Summary**: With a good subjective well-being and unremarkable wound\nconditions, Mr. Havers was discharged on 04/05/2017 for further\noutpatient care. Clinical examination reveals slight swelling of the\nwound area. The wound is not dehiscent and shows no signs of irritation.\nThe patient is mobilizing independently.\n\n**CT Chest/Abdomen/Pelvis from 04/01/2017: **\n\n[Clinical Information, Question, Justification]{.underline}: Liposarcoma\nof the thigh. Staging.\n\n[Technique]{.underline}: Digital overview radiographs. Following\nintravenous contrast agent administration (100 ml Xenetix), CT of the\nchest and entire abdomen in the venous contrast phase. Reconstruction of\nthe primary dataset with a slice thickness of 0.625 mm. Multiplanar\nreconstruction. Total DLP: 885 mGy\\*cm.\n\n[Findings]{.underline}: There are no prior images available for\ncomparison.\n\n[Chest]{.underline}: Lungs are evenly ventilated and normally developed\nbilaterally. No pneumothorax on either side. Minimal right-sided pleural\neffusion. Mild basilar hypoventilation, particularly in the right lower\nlobe. Calcified granuloma in the apical right lower lobe. No suspicious\npulmonary nodules.\n\nHeart shows enlargement of the left ventricle and left atrium. Coronary\nartery sclerosis. Atherosclerosis of the aortic arch. No pericardial\neffusion. Aorta and pulmonary trunk have normal diameters. No central\npulmonary artery embolism. No pathologically enlarged mediastinal or\nhilar lymph nodes. Symmetric appearance of the neck soft tissues.\nThyroid gland without focal lesions. Axillary lymph nodes are of normal\nsize.\n\n[Abdomen]{.underline}: Liver is of normal size and has a smooth contour.\nNo signs of cholestasis. No portal vein thrombosis. No suspicious\nintrahepatic lesions. Gallbladder appears normal. Common bile duct is\nnot dilated. Spleen is not enlarged. Pancreas shows regular lobulation,\nand there is no dilatation of the pancreatic duct. Both kidneys are free\nfrom urinary tract obstruction. No solid intrarenal masses. Few renal\ncysts. Adrenal glands appear unremarkable. Urinary bladder shows no\nfocal wall thickening. Prostate is not enlarged. Advanced\natherosclerosis of the abdominal aorta and pelvic vessels. History of\nstenting of the left external iliac artery with no reocclusion.\nMesenteric, para-aortic, and parailiac lymph nodes are not\npathologically enlarged. No free intraperitoneal fluid or air is\ndetected. Osseous Structures: Degenerative changes in the spine. No\nevidence of suspicious osseous destruction suggestive of tumors. Soft\ntissue mantle appears unremarkable.\n\n**Assessment**: No thoracoabdominal metastases.\n\n**Current Recommendations**:\n\n- Regular wound inspections and dressing changes.\n\n- Documentation of drainage output and removal if the output is \\<20\n ml/24 hours, expected removal on 04/23/2017 at our outpatient\n clinic.\n\n- Removal of sutures is not required for absorbable sutures.\n\n- According to the tumor board decision dated 04/11/2017, we recommend\n regular follow-up according to the schedule.\n\n**Sarcoma Follow-up Schedule Stage I**\n\n- Local Follow-up:\n\n 1. MRI right thigh: Years 1-5: every 6 months\n\n 2. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 3. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 4. Years 6-10: every 12 months in alternation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ -------------------\n Aspirin 100 mg 1-0-0-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Enoxaparin (Lovenox) Variable 0-0-1-0\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Acetaminophen (Tylenol) 500 mg 2-2-2-2 if needed\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------- ---------------------\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.74 mg/dL 0.70-1.20 mg/dL\n Blood Urea Nitrogen 33 mg/dL 17-48 mg/dL\n C-Reactive Protein 1.7 mg/dL \\< 5.0 mg/dL\n Thyroid-Stimulating Hormone 3.58 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 16.5 g/dL 13.5-17.0 g/dL\n Hematocrit 49.3% 39.5-50.5%\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.63 K/µL 3.90-10.50 K/µL\n Platelets 301 K/µL 150-370 K/µL\n Mean Corpuscular Volume 95.7 fL 80.0-99.0 fL\n Mean Corpuscular Hemoglobin 32.0 pg 27.0-33.5 pg\n Mean Corpuscular Hemoglobin Concentration 33.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.4 fL 7.0-12.0 fL\n Red Cell Distribution Width 12.1% 11.6-14.4%\n Activated Partial Thromboplastin Time 32.4 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented to our outpatient surgery clinic on\n04/23/2017.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Medical History:** We kindly assume that you are familiar with the\npatient\\'s detailed medical history and refer to our previous discharge\nletter.\n\n**Current Presentation:** The patient presented today for a follow-up\nvisit in our clinic. He reported no complaints. The Redon drain has not\nproduced any secretions in the last 2 days.\n\nClinical examination revealed uneventful wound conditions with applied\nSteri-strips. There is no evidence of infection. The Redon drain\ncontains serous wound secretions.\n\nProcedure: The Redon drain is being removed today. With nearly fully\nhealed wound conditions, we recommend initiating scar massage with fatty\ntopical products in the near future.\n\n**MRI of the Right Thigh on** 04/23/2017**:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB. Recurrence? Regional behavior? Lymph nodes?\n\n[Technique]{.underline}: 3 Tesla MRI of the right thigh, both plain and\nafter the administration of 8 ml of Gadovist intravenously. Supine\nposition, surface coil.\n\nSequences: TIRM coronal and axial, T2-TSE coronal and axial, T1 VIBE\nDixon axial, EPI-DWI with ADC map axial, T1-Starvibe vascular images\nplain and post-contrast axial with subtraction images, T1-TSE FS\npost-contrast coronal.\n\n[Findings]{.underline}: Minor FLAIR hyperintense streaky signal\nalteration in the surgical area, most likely scar-related, with slight\ndiffusion restriction and streaky contrast enhancement. No evidence of a\nrecurrent suspicious substrate. No nodular contrast enhancement.\nSlightly accentuated inguinal lymph nodes on the right, most likely\nreactive. Unremarkable visualization of the remaining soft tissue.\nNormal bone marrow signal. Bladder filled. Unremarkable representation\nof the imaged pelvic organs.\n\n[Assessment]{.underline}: Following the resection of a myxoid\nliposarcoma on the right medial thigh, there is a regular postoperative\nfinding. No indication of local recurrence.\n\n**Chest X-ray in Two Planes on 04/23/2017: **\n\n[Clinical Background, Question, Justification]{.underline}: Myxoid\nliposarcoma of the right thigh, initial diagnosis in 2022. Follow-up.\nMetastases?\n\n[Findings]{.underline}: No corresponding prior images for comparison.\nThe upper mediastinum is centrally located and not widened. Hila are\nfree. No acute congestion. No confluent pneumonic infiltrate. No\nevidence of larger intrapulmonary lesions. A 7 mm spot shadow is noted\nright suprahilar, primarily representing a vascular structure. No\neffusions. No pneumothorax.\n\n**Current Recommendations:** The patient would like to continue\nfollow-up care with us, so we scheduled an MRI control appointment to\nassess the possibility of local recurrence. On this day, a two-view\nchest X-ray is also required.\n\n**We recommend the following follow-up schedule:**\n\n- Local Follow-up:\n\n 5. MRI right thigh: Years 1-5: every 6 months\n\n 6. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 7. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 8. Years 6-10: every 12 months in alternation\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented for tumor follow-up on 02/10/2018, in our\noutpatient surgery clinic for a discussion of findings.\n\n**Diagnosis**: Myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a regular postoperative finding on the\nright thigh.\n\nThe control MRI with contrast of the right thigh on 04/23/2017 revealed\nmorphologically:\n\n- No evidence of a local-regional recurrence.\n\n- In pulmonary follow-up using conventional chest X-ray on 04/23/2017,\n no signs of pulmonary metastasis were detected.\n\n**Current Recommendations:** Sarcoma Follow-up Schedule Stage I\n\n- Local Follow-up:\n\n 9. MRI right thigh: Years 1-5: every 6 months\n\n 10. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 11. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 12. Years 6-10: every 12 months in alternation\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting to you on our patient Mr. John Havers, born on\n05/29/1953, who presented himself on **08/01/2018** at our outpatient\nsurgery clinic for a discussion of findings as part of tumor follow-up.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a normal postoperative condition in\nthe right thigh.\n\n**MRI of the Right Thigh on 08/01/2018:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh. Progress\nassessment.\n\n[Method]{.underline}: 1.5 Tesla. Localization sequences. TIRM and T2 TSE\ncoronal. TIRM, T2 TSE, VIBE DIXON, and RESOLVE-DWI axial. StarVIBE FS\nbefore and after contrast + subtraction. T1 TSE FS coronal after\ncontrast.\n\n[Findings]{.underline}: Comparison with MRI from 04/23/2017.\nPost-resection of a myxoid liposarcoma in the proximal medial right\nthigh soft tissue. In the surgical area, there is no evidence of a\nsuspicious nodular, contrast-affine lesion, and no evidence of\nmalignancy-suspected diffusion restriction. Slight scar-related changes\nin the access path. Otherwise, unremarkable presentation of soft tissues\nand included bony structures. No inguinal lymphadenopathy. Assessment:\nFor myxoid liposarcoma, there has been consistent evidence since\n02/2018:\n\n**Chest CT on 08/01/2018**:\n\n[Clinical Background, Question, Justification: Liposarcoma on the thigh.\nStaging.]{.underline} After risk history assessment, oral and written\nexplanation of contrast agent application and examination procedure, as\nwell as potential risks of the examination (see also informed consent\nform). Written patient consent.\n\n[Method]{.underline}: Digital overview radiographs. After intravenous\ncontrast agent administration (80 ml of Imeron), CT of the chest in\nvenous contrast phase, reconstruction of the primary dataset with a\nslice thickness of 0.625 mm. Total DLP 185 mGy\\*cm.\n\n[Findings]{.underline}: For comparison, there is a CT of the\nchest/abdomen/pelvis from 04/01/2018. No evidence of suspicious\npulmonary nodules. Several partly calcified micronodules bipulmonary,\nespecially in the right lower lobe (ex. S303/IMA179). Partial\nunderventilation bipulmonary. No pleural effusion. No evidence of\npathologically enlarged lymph nodes. Constant calcified right hilar\nlymph nodes. Calcifying aortic sclerosis along with coronary sclerosis.\nHepatic steatosis. Individual renal cysts. Slightly shrunken left\nadrenal gland. Degenerative changes of the axial skeleton without\nevidence of a malignancy-suspected osseous lesion.\n\n[Assessment]{.underline}: No evidence of a new thoracic tumor\nmanifestation.\n\n**Recommendations:** Sarcoma Follow-up\n\n- Local Follow-up:\n\n 13. MRI right thigh: Years 1-5: every 6 months\n\n 14. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 15. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 16. Years 6-10: every 12 months in alternation\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n RBC 5.2 M/µL 4.3-5.8 M/µL\n WBC 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n International Normalized Ratio (INR) 0.94 0.90-1.25\n Activated Partial Thromboplastin Time (aPTT) 30.1 sec 25.0-38.0 sec\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who was admitted to our clinic from 08/14/2023 to\n09/02/2023.\n\n**Diagnosis:** Pulmonary Metastasis from Myxoid Liposarcoma\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n<!-- -->\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Medical History:** Mr. Havers has been under our care for myxoid\nliposarcoma, which was previously excised from his right medial thigh.\nHe had a stable postoperative course and was scheduled for regular\nfollow-up to monitor for any potential recurrence or metastasis.\n\n**Current Presentation:** During a follow-up appointment on 08/14/2023,\nMr. Havers complained of mild shortness of breath, occasional coughing,\nand intermittent chest discomfort. He reported no significant weight\nloss but noted a decrease in his overall energy levels. Physical\nexamination revealed decreased breath sounds in the right lung base.\n\n**Physical Examination:** Patient in adequate general condition.\nOriented in all aspects. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable. Lungs: Normal chest shape, moderately\nmobile, decreased breath sounds in the right lung base. Heart: Regular\nheart action, normal rate; heart sounds clear, no pathological sounds.\nAbdomen: Peristalsis and bowel sounds normal in all quadrants; soft\nabdomen, markedly obese, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation is unremarkable.\n\n**Chest X-ray (08/14/2023):** A chest X-ray was performed, which\nrevealed a suspicious opacity in the right lower lung field.\n\n**CT Chest (08/16/2023):** In light of the chest X-ray findings, a\ncontrast-enhanced CT scan of the chest was conducted to obtain more\ndetailed information. The CT imaging demonstrated a well-defined,\nirregularly shaped lesion in the right lower lobe of the lung, measuring\napproximately 2.5 cm in diameter. The lesion exhibited characteristics\nhighly suggestive of a metastatic deposit. There were no other\nsignificant abnormalities noted in the chest.\n\n**Histology (08/21/2023):** Based on the CT findings, a CT-guided core\nneedle biopsy of the pulmonary lesion was performed to confirm the\nnature of the lesion. Histopathological examination of the biopsy\nspecimen confirmed the presence of myxoid liposarcoma cells in the\npulmonary lesion. Immunohistochemical staining for MDM2 and CDK4\nsupported the diagnosis of metastatic myxoid liposarcoma.\n\n**Treatment Discussion:** Given the diagnosis of a pulmonary metastasis\nfrom myxoid liposarcoma, the case was reviewed in the interdisciplinary\ntumor board. The consensus decision was to pursue surgical resection of\nthe pulmonary metastasis, as it remained localized and resectable. The\npatient and his family were informed of the treatment options and\nassociated risks, and they provided informed consent for the procedure.\n\n**Surgery Report (08/29/2023):** Mr. Havers underwent a right lower\nlobectomy with lymph node dissection to remove the pulmonary metastasis.\nThe procedure was performed by our thoracic surgery team and was\ncompleted without any immediate complications. Intraoperative frozen\nsection analysis confirmed the presence of metastatic myxoid liposarcoma\nin the resected lung tissue.\n\n**Postoperative Course:** Mr. Havers postoperative course was\nuneventful, and he demonstrated good respiratory recovery. He was\nmanaged with adequate pain control and underwent chest physiotherapy to\nprevent postoperative complications. Pathological examination of the\nresected lung tissue confirmed the presence of metastatic myxoid\nliposarcoma, with clear surgical margins.\n\n**Current Recommendations:**\n\n1. **Follow-up:** A strict follow-up plan should be established for Mr.\n Havers to monitor for any potential recurrence or new metastatic\n lesions. This should include regular clinical assessments, chest\n imaging, and other relevant investigations.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n --------------------- ------------- ---------------------\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 39 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.5 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.6 g/dL 13.5-17.0 g/dL\n Hematocrit 49.4 % 39.5-50.5 %\n RBC 5.1 M/µL 4.3-5.8 M/µL\n WBC 10.04 K/µL 3.90-10.50 K/µL\n Platelets 166 K/µL 150-370 K/µL\n MCV 95.2 fL 80.0-99.0 fL\n MCH 32.6 pg 27.0-33.5 pg\n MCHC 33.2 g/dL 31.5-36.0 g/dL\n MPV 11.4 fL 7.0-12.0 fL\n RDW-CV 12.5 % 11.5-15.0 %\n Prothrombin Time 122 % 78-123 %\n INR 0.99 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n\n\n\n\nHere is the query:\nWhich medication is NOT listed in Mr. Havers' medication upon discharge?\n\nChoose the correct answer from the following options:\nA. Empagliflozin\nB. Metformin\nC. Atorvastatin\nD. Ramipril\nE. Pantoprazole\n\n\nYour response:\n", "role": "user" }, { "content": "Ramipril", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953, who\nreceived an MRI of the right proximal thigh for further clarification of\na potential tumor.\n\n**MRI of the right thigh, plain and with contrast agent, on\n02/19/2017:**\n\n[Technique]{.underline}: Surface coil, localization scan, coronal T1 SE,\ntransverse, coronal, sagittal T2 TSE with fat suppression. After\nintravenous contrast administration, T1-TSE transverse and T1-TSE FS\n(coronal, T2 TSE FS coronal as an additional fat-saturated sequence in\nthe same section level for exploring relevant edema).\n\n[Findings]{.underline}: Normal bone marrow signal consistent with age.\nNo signs of fractures. Coexistence of moderate degenerative changes in\nthe hip joints, more pronounced on the right than on the left. Mild\nactivation of the muscles in the left proximal adductor region. Ventral\nto the gracilis muscle and dorsal to the sartorius muscle at the level\nof the middle third of the right thigh is a subfascial intermuscular\noval mass lesion with a high-signal appearance on T2-weighted images and\na low-signal appearance on T1-weighted images. It is partially septated,\nwell-demarcated, and shows strong contrast enhancement. No evidence of\nblood degradation products. Dimensions are 35 x 45 x 40 mm. No evidence\nof suspiciously enlarged lymph nodes. Other assessed soft tissues are\nunremarkable for the patient\\'s age.\n\n[Assessment]{.underline}: Overall, a high suspicion of a mucinous mass\nlesion in the region of the right adductor compartment. Differential\nDiagnosis: Mucinous liposarcoma. Further histological evaluation is\nstrongly recommended.\n\n**Current Recommendations:** Presentation at the clinic for surgery for\nfurther differential diagnostic clarification.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953. He was\nunder our inpatient care from 03/10/2017 to 03/12/2017.\n\n**Diagnosis:** Soft tissue tumor of the right proximal thigh\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Treatment**: Incisional biopsy on 03/10/2017\n\n**Histology:**\n\n[Microscopy]{.underline}: (Hematoxylin and Eosin staining):\nHistologically, an infiltrate of a mesenchymal neoplasm is evident in a\nsection prepared by us and stained with HE. There are areas with an\nestimated tumor percentage of approximately 90% that were selected and\nlabeled for molecular pathology analysis.\n\n[Molecular Pathology]{.underline}: After macrodissection of labeled\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused next-generation sequencing technology. The\nanalysis was performed using FusioPlex Sarcoma v2 assays, allowing\ndetection of fusions in 63 genes.\n\n**Medical History:** We may kindly assume that you are familiar with Mr.\nHavers's medical history. The patient presented to our surgery clinic\ndue to a mass in the right proximal thigh. The swelling was first\nnoticed approximately 3 months ago and has shown significant enlargement\nsince. The patient subsequently consulted a general surgeon, who\nreferred him to our center after performing an MRI, suspecting an\nintramuscular liposarcoma. After presenting the case to our\ninterdisciplinary tumor board, the decision was made to perform an\nincisional biopsy. The patient was admitted for the above procedure on\n03/10/2017.\n\n**Physical Examination:** On clinical examination, a patient in slightly\nreduced general and nutritional status was observed. Approximately 6 x 7\nx 4 cm-sized tumor in the right proximal thigh, well mobile,\nintramuscular. Numbness in both legs at L5/S1.\n\nNo change in skin color. No fluctuation or redness. The rest of the\nclinical examination was unremarkable.\n\n**Treatment and Progression:** Following routine preoperative\npreparations and informed consent, the above-mentioned procedure was\nperformed under general anesthesia on 03/10/2017. The intraoperative and\npostoperative courses were uncomplicated.\n\nInitial mild swelling regressed over time. The inserted drainage was\nremoved on the second postoperative day. The patient mobilized\nindependently on the ward. Pain management was provided as needed.\n\nWith the patient\\'s subjective well-being and inconspicuous wound\nconditions, we were able to discharge Mr. Havers on 03/12/2017 for\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- Suture material to be shortened on the 14th postoperative day.\n\n- Follow-up appointments in our outpatient clinic\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin Calcium (Lipitor) 21.7 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole Sodium (Protonix) 22.6 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Urea 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Complete Blood Count \\- \\-\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n Erythrocytes 5.2 M/µL 4.3-5.8 M/µL\n Leukocytes 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n INR 0.94 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n\n**Addition: Histology Report:**\n\n[Microscopy:]{.underline} (Hematoxylin and Eosin staining):\nHistologically, infiltrates of a mesenchymal neoplasm can be seen in a\nsection we prepared. Below this are areas estimated to contain 90%\ntumor, which have been selected and labeled for molecular pathological\nanalysis.\n\n[Molecular Pathology:]{.underline} After macrodissection of the marked\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused Next-Generation Sequencing technology. The\nexamination was performed using the FusioPlex Sarcoma v2 Assays, that\nallows for the detection of fusions involving 63 genes.\n\n[Diagnosis:]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma, Grade 1 according to\n FNCLCC (Sum score 2 + 0 + 1 = 3), with the detection of a FUS: DDIT3\n fusion transcript (right adductor compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue.\n\n- In addition to previous reports, myxoid neoplasm is characterized by\n minimal cell density/round cell areas, here less than 25%, according\n to FNCLCC (=2 points for tumor differentiation).\n\n- No evidence of necrosis (=0 points).\n\n- 2 mitotic figures in 10 high-power fields (=1 point).\n\n- Total score is 2 + 0 + 1 = 3, corresponding to Grade 1 according to\n FNCLCC.\n\n[Diagnosis]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma (right adductor\n compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue\n (subcutaneous).\n\n[Comment]{.underline}: The present biopsy material corresponds to Grade\n1 according to FNCLCC. A supplementary report follows.\n\n**Supplementary Report from: 03/29/2017:**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh. Encapsulated subfascial tumor, palpably indurated.\nAdipose tissue adjacent to the tumor, macroscopically lighter and finer\nthan the subcutaneous adipose tissue towards the skin.\n\n[Material]{.underline}: Microscopy and Molecular Pathology Interphase\nFISH analysis using a two-color break-apart probe to examine a\nchromosomal break in the FUS gene (chromosome 16p11.2) and in the DDIT3\ngene (chromosome 12q13.3-q14.1).\n\nInterphase FISH analysis reveals a specific break event in the FUS gene\n(FUS-FISH positive). This indicates the presence of a FUS translocation.\nSimilarly, in interphase FISH analysis, a specific break event is\ndetectable in the DDIT3 gene (DDIT3-FISH positive), indicating the\npresence of a DDIT3 translocation.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n[Comment]{.underline}: The cytogenetic findings are indicative of a\nmyxoid liposarcoma. Technical validation by RNA sequencing will be\nprovided in a supplemental report. This does not affect the above\ndiagnosis.\n\n**Supplementary Report from: 03/18/2017:**\n\n[Microscopy: MDM2, S100:]{.underline} Partial weak expression of S100\nprotein by the lesional cells, occasionally including pre-existing\nadipocytes. No abnormal expression of MDM2. No abnormal expression of\nMDM2 in mature adipose tissue.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n**Main Report from: 03/18/2017**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh, as per MRI 02/19/2017. Encapsulated subfascial tumor,\npalpably indurated located in the right adductor compartment. Adipose\ntissue adjacent to the tumor, macroscopically lighter and finer than the\nsubcutaneous adipose tissue towards the skin.\n\n[Macroscopy:]{.underline}\n\nTumor: Brown, nodular piece of tissue, 20 x 14 x 10 mm, with smooth and\nrough surface. Cut surface shiny and mottled, sometimes gray, sometimes\nbrown.\n\nSubcutaneous adipose tissue: A piece of adipose tissue, 25 x 20 x 5 mm.\n\n[Microscopy:]{.underline}\n\nModerately cell dense mesenchymal proliferation with a myxoid matrix.\nPredominantly round nuclei, moderately dense nuclear chromatin, slight\npleomorphism. Occasional adipocytic cells with univacuolar cytoplasm.\n\nPartially dense, ribbon-like connective tissue as well as mature\nunivacuolar adipose tissue.\n\n[Diagnosis:]{.underline}\n\nIncisional biopsy suspected of a myxoid liposarcoma. Predominantly\nmature fatty tissue as well as fascial tissue.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient Mr. John Havers, born on\n05/29/1953, who was admitted to our hospital from 03/29/2017 to\n04/05/2017.\n\n**Diagnoses**:\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n- Incisional biopsy on 03/10/2017\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Current Presentation**: Neoplasm of uncertain or unknown behavior.\n\n**Treatment**: On 04/01/2017, en bloc tumor excision with removal of the\nold biopsy scar, partial resection of the M. gracilis, fibers of the M.\nsartorius and M. adductor longus, and ligation of the V. saphena magna\nwas performed.\n\n**Histology from 04/11/2017**\n\nClinical Information: Myxoid liposarcoma, localized in the right thigh.\n\n[Macroscopy Tumor, right thigh]{.underline}: A triple surgical resection\nwas performed, removing skin and subcutaneous tissue and the underlying\nsoft tissue and muscle. The size of the excised skin spindle was 130 x\n45 mm with a resection depth of up to 48 mm. A wound 25 mm long and 6 mm\nwide was noted on the skin surface. The muscle attached\nlaterally/dorsally measured 75 x 25 x 6 mm. Two nodules were noted on\nthe cut surface. The larger nodule, located in the subcutaneous tissue,\nmeasured 33 mm (proximal/distal) x 36 mm (anterior/dorsal) x 30 mm. Its\ndistance from the proximal preparation cap was 26 mm, from the distal\npreparation cap more than 60 mm, from the ventral soft tissue 20 mm, and\nfrom the dorsal soft tissue 3 mm, with less than 1 mm basal extension.\nSuperficially, it was surrounded by a delicate capsule. A separate\nnodule measuring 20 mm (proximal/distal) x 24 mm (ventral/dorsal) x 20\nmm was found immediately ventro-distal to the first nodule. This nodule\nwas located more than 40 mm from the proximal preparation cap, more than\n50 mm from the distal preparation cap, 12 mm ventrally, 11 mm dorsally,\nand 5 mm basally. Consequently, the maximum size of the tumor from\nproximal to distal was 53 mm. No macroscopic necrotic areas were evident\non the cut surface of the nodule. However, partial necrosis of the\nsubcutaneous fatty tissue in the vicinity of the described wound was\nobserved.\n\n[Microscopy HE, PAS:]{.underline} Histomorphologically, there is a\nmoderately cell-dense proliferation with a significant myxoid matrix in\nthe area of the two confluent nodules, with a maximum diameter of 53 mm.\nThere are also areas with relative cell poverty. Within the myxoid\nmatrix, there are blood vessels with a distinct growth pattern referred\nto as the \\\"chicken wire pattern.\\\" No clear tumor necroses are evident.\nThe tumor cell nuclei have a round configuration with moderately dense\nchromatin. Apoptotic figures are increased. The number of mitoses is\nlow.The lesion was completely removed with a minimal margin of 0.5 mm\nfrom the posterior resection edge. In the superficial subcutaneous\ntissue, there is a band-like necrosis directly related to superficial\ngranulation tissue. The included skin spindle shows regular epidermal\ncovering and a largely unremarkable dermis.\n\n[Diagnosis]{.underline}: Skin/subcutaneous excision with a maximum 53 mm\nmyxoid liposarcoma that was completely removed (minimum distance to\nposterior cutoff plane 0.5 mm).\n\n[Comment]{.underline}: In view of the present morphology and knowledge\nof the molecular pathological examination results with proven break\nevents in the FUS gene and DDIT3 gene as part of interphase FISH\nanalysis, the diagnosed condition is myxoid liposarcoma.\n\nAccording to the FNCLCC grading scheme, this corresponds to grade 1:\nHistological type: 2 points + mitotic index 1 point + necrosis index 0\npoints = 3 points.\n\nICD-O-3 tumor classification: Myxoid liposarcoma TNM (8th edition): pT2\npNX L0 V0 Pn0 G1 R0\n\n**Medical History:** We assume that you are familiar with Mr. Havers's\nmedical history, and we refer to our previous correspondence.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds.\n\nHeart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys.\n\nNormal peripheral pulses; joints freely movable. Strength, motor\nfunction, and sensation are unremarkable.\n\n**Therapy and Progression**: The patient presented to our surgical\nclinic because of a mass in the right proximal thigh. The swelling was\nfirst noticed about 3 months ago and has increased significantly in size\nsince then. MRI findings raised suspicion of a liposarcoma. After\nconsultation in the interdisciplinary tumor board, the indication for\nincisional biopsy was performed on 03/10/2017. The histopathological\nexamination confirmed the presence of a myxoid liposarcoma, leading to\nthe decision for en bloc excision. The patient was extensively informed\nabout the procedure and the risks and gave his consent. The patient was\nadmitted for the procedure on 03/29/2017.\n\nUpon clinical examination, a patient in good general and nutritional\ncondition was noted. Other general clinical findings were unremarkable.\nA wound healing disorder of 2 cm was observed in the area of the wound\nafter incisional biopsy.\n\n**Sarcoma Tumor Board Recommendation dated 03/11/2017:** R0 G1 finding,\nstandard sarcoma follow-up.\n\n**Procedure**: Following standard preoperative preparations and informed\nconsent, the aforementioned procedure was performed on 03/01/2017 under\ngeneral anesthesia. The intraoperative and postoperative course was\nuneventful.\n\nOn the first postoperative day, there was slight swelling in the\naffected area, which gradually subsided. Analgesia was sufficient with\nAcetaminophen as needed. Thrombosis prophylaxis was administered with\nsubcutaneous Enoxaparin 0.4 mL. The patient mobilized independently on\nthe ward. The inserted drainage could not be removed so far due to\nexcessive drainage output. During the hospital stay, a staging CT of the\nchest and abdomen was performed. No thoracoabdominal metastases were\ndetected.\n\n**Summary**: With a good subjective well-being and unremarkable wound\nconditions, Mr. Havers was discharged on 04/05/2017 for further\noutpatient care. Clinical examination reveals slight swelling of the\nwound area. The wound is not dehiscent and shows no signs of irritation.\nThe patient is mobilizing independently.\n\n**CT Chest/Abdomen/Pelvis from 04/01/2017: **\n\n[Clinical Information, Question, Justification]{.underline}: Liposarcoma\nof the thigh. Staging.\n\n[Technique]{.underline}: Digital overview radiographs. Following\nintravenous contrast agent administration (100 ml Xenetix), CT of the\nchest and entire abdomen in the venous contrast phase. Reconstruction of\nthe primary dataset with a slice thickness of 0.625 mm. Multiplanar\nreconstruction. Total DLP: 885 mGy\\*cm.\n\n[Findings]{.underline}: There are no prior images available for\ncomparison.\n\n[Chest]{.underline}: Lungs are evenly ventilated and normally developed\nbilaterally. No pneumothorax on either side. Minimal right-sided pleural\neffusion. Mild basilar hypoventilation, particularly in the right lower\nlobe. Calcified granuloma in the apical right lower lobe. No suspicious\npulmonary nodules.\n\nHeart shows enlargement of the left ventricle and left atrium. Coronary\nartery sclerosis. Atherosclerosis of the aortic arch. No pericardial\neffusion. Aorta and pulmonary trunk have normal diameters. No central\npulmonary artery embolism. No pathologically enlarged mediastinal or\nhilar lymph nodes. Symmetric appearance of the neck soft tissues.\nThyroid gland without focal lesions. Axillary lymph nodes are of normal\nsize.\n\n[Abdomen]{.underline}: Liver is of normal size and has a smooth contour.\nNo signs of cholestasis. No portal vein thrombosis. No suspicious\nintrahepatic lesions. Gallbladder appears normal. Common bile duct is\nnot dilated. Spleen is not enlarged. Pancreas shows regular lobulation,\nand there is no dilatation of the pancreatic duct. Both kidneys are free\nfrom urinary tract obstruction. No solid intrarenal masses. Few renal\ncysts. Adrenal glands appear unremarkable. Urinary bladder shows no\nfocal wall thickening. Prostate is not enlarged. Advanced\natherosclerosis of the abdominal aorta and pelvic vessels. History of\nstenting of the left external iliac artery with no reocclusion.\nMesenteric, para-aortic, and parailiac lymph nodes are not\npathologically enlarged. No free intraperitoneal fluid or air is\ndetected. Osseous Structures: Degenerative changes in the spine. No\nevidence of suspicious osseous destruction suggestive of tumors. Soft\ntissue mantle appears unremarkable.\n\n**Assessment**: No thoracoabdominal metastases.\n\n**Current Recommendations**:\n\n- Regular wound inspections and dressing changes.\n\n- Documentation of drainage output and removal if the output is \\<20\n ml/24 hours, expected removal on 04/23/2017 at our outpatient\n clinic.\n\n- Removal of sutures is not required for absorbable sutures.\n\n- According to the tumor board decision dated 04/11/2017, we recommend\n regular follow-up according to the schedule.\n\n**Sarcoma Follow-up Schedule Stage I**\n\n- Local Follow-up:\n\n 1. MRI right thigh: Years 1-5: every 6 months\n\n 2. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 3. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 4. Years 6-10: every 12 months in alternation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ -------------------\n Aspirin 100 mg 1-0-0-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Enoxaparin (Lovenox) Variable 0-0-1-0\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Acetaminophen (Tylenol) 500 mg 2-2-2-2 if needed\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------- ---------------------\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.74 mg/dL 0.70-1.20 mg/dL\n Blood Urea Nitrogen 33 mg/dL 17-48 mg/dL\n C-Reactive Protein 1.7 mg/dL \\< 5.0 mg/dL\n Thyroid-Stimulating Hormone 3.58 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 16.5 g/dL 13.5-17.0 g/dL\n Hematocrit 49.3% 39.5-50.5%\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.63 K/µL 3.90-10.50 K/µL\n Platelets 301 K/µL 150-370 K/µL\n Mean Corpuscular Volume 95.7 fL 80.0-99.0 fL\n Mean Corpuscular Hemoglobin 32.0 pg 27.0-33.5 pg\n Mean Corpuscular Hemoglobin Concentration 33.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.4 fL 7.0-12.0 fL\n Red Cell Distribution Width 12.1% 11.6-14.4%\n Activated Partial Thromboplastin Time 32.4 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented to our outpatient surgery clinic on\n04/23/2017.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Medical History:** We kindly assume that you are familiar with the\npatient\\'s detailed medical history and refer to our previous discharge\nletter.\n\n**Current Presentation:** The patient presented today for a follow-up\nvisit in our clinic. He reported no complaints. The Redon drain has not\nproduced any secretions in the last 2 days.\n\nClinical examination revealed uneventful wound conditions with applied\nSteri-strips. There is no evidence of infection. The Redon drain\ncontains serous wound secretions.\n\nProcedure: The Redon drain is being removed today. With nearly fully\nhealed wound conditions, we recommend initiating scar massage with fatty\ntopical products in the near future.\n\n**MRI of the Right Thigh on** 04/23/2017**:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB. Recurrence? Regional behavior? Lymph nodes?\n\n[Technique]{.underline}: 3 Tesla MRI of the right thigh, both plain and\nafter the administration of 8 ml of Gadovist intravenously. Supine\nposition, surface coil.\n\nSequences: TIRM coronal and axial, T2-TSE coronal and axial, T1 VIBE\nDixon axial, EPI-DWI with ADC map axial, T1-Starvibe vascular images\nplain and post-contrast axial with subtraction images, T1-TSE FS\npost-contrast coronal.\n\n[Findings]{.underline}: Minor FLAIR hyperintense streaky signal\nalteration in the surgical area, most likely scar-related, with slight\ndiffusion restriction and streaky contrast enhancement. No evidence of a\nrecurrent suspicious substrate. No nodular contrast enhancement.\nSlightly accentuated inguinal lymph nodes on the right, most likely\nreactive. Unremarkable visualization of the remaining soft tissue.\nNormal bone marrow signal. Bladder filled. Unremarkable representation\nof the imaged pelvic organs.\n\n[Assessment]{.underline}: Following the resection of a myxoid\nliposarcoma on the right medial thigh, there is a regular postoperative\nfinding. No indication of local recurrence.\n\n**Chest X-ray in Two Planes on 04/23/2017: **\n\n[Clinical Background, Question, Justification]{.underline}: Myxoid\nliposarcoma of the right thigh, initial diagnosis in 2022. Follow-up.\nMetastases?\n\n[Findings]{.underline}: No corresponding prior images for comparison.\nThe upper mediastinum is centrally located and not widened. Hila are\nfree. No acute congestion. No confluent pneumonic infiltrate. No\nevidence of larger intrapulmonary lesions. A 7 mm spot shadow is noted\nright suprahilar, primarily representing a vascular structure. No\neffusions. No pneumothorax.\n\n**Current Recommendations:** The patient would like to continue\nfollow-up care with us, so we scheduled an MRI control appointment to\nassess the possibility of local recurrence. On this day, a two-view\nchest X-ray is also required.\n\n**We recommend the following follow-up schedule:**\n\n- Local Follow-up:\n\n 5. MRI right thigh: Years 1-5: every 6 months\n\n 6. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 7. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 8. Years 6-10: every 12 months in alternation\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented for tumor follow-up on 02/10/2018, in our\noutpatient surgery clinic for a discussion of findings.\n\n**Diagnosis**: Myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a regular postoperative finding on the\nright thigh.\n\nThe control MRI with contrast of the right thigh on 04/23/2017 revealed\nmorphologically:\n\n- No evidence of a local-regional recurrence.\n\n- In pulmonary follow-up using conventional chest X-ray on 04/23/2017,\n no signs of pulmonary metastasis were detected.\n\n**Current Recommendations:** Sarcoma Follow-up Schedule Stage I\n\n- Local Follow-up:\n\n 9. MRI right thigh: Years 1-5: every 6 months\n\n 10. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 11. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 12. Years 6-10: every 12 months in alternation\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting to you on our patient Mr. John Havers, born on\n05/29/1953, who presented himself on **08/01/2018** at our outpatient\nsurgery clinic for a discussion of findings as part of tumor follow-up.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a normal postoperative condition in\nthe right thigh.\n\n**MRI of the Right Thigh on 08/01/2018:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh. Progress\nassessment.\n\n[Method]{.underline}: 1.5 Tesla. Localization sequences. TIRM and T2 TSE\ncoronal. TIRM, T2 TSE, VIBE DIXON, and RESOLVE-DWI axial. StarVIBE FS\nbefore and after contrast + subtraction. T1 TSE FS coronal after\ncontrast.\n\n[Findings]{.underline}: Comparison with MRI from 04/23/2017.\nPost-resection of a myxoid liposarcoma in the proximal medial right\nthigh soft tissue. In the surgical area, there is no evidence of a\nsuspicious nodular, contrast-affine lesion, and no evidence of\nmalignancy-suspected diffusion restriction. Slight scar-related changes\nin the access path. Otherwise, unremarkable presentation of soft tissues\nand included bony structures. No inguinal lymphadenopathy. Assessment:\nFor myxoid liposarcoma, there has been consistent evidence since\n02/2018:\n\n**Chest CT on 08/01/2018**:\n\n[Clinical Background, Question, Justification: Liposarcoma on the thigh.\nStaging.]{.underline} After risk history assessment, oral and written\nexplanation of contrast agent application and examination procedure, as\nwell as potential risks of the examination (see also informed consent\nform). Written patient consent.\n\n[Method]{.underline}: Digital overview radiographs. After intravenous\ncontrast agent administration (80 ml of Imeron), CT of the chest in\nvenous contrast phase, reconstruction of the primary dataset with a\nslice thickness of 0.625 mm. Total DLP 185 mGy\\*cm.\n\n[Findings]{.underline}: For comparison, there is a CT of the\nchest/abdomen/pelvis from 04/01/2018. No evidence of suspicious\npulmonary nodules. Several partly calcified micronodules bipulmonary,\nespecially in the right lower lobe (ex. S303/IMA179). Partial\nunderventilation bipulmonary. No pleural effusion. No evidence of\npathologically enlarged lymph nodes. Constant calcified right hilar\nlymph nodes. Calcifying aortic sclerosis along with coronary sclerosis.\nHepatic steatosis. Individual renal cysts. Slightly shrunken left\nadrenal gland. Degenerative changes of the axial skeleton without\nevidence of a malignancy-suspected osseous lesion.\n\n[Assessment]{.underline}: No evidence of a new thoracic tumor\nmanifestation.\n\n**Recommendations:** Sarcoma Follow-up\n\n- Local Follow-up:\n\n 13. MRI right thigh: Years 1-5: every 6 months\n\n 14. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 15. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 16. Years 6-10: every 12 months in alternation\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n RBC 5.2 M/µL 4.3-5.8 M/µL\n WBC 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n International Normalized Ratio (INR) 0.94 0.90-1.25\n Activated Partial Thromboplastin Time (aPTT) 30.1 sec 25.0-38.0 sec\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who was admitted to our clinic from 08/14/2023 to\n09/02/2023.\n\n**Diagnosis:** Pulmonary Metastasis from Myxoid Liposarcoma\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n<!-- -->\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Medical History:** Mr. Havers has been under our care for myxoid\nliposarcoma, which was previously excised from his right medial thigh.\nHe had a stable postoperative course and was scheduled for regular\nfollow-up to monitor for any potential recurrence or metastasis.\n\n**Current Presentation:** During a follow-up appointment on 08/14/2023,\nMr. Havers complained of mild shortness of breath, occasional coughing,\nand intermittent chest discomfort. He reported no significant weight\nloss but noted a decrease in his overall energy levels. Physical\nexamination revealed decreased breath sounds in the right lung base.\n\n**Physical Examination:** Patient in adequate general condition.\nOriented in all aspects. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable. Lungs: Normal chest shape, moderately\nmobile, decreased breath sounds in the right lung base. Heart: Regular\nheart action, normal rate; heart sounds clear, no pathological sounds.\nAbdomen: Peristalsis and bowel sounds normal in all quadrants; soft\nabdomen, markedly obese, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation is unremarkable.\n\n**Chest X-ray (08/14/2023):** A chest X-ray was performed, which\nrevealed a suspicious opacity in the right lower lung field.\n\n**CT Chest (08/16/2023):** In light of the chest X-ray findings, a\ncontrast-enhanced CT scan of the chest was conducted to obtain more\ndetailed information. The CT imaging demonstrated a well-defined,\nirregularly shaped lesion in the right lower lobe of the lung, measuring\napproximately 2.5 cm in diameter. The lesion exhibited characteristics\nhighly suggestive of a metastatic deposit. There were no other\nsignificant abnormalities noted in the chest.\n\n**Histology (08/21/2023):** Based on the CT findings, a CT-guided core\nneedle biopsy of the pulmonary lesion was performed to confirm the\nnature of the lesion. Histopathological examination of the biopsy\nspecimen confirmed the presence of myxoid liposarcoma cells in the\npulmonary lesion. Immunohistochemical staining for MDM2 and CDK4\nsupported the diagnosis of metastatic myxoid liposarcoma.\n\n**Treatment Discussion:** Given the diagnosis of a pulmonary metastasis\nfrom myxoid liposarcoma, the case was reviewed in the interdisciplinary\ntumor board. The consensus decision was to pursue surgical resection of\nthe pulmonary metastasis, as it remained localized and resectable. The\npatient and his family were informed of the treatment options and\nassociated risks, and they provided informed consent for the procedure.\n\n**Surgery Report (08/29/2023):** Mr. Havers underwent a right lower\nlobectomy with lymph node dissection to remove the pulmonary metastasis.\nThe procedure was performed by our thoracic surgery team and was\ncompleted without any immediate complications. Intraoperative frozen\nsection analysis confirmed the presence of metastatic myxoid liposarcoma\nin the resected lung tissue.\n\n**Postoperative Course:** Mr. Havers postoperative course was\nuneventful, and he demonstrated good respiratory recovery. He was\nmanaged with adequate pain control and underwent chest physiotherapy to\nprevent postoperative complications. Pathological examination of the\nresected lung tissue confirmed the presence of metastatic myxoid\nliposarcoma, with clear surgical margins.\n\n**Current Recommendations:**\n\n1. **Follow-up:** A strict follow-up plan should be established for Mr.\n Havers to monitor for any potential recurrence or new metastatic\n lesions. This should include regular clinical assessments, chest\n imaging, and other relevant investigations.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n --------------------- ------------- ---------------------\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 39 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.5 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.6 g/dL 13.5-17.0 g/dL\n Hematocrit 49.4 % 39.5-50.5 %\n RBC 5.1 M/µL 4.3-5.8 M/µL\n WBC 10.04 K/µL 3.90-10.50 K/µL\n Platelets 166 K/µL 150-370 K/µL\n MCV 95.2 fL 80.0-99.0 fL\n MCH 32.6 pg 27.0-33.5 pg\n MCHC 33.2 g/dL 31.5-36.0 g/dL\n MPV 11.4 fL 7.0-12.0 fL\n RDW-CV 12.5 % 11.5-15.0 %\n Prothrombin Time 122 % 78-123 %\n INR 0.99 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was under our inpatient care from 03/25/2016 to\n03/30/2016.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- Uncomplicated biopsy, pending results\n\n- LifeVest has been adjusted\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Medical History:** The patient was admitted with suspected myocarditis\ndue to a significantly impaired pump function noticed during outpatient\nvisits. Anamnestically, the patient reported experiencing fatigue and\nexertional dyspnea since mid-December, with no recollection of a\npreceding infection. Antiviral therapy with Interferon/Ribavirin for\nchronic Hepatitis C had been ongoing since November. An outpatient\nevaluation had excluded relevant coronary artery disease.\n\n**Current Presentation:** Suspected inflammatory/dilated cardiomyopathy,\nIndication for biopsy\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Coronary Angiography**: Globally significantly impaired left\nventricular function (EF: 28%)\n\n[Myocardial biopsy:]{.underline} Uncomplicated retrieval of LV\nendomyocardial biopsies\n\n[Recommendation]{.underline}: A conservative medical approach is\nrecommended, and further therapeutic decisions will depend on the\nhistological, immunohistological, and molecular biological examination\nresults of the now-retrieved myocardial biopsies.\n\n[Procedure]{.underline}: Femoral closure system is applied, 6 hours of\nbed rest, administration of 100 mg/day of Aspirin for 4 weeks following\nleft ventricular heart biopsy.\n\n**Echocardiography before Heart Catheterization**:\n\nPerformed in sinus rhythm. Satisfactory ultrasound condition.\n\n[Findings]{.underline}: Moderately dilated left ventricle (LVDd 64mm).\nMarkedly reduced systolic LV function (EF 28%). Global longitudinal\nstrain (2D speckle tracking): -8.6%.\n\nRegional wall motion abnormalities: despite global hypokinesia, the\nposterolateral wall (basal) contracts best. Diastolic dysfunction Grade\n1 (LV relaxation disorder) (E/A 0.7) (E/E\\' mean 13.8). No LV\nhypertrophy. Morphologically age-appropriate heart valves. Moderately\ndilated left atrium (LA Vol. 71ml). Mild mitral valve insufficiency\n(Grade 1 on a 3-grade scale). Normal-sized right ventricle. Moderately\nreduced RV function Normal-sized right atrium. Minimal tricuspid valve\ninsufficiency (Grade 0-1 on a 3-grade scale). Systolic pulmonary artery\npressure in the normal range (systolic PAP 27mmHg).\n\nNo thrombus detected. Minimal pericardial effusion, circular, maximum\n2mm, no hemodynamic relevance.\n\n**Echocardiography after Heart Catheterization:**\n\n[Indication]{.underline}: Follow-up on pericardial effusion.\n\n[Examination]{.underline}: TTE at rest, including duplex and\nquantitative determination of parameters. [Echocardiographic\nFinding:]{.underline} Regarding pericardial effusion, the status is the\nsame. Circular effusion, maximum 2mm.\n\n**ECG after Heart Catheterization:**\n\n76/min, sinus rhythm, complete left bundle branch block.\n\n**Summary:** On 03/26/2016, biopsy and left heart catheterization were\nsuccessfully performed without complications. Here, too, the patient\nexhibited a significantly impaired pump function, currently at 28%.\n\n**Therapy and Progression:**\n\nThroughout the inpatient stay, the patient remained cardiorespiratorily\nstable at all times. Malignant arrhythmias were ruled out via telemetry.\nAfter the intervention, echocardiography showed no pericardial effusion.\nThe results of the endomyocardial biopsies are still pending. An\nappointment for results discussion and evaluation of further procedures\nat our facility should be scheduled in 3 weeks. Following the biopsy,\nAspirin 100 as specified should be given for 4 weeks. We intensified the\nongoing heart failure therapy and added Spironolactone to the\nmedication, recommending further escalation based on hemodynamic\ntolerability.\n\n**Current Recommendations:** Close cardiological follow-up examinations,\nelectrolyte monitoring, and echocardiography are advised. Depending on\nthe left ventricular ejection fraction\\'s course, the implantation of an\nICD or ICD/CRT system should be considered after 3 months. On the day of\ndischarge, we initiated the adjustment of a Life Vest, allowing the\npatient to return home in good general condition.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------ ------------- ---------------------\n Absolute Erythroblasts 0.01/nL \\< 0.01/nL\n Sodium 134 mEq/L 136-145 mEq/L\n Potassium 4.5 mEq/L 3.5-4.5 mEq/L\n Creatinine (Jaffé) 1.25 mg/dL 0.70-1.20 mg/dL\n Urea 50 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n CRP 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine 14.2 ng/L 9.30-17.00 ng/L\n TSH 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Erythrocytes 3.7 /pL 4.3-5.8/pL\n Leukocytes 9.56/nL 3.90-10.50/nL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n PTT Actin-FS 25.3 sec. 22.0-29.0 sec.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the pending findings of the myocardial biopsies\ntaken from Mr. David Romero, born on 02/16/1942 on 03/26/2016 due to the\ndeterioration of LV function from 40% to 28% after interferon therapy\nfor HCV infection.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Myocardial Biopsy on 01/27/2014:**\n\n[Molecular Biology:]{.underline}\n\nPCR examinations performed under the question of myocardial infection\nwith cardiotropic pathogens yielded a positive detection of HCV-specific\nRNA in myocardial tissue without quantification possibility\n(methodically determined). Otherwise, there was no evidence of\nmyocardial infection with enteroviruses, adenoviruses, Epstein-Barr\nvirus, Human Herpes Virus Type 6 A/B, or Erythrovirus genotypes 1/2 in\nthe myocardium.\n\n[Assessment]{.underline}: Positive HCV-mRNA detection in myocardial\ntissue. This positive test result does not unequivocally prove an\ninfection of myocardial cells, as contamination of the tissue sample\nwith HCV-infected peripheral blood cells cannot be ruled out in chronic\nhepatitis.\n\n**Histology and Immunohistochemistry**:\n\nUnremarkable endocardium, normal cell content of the interstitium with\nonly isolated lymphocytes and histiocytes in the histologically examined\nsamples. Quantitatively, immunohistochemically examined native\npreparations showed borderline high CD3-positive lymphocytes with a\ndiffuse distribution pattern at 10.2 cells/mm2. No increased\nperforin-positive cytotoxic T cells. The expression of cell adhesion\nmolecules is discreetly elevated. Otherwise, only slight perivascular\nbut no interstitial fibrosis. Cardiomyocytes are properly arranged and\nslightly hypertrophied (average diameter around 23 µm), the surrounding\ncapillaries are unremarkable. No evidence of acute\ninflammation-associated myocardial cell necrosis (no active myocarditis)\nand no interstitial scars from previous myocyte loss. No lipomatosis.\n\n[Assessment:]{.underline} Based on the myocardial biopsy findings, there\nis positive detection of HCV-RNA in the myocardial tissue samples, with\nthe possibility of tissue contamination with HCV-infected peripheral\nblood cells. Significant myocardial inflammatory reaction cannot be\ndocumented histologically and immunohistochemically. In the endocardial\nsamples, apart from mild hypertrophy of properly arranged\ncardiomyocytes, there are no significant signs of myocardial damage\n(interstitial fibrosis or scars from previous myocyte loss). Therefore,\nthe present findings do not indicate the need for specific further\nantiviral or anti-inflammatory therapy, and the existing heart failure\nmedication can be continued unchanged. If LV function impairment\npersists for an extended period, there is an indication for\nantiarrhythmic protection of the patient using an ICD.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe thank you for referring your patient Mr. David Romero, born on\n02/16/1942, to us for echocardiographic follow-up on 05/04/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Echocardiography: M-mode and 2-dimensional.**\n\nThe left ventricle measures approximately 65/56 mm (normal up to 56 mm).\n\nThe right atrium and right ventricle are of normal dimensions.\n\nGlobal progressive reduction in contractility, morphologically\nunremarkable.\n\nIn Doppler echocardiography, normal heart valves are observed.\n\nMitral valve insufficiency Grade I.\n\n[Assessment]{.underline}: Dilated cardiomyopathy with slightly reduced\nleft ventricular function. MI I TII °, PAP 23 mm Hg + CVP. No more\npulmonary embolism detectable.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942 to us for echocardiographic follow-up on 06/15/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Echocardiography from 06/15/2016**: Good ultrasound conditions.\n\nThe left ventricle is dilated to approximately 65/57 mm (normal up to 56\nmm). The left atrium is dilated to 48 mm. Normal thickness of the left\nventricular myocardium. Ejection fraction is around 28%. Heart valves\nshow normal flow velocities.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing,\npotassium and creatinine levels were obtained. If EF remains this low,\nan ICD may be indicated.\n\n**Lab results from 06/15/2016:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.8 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n Platelet Count 280 K/µL 150-370 K/µL\n MC 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting to you about Mr. David Romero, born on 02/16/1942, who\npresented himself at our Cardiology University Outpatient Clinic on\n06/30/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ---------------- ---------------\n Aspirin 100 mg/tablet 1-0-0\n Ramipril (Altace) 2.5 mg/tablet 1-0-1\n Carvedilol (Coreg) 12.5 mg/tablet 1-0-1\n Torasemide (Torem) 5 mg/tablet 1-0-0\n Spironolactone (Aldactone) 25 mg/tablet 1-0-0\n L-Thyroxine (Synthroid) 50 µg/tablet 1-0-0\n\n**Echocardiography on 06/30/2016:** In sinus rhythm. Adequate ultrasound\nwindow.\n\nModerately dilated left ventricle (LVDd 63mm). Significantly reduced\nsystolic LV function (EF biplane 29%). No LV hypertrophy.\n\n**ECG on 06/30/2016:** Sinus rhythm, regular tracing, heart rate 69/min,\ncomplete left bundle branch block, QRS 135 ms, ERBS with left bundle\nbranch block.\n\n**Assessment**: Mr. Romero presents himself for the follow-up assessment\nof known dilated cardiomyopathy. He currently reports minimal dyspnea.\nCoronary heart disease has been ruled out. No virus was detected\nbioptically. However, the recent echocardiography still shows severely\nimpaired LV function.\n\n**Current Recommendations:** Given the presence of left bundle branch\nblock, there is an indication for CRT-D implantation. For this purpose,\nwe have scheduled a pre-admission appointment, with the implantation\nplanned for 07/04/2016. We kindly request a referral letter. The\nLifeVest should continue to be worn until the implantation, despite the\npressure sores on the thorax.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was in our inpatient care from 07/04/2016 to\n07/06/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation:** The current admission was elective for CRT-D\nimplantation in dilated cardiomyopathy with severely impaired LV\nfunction despite full heart failure medication and complete left bundle\nbranch block. Please refer to previous medical records for a detailed\nhistory. On 07/05/2016, a CRT-ICD system was successfully implanted. The\nperi- and post-interventional course was uncomplicated. Pneumothorax was\nruled out post-interventionally. The wound conditions are\nirritation-free. The ICD card was given to the patient. We request\noutpatient follow-up on the above-mentioned date for wound inspection\nand CRT follow-up. Please adjust the known cardiovascular risk factors.\n\n**Findings:**\n\n**ECG upon Admission:** Sinus rhythm 66/min, PQ 176ms, QRS 126ms, QTc\n432ms, Complete left bundle branch block with corresponding excitation\nregression disorder.\n\n**Procedure**: Implantation of a CRT-D with left ventricular multipoint\npacing left pectoral. Smooth triple puncture of the lateral left\nsubclavian vein and implantation of an active single-coil electrode in\nthe RV apex with very good electrical values. Trouble-free probing of\nthe CS and direct venography using a balloon occlusion catheter.\nIdentification of a suitable lateral vein and implantation of a\nquadripolar electrode (Quartet, St. Jude Medical) with very good\nelectrical values. No phrenic stimulation up to 10 volts in all\npolarities. Finally, implantation of an active P/S electrode in the\nright atrial roof with equally very good electrical values. Connection\nto the device and submuscular implantation. Wound irrigation and layered\nwound closure with absorbable suture material. Finally, extensive\ntesting of all polarities of the LV electrode and activation of\nmultipoint pacing. Final setting of the ICD.\n\n**Chest X-ray on 07/05/2016:**\n\n[Clinical status, question, justifying indication:]{.underline} History\nof CRT-D implantation. Question about lead position, pneumothorax?\n\n**Findings**: New CRT-D unit left pectoral with leads projected onto the\nright ventricle, the right atrium, and the sinus coronarius. No\npneumothorax.\n\nNormal heart size. No pulmonary congestion. No diffuse infiltrates. No\npleural effusions.\n\n**ECG at Discharge:** Continuous ventricular PM stimulation, HR: 66/min.\n\n**Current Recommendations:**\n\n- We request a follow-up appointment in our Pacemaker Clinic. Please\n provide a referral slip.\n\n- We ask for the protection of the left arm and avoidance of\n elevations \\> 90 degrees. Self-absorbing sutures have been used.\n\n- We request regular wound checks.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942, who presented to our Cardiological University Outpatient\nClinic on 08/26/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation**: Slightly increasing exertional dyspnea, no\ncoronary heart disease.\n\n**Cardiovascular Risk Factors:**\n\n- Family history: No\n\n- Smoking: No\n\n- Hypertension: No\n\n- Diabetes: Yes\n\n- Dyslipidemia: Yes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Findings**:\n\n**Resting ECG:** Sinus rhythm, 83 bpm. Blood pressure: 120/70 mmHg.\n\n**Echocardiography: M-mode and 2-dimensional**\n\nLeft ventricle dimensions: Approximately 57/45 mm (normal up to 56 mm),\nmoderately dilated\n\n- Right atrium and right ventricle: Normal dimensions\n\n- Normal thickness of left ventricular muscle\n\n- Globally, mild reduction in contractility\n\n- Heart valves: Morphologically normal\n\n- Doppler-Echocardiography: No significant valve regurgitation\n\n**Assessment**: Mildly dilated cardiomyopathy with slightly reduced left\nventricular function. Ejection fraction at 45 - 50%. Mild diastolic\ndysfunction. Mild tricuspid regurgitation, pulmonary artery pressure 22\nmm Hg, and left ventricular filling pressure slightly increased.\n\n**Stress Echocardiography: Stress echocardiography with exercise test**\n\n- Stress test protocol: Treadmill exercise test\n\n- Reason for stress test: Exertional dyspnea\n\n- Quality of the ultrasound: Good\n\n- Initial workload: 50 watts\n\n- Maximum workload achieved: 150 Watt\n\n- Blood pressure response: Systolic BP increased from 112/80 mmHg to\n 175/90 mmHg\n\n- Heart rate response: Increased from 71bpm to 124bpm\n\n- Exercise terminated due to leg pain\n\n**Resting ECG:** Sinus rhythm**.** No significant changes during\nexercise\n\n**Echocardiography at rest:** Normokinesis of all left ventricular\nsegments EF: 45 - 50%\n\n**Echocardiography during exercise:** Increased contractility and wall\nthickening of all segments\n\n[Summary]{.underline}: No dynamic wall motion abnormalities. No evidence\nof exercise-induced myocardial ischemia\n\n**Carotid Doppler Ultrasound:** Both common carotid arteries are\nsmooth-walled**.** Intima-media thickness: 0.8 mm**.** Small plaque in\nthe carotid bulb on both sides**.** Normal flow in the internal and\nexternal carotid arteries**.** Normal dimensions and flow in the\nvertebral arteries\n\n**Summary:** Non-obstructive carotid plaques**.** Indicated to lower LDL\nto below 1.8 mmol/L\n\n**Summary:**\n\n- Stress echocardiography shows no evidence of ischemia, EF \\>45-50%\n\n- Carotid duplex shows minimal non-obstructive plaques\n\n- Increase Simvastatin to 20 mg, target LDL-C \\< 1.8 mmol/L\n\n\n\n### text_7\n**Dear colleague, **\n\nWe would like to inform you about the results of the cardiac\ncatheterization of Mr. David Romero, born on 02/16/1942 performed by us\non 08/10/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Procedure:** Right femoral artery puncture. Left ventriculography with\na 5F pigtail catheter in the right anterior oblique projection. Coronary\nangiography with 5F JL4.0 and 5F JR 4.0 catheters. End-diastolic\npressure in the left ventricle within the normal range, measured in\nmmHg. No pathological pressure gradient across the aortic valve.\n\n**Coronary angiography:**\n\n- Unremarkable left main stem.\n\n- The left anterior descending (LAD) artery shows mild wall changes,\n with a maximum stenosis of 20-\\<30%.\n\n- The robust right coronary artery (RCA) is stenosed proximally by\n 30-40%, subsequently ectatic and then stenosed to 40-\\<50% distally.\n Slow contrast clearance. The right coronary artery is also stenosed\n up to 30%.\n\n- Left-dominant coronary circulation.\n\n**Assessment**: Diffuse coronary atherosclerosis with less than 50%\nstenosis in the RCA and evidence of endothelial dysfunction.\n\n**Current Recommendations:**\n\n- Initiation of Ranolazine\n\n- Additional stress myocardial perfusion scintigraphy\n\n\n\n### text_8\n**Dear colleague, **\n\nWe would like to inform you about the results of the Myocardial\nPerfusion Scintigraphy performed on our patient, Mr. David Romero, born\non 02/16/1942, on 09/23/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Myocardial Perfusion Scintigraphy:**\n\nThe myocardial perfusion scintigraphy was conducted using 365 MBq of\n99m-Technetium MIBI during pharmacological stress and 383 MBq of\n99m-Technetium MIBI at rest.\n\n[Technique]{.underline}: Initially, the patient was pharmacologically\nstressed with the intravenous administration of 400 µg of Regadenoson\nover 20 seconds, accompanied by ergometer exercise at 50 W.\nSubsequently, the intravenous injection of the radiopharmaceutical was\nperformed. The maximum blood pressure achieved during the stress phase\nwas 143/84 mm Hg, and the maximum heart rate reached was 102 beats per\nminute.\n\nApproximately 60 minutes later, ECG-triggered acquisition of a\n360-degree SPECT study was conducted with reconstructions of short and\nlong-axis slices.\n\nDue to inhomogeneities in the myocardial wall segments during stress,\nrest images were acquired on another examination day. Following the\nintravenous injection of the radiopharmaceutical, ECG-triggered\nacquisition of a 360-degree SPECT study was performed, including\nshort-axis and long-axis slices, approximately 60 minutes later.\n\n[Clinical Information:]{.underline} Known coronary heart disease (RCA\n50%). ICD/CRT pacemaker.\n\n[Findings]{.underline}: No clear perfusion defects are seen in the\nscintigraphic images acquired after pharmacologic exposure to\nRegadenoson. This finding remains unchanged in the scintigraphic images\nacquired at rest.\n\nQuantitative analysis shows a normal-sized ventricle with a normal left\nventricular ejection fraction (LVEF) of 53% under exercise conditions\nand 47% at rest (EDV 81 mL). There are no clear wall motion\nabnormalities. In the gated SPECT analysis, there are no definite wall\nmotion abnormalities observed in both stress and rest conditions.\n\n**Quantitative Scoring:**\n\n- SSS (Summed Stress Score): 3 (4.4%)\n\n- SRS (Summed Rest Score): 0 (0.0%)\n\n- SDS (Summed Difference Score): 3 (4.4%)\n\n**Assessment**: No evidence of myocardial perfusion defects with\nRegadenoson stress or at rest. Normal ventricular size and function with\nno significant wall motion abnormalities.\n\n\n\n### text_9\n**Dear colleague, **\n\nWe would like to report on our patient, Mr. David Romero, born on\n02/16/1942, who was under our inpatient care from 05/20/2023 to\n05/21/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medical History:** The patient was admitted for device replacement due\nand upgrading to a CRT-P pacemaker. At admission, the patient reported\nno complaints of fever, cough, dyspnea, chest pain, or melena.\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Medication upon Admission**\n\n **Medication** **Dosage** **Frequency**\n --------------------------- -------------- ----------------------\n Insulin glargine (Lantus) 450 E/1.5 ml 0-0-0-6-8 IU\n Insulin lispro (Humalog) 300 E/3 ml 5-8 IU-5-8 IU-5-8 IU\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Colecalciferol 12.5 mcg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n\n**Therapy and Progression:** The patient\\'s current admission was\nelective for the implantation of a 3-chamber CRT-D device due to device\ndepletion. The procedure was performed without complications on\n05/20/2023. The post-interventional course was uneventful. The\nimplantation site showed no irritation or significant hematoma at the\ntime of discharge, and no pneumothorax was detected on X-ray.\n\nTo protect the surgical wound, we request dry wound dressing for the\nnext 10 days and clinical wound checks. Suture removal is not necessary\nwith absorbable suture material. We advise against arm elevation for the\nnext 4 weeks, avoiding heavy lifting on the side of the device pocket\nand gradual, pain-adapted full range of motion after 4 weeks.\n\n**Current Recommendations:** We kindly request an outpatient follow-up\nappointment in our Pacemaker Clinic.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage ** **Frequency**\n ----------------------------- --------------- -----------------------\n Insulin glargine (Lantus) 450 E./1.5 ml 0-0-0-/6-8 IU\n Insulin lispro (Humalog) 300 E./3 ml 5-8 IU/-5-8 IU/5-8 IU\n Levothyroxine (Synthroid) 100 µg 1-0-0-0\n Colecalciferol (Vitamin D3) 12.5 µg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Colecalciferol 12.5 µg 2-0-0-0\n\n**Addition: Findings:**\n\n**ECG at Discharge:** Sinus rhythm, ventricular pacing, QRS 122ms, QTc\n472ms\n\n**Rhythm Examination on 05/20/2023:**\n\n[Results:]{.underline} Replacement of a 3-chamber CRT-D device (new:\nSJM/Abbott Quadra Assura) due to impending battery depletion:\nUncomplicated replacement. Tedious freeing of the submuscular device and\nproximal lead portions using a plasma blade. Extraction of the old\ndevice. Connection to the new device. Avoidance of device fixation in\nthe submuscular position. Hemostasis by electrocauterization. Layered\nwound closure. Skin closure with absorbable intracutaneous sutures. End\nadjustment of the CRT-D device is complete. [Procedure]{.underline}:\nCompression of the wound with a sandbag and local cooling. First\noutpatient follow-up in 8 weeks through our pacemaker clinic (please\nschedule an appointment before discharge). Postoperative chest X-ray is\nnot necessary. Cefuroxime 1.5 mg again tonight.\n\n**Transthoracic Echocardiography on 05/18/2023**\n\n**Results:** Globally mildly impaired systolic LV function. Diastolic\ndysfunction Grade 1 (LV relaxation disorder).\n\n- Right Ventricle: Normal-sized right ventricle. Normal RV function.\n Pulmonary arterial pressure is normal.\n\n- Left Atrium: Slightly dilated left atrium.\n\n- Right Atrium: Normal-sized right atrium.\n\n- Mitral Valve: Morphologically unremarkable. Minimal mitral valve\n regurgitation.\n\n- Aortic Valve: Mildly sclerotic aortic valve cusps. No aortic valve\n insufficiency. No aortic valve stenosis (AV PGmax 7 mmHg).\n\n- Tricuspid Valve: Delicate tricuspid valve leaflets. Minimal\n tricuspid valve regurgitation (TR Pmax 26 mmHg).\n\n- Pulmonary Valve: No pulmonary valve insufficiency. Pericardium: No\n pericardial effusion.\n\n**Assessment**: Examination in sinus rhythm with bundle branch block.\nModerate ultrasound windows. Normal-sized left ventricle (LVED 54 mm)\nwith mildly reduced systolic LV function (EF biplan 55%) with mildly\nreduced contractility without regional emphasis. Mild LV hypertrophy,\npredominantly septal, without obstruction. Diastolic dysfunction Grade 1\n(E/A 0.47) with a normal LV filling index (E/E\\' mean 3.5). Slightly\nsclerotic aortic valve without stenosis, no AI. Slightly dilated left\natrium (LAVI 31 ml/m²). Minimal MI. Normal-sized right ventricle with\nnormal function. Normal-sized right atrium (RAVI 21 ml/m²). Minimal TI.\nAs far as assessable, systolic PA pressure is within the normal range.\nThe IVC cannot be viewed from the subcostal angle. No thrombi are\nvisible. As far as assessable, no pericardial effusion is visible.\n\n**Chest X-ray in two planes on 05/20/2023: **\n\n[Clinical Information, Question, Justification:]{.underline} Post CRT\ndevice replacement. Inquiry about position, pneumothorax.\n\n[Findings]{.underline}: No pneumothorax following CRT device\nreplacement.\n\n\n\n### text_10\n**Dear colleague, **\n\nWe are writing to provide an update on Mr. David Romero, born on\n02/16/1942, who presented at our Rhythm Clinic on 09/29/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ------------------ ---------------\n Lantus (Insulin glargine) 450 Units/1.5 mL 0-0-0-/6-8\n Humalog (Insulin lispro) 300 Units/3 mL 5-8/0/5-8/5-8\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n Lipitor (Atorvastatin) 21.7 mg 0-0-1-0\n Norvasc (Amlodipine) 6.94 mg 1-0-0-0\n Altace (Ramipril) 5 mg 1-0-0-0\n Demadex (Torasemide) 5 mg 0-0-0.5-0\n Coreg (Carvedilol) 25 mg 0.5-0-0.5-0\n Zocor (Simvastatin) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n\n**Measurement Results:**\n\nBattery/Capacitor: Status: OK, Voltage: 8.4V\n\n- Right Atrial: 375 Ohms 3.80 mV 0.375 V 0.50 ms\n\n- Right Ventricular: 388 Ohms 11.80 mV 0.750 V 0.50 ms\n\n- Left Ventricular: 350 Ohms 0.625 V 0.50 ms\n\n- Defibrillation Impedance: Right Ventricular: 48 Ohms\n\n**Implant Settings:**\n\n- Bradycardia Setting: Mode: DDD\n\n- Tachycardia Settings: Zone Detection Interval (ms) Detection Beats\n ATP Shocks Details Status\n\n - VFVF 260 ms 30 /\n\n - VTVT1 330 ms 55 /\n\n<!-- -->\n\n- Probe Settings: Lead Sensitivity Sensing Polarity/Vector\n Amplification/Pulse Width Stimulation Polarity/Vector Auto Amplitude\n Control\n\n - Right Atrial: 0.30 mV Bipolar/ 1.375 V/0.50 ms Bipolar/\n\n - Right Ventricular: Bipolar/ 2.000 V/0.50 ms Bipolar/\n\n - Left Ventricular: 2.000 V/0.50 ms tip 1 - RV Coil\n\n**Assessment:**\n\n- Routine visit with normal device function.\n\n- Normal sinus rhythm with a heart rate of 65/min.\n\n- Balanced heart rate histogram with a plateau at 60-70 bpm.\n\n- Wound conditions are unremarkable.\n\n- Battery status: OK.\n\n- Atrial probe: Intact\n\n- Right ventricular probe: Intact\n\n- Left ventricular probe: Intact\n\n- A follow-up appointment for the patient is requested in 6 months.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.8 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 5.9 mg/L \\< 5.0 mg/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n MCV 92.7 fL 80.0-99.0 fL\n MCH 31.8 pg 27.0-33.5 pg\n MCHC 33.9 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.2% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n\n\n\nHere is the query:\nWhat was Mr. Romero's reported blood pressure on 09/29/2023?\n\nChoose the correct answer from the following options:\nA. 120/70 mmHg\nB. 143/84 mmHg\nC. 175/90 mmHg\nD. 110/70 mmHg\nE. Not specified\n\n\nYour response:\n", "role": "user" }, { "content": "Not specified", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was under our inpatient care from 03/25/2016 to\n03/30/2016.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- Uncomplicated biopsy, pending results\n\n- LifeVest has been adjusted\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Medical History:** The patient was admitted with suspected myocarditis\ndue to a significantly impaired pump function noticed during outpatient\nvisits. Anamnestically, the patient reported experiencing fatigue and\nexertional dyspnea since mid-December, with no recollection of a\npreceding infection. Antiviral therapy with Interferon/Ribavirin for\nchronic Hepatitis C had been ongoing since November. An outpatient\nevaluation had excluded relevant coronary artery disease.\n\n**Current Presentation:** Suspected inflammatory/dilated cardiomyopathy,\nIndication for biopsy\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Coronary Angiography**: Globally significantly impaired left\nventricular function (EF: 28%)\n\n[Myocardial biopsy:]{.underline} Uncomplicated retrieval of LV\nendomyocardial biopsies\n\n[Recommendation]{.underline}: A conservative medical approach is\nrecommended, and further therapeutic decisions will depend on the\nhistological, immunohistological, and molecular biological examination\nresults of the now-retrieved myocardial biopsies.\n\n[Procedure]{.underline}: Femoral closure system is applied, 6 hours of\nbed rest, administration of 100 mg/day of Aspirin for 4 weeks following\nleft ventricular heart biopsy.\n\n**Echocardiography before Heart Catheterization**:\n\nPerformed in sinus rhythm. Satisfactory ultrasound condition.\n\n[Findings]{.underline}: Moderately dilated left ventricle (LVDd 64mm).\nMarkedly reduced systolic LV function (EF 28%). Global longitudinal\nstrain (2D speckle tracking): -8.6%.\n\nRegional wall motion abnormalities: despite global hypokinesia, the\nposterolateral wall (basal) contracts best. Diastolic dysfunction Grade\n1 (LV relaxation disorder) (E/A 0.7) (E/E\\' mean 13.8). No LV\nhypertrophy. Morphologically age-appropriate heart valves. Moderately\ndilated left atrium (LA Vol. 71ml). Mild mitral valve insufficiency\n(Grade 1 on a 3-grade scale). Normal-sized right ventricle. Moderately\nreduced RV function Normal-sized right atrium. Minimal tricuspid valve\ninsufficiency (Grade 0-1 on a 3-grade scale). Systolic pulmonary artery\npressure in the normal range (systolic PAP 27mmHg).\n\nNo thrombus detected. Minimal pericardial effusion, circular, maximum\n2mm, no hemodynamic relevance.\n\n**Echocardiography after Heart Catheterization:**\n\n[Indication]{.underline}: Follow-up on pericardial effusion.\n\n[Examination]{.underline}: TTE at rest, including duplex and\nquantitative determination of parameters. [Echocardiographic\nFinding:]{.underline} Regarding pericardial effusion, the status is the\nsame. Circular effusion, maximum 2mm.\n\n**ECG after Heart Catheterization:**\n\n76/min, sinus rhythm, complete left bundle branch block.\n\n**Summary:** On 03/26/2016, biopsy and left heart catheterization were\nsuccessfully performed without complications. Here, too, the patient\nexhibited a significantly impaired pump function, currently at 28%.\n\n**Therapy and Progression:**\n\nThroughout the inpatient stay, the patient remained cardiorespiratorily\nstable at all times. Malignant arrhythmias were ruled out via telemetry.\nAfter the intervention, echocardiography showed no pericardial effusion.\nThe results of the endomyocardial biopsies are still pending. An\nappointment for results discussion and evaluation of further procedures\nat our facility should be scheduled in 3 weeks. Following the biopsy,\nAspirin 100 as specified should be given for 4 weeks. We intensified the\nongoing heart failure therapy and added Spironolactone to the\nmedication, recommending further escalation based on hemodynamic\ntolerability.\n\n**Current Recommendations:** Close cardiological follow-up examinations,\nelectrolyte monitoring, and echocardiography are advised. Depending on\nthe left ventricular ejection fraction\\'s course, the implantation of an\nICD or ICD/CRT system should be considered after 3 months. On the day of\ndischarge, we initiated the adjustment of a Life Vest, allowing the\npatient to return home in good general condition.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------ ------------- ---------------------\n Absolute Erythroblasts 0.01/nL \\< 0.01/nL\n Sodium 134 mEq/L 136-145 mEq/L\n Potassium 4.5 mEq/L 3.5-4.5 mEq/L\n Creatinine (Jaffé) 1.25 mg/dL 0.70-1.20 mg/dL\n Urea 50 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n CRP 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine 14.2 ng/L 9.30-17.00 ng/L\n TSH 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Erythrocytes 3.7 /pL 4.3-5.8/pL\n Leukocytes 9.56/nL 3.90-10.50/nL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n PTT Actin-FS 25.3 sec. 22.0-29.0 sec.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the pending findings of the myocardial biopsies\ntaken from Mr. David Romero, born on 02/16/1942 on 03/26/2016 due to the\ndeterioration of LV function from 40% to 28% after interferon therapy\nfor HCV infection.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Myocardial Biopsy on 01/27/2014:**\n\n[Molecular Biology:]{.underline}\n\nPCR examinations performed under the question of myocardial infection\nwith cardiotropic pathogens yielded a positive detection of HCV-specific\nRNA in myocardial tissue without quantification possibility\n(methodically determined). Otherwise, there was no evidence of\nmyocardial infection with enteroviruses, adenoviruses, Epstein-Barr\nvirus, Human Herpes Virus Type 6 A/B, or Erythrovirus genotypes 1/2 in\nthe myocardium.\n\n[Assessment]{.underline}: Positive HCV-mRNA detection in myocardial\ntissue. This positive test result does not unequivocally prove an\ninfection of myocardial cells, as contamination of the tissue sample\nwith HCV-infected peripheral blood cells cannot be ruled out in chronic\nhepatitis.\n\n**Histology and Immunohistochemistry**:\n\nUnremarkable endocardium, normal cell content of the interstitium with\nonly isolated lymphocytes and histiocytes in the histologically examined\nsamples. Quantitatively, immunohistochemically examined native\npreparations showed borderline high CD3-positive lymphocytes with a\ndiffuse distribution pattern at 10.2 cells/mm2. No increased\nperforin-positive cytotoxic T cells. The expression of cell adhesion\nmolecules is discreetly elevated. Otherwise, only slight perivascular\nbut no interstitial fibrosis. Cardiomyocytes are properly arranged and\nslightly hypertrophied (average diameter around 23 µm), the surrounding\ncapillaries are unremarkable. No evidence of acute\ninflammation-associated myocardial cell necrosis (no active myocarditis)\nand no interstitial scars from previous myocyte loss. No lipomatosis.\n\n[Assessment:]{.underline} Based on the myocardial biopsy findings, there\nis positive detection of HCV-RNA in the myocardial tissue samples, with\nthe possibility of tissue contamination with HCV-infected peripheral\nblood cells. Significant myocardial inflammatory reaction cannot be\ndocumented histologically and immunohistochemically. In the endocardial\nsamples, apart from mild hypertrophy of properly arranged\ncardiomyocytes, there are no significant signs of myocardial damage\n(interstitial fibrosis or scars from previous myocyte loss). Therefore,\nthe present findings do not indicate the need for specific further\nantiviral or anti-inflammatory therapy, and the existing heart failure\nmedication can be continued unchanged. If LV function impairment\npersists for an extended period, there is an indication for\nantiarrhythmic protection of the patient using an ICD.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient Mr. David Romero, born on\n02/16/1942, to us for echocardiographic follow-up on 05/04/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Echocardiography: M-mode and 2-dimensional.**\n\nThe left ventricle measures approximately 65/56 mm (normal up to 56 mm).\n\nThe right atrium and right ventricle are of normal dimensions.\n\nGlobal progressive reduction in contractility, morphologically\nunremarkable.\n\nIn Doppler echocardiography, normal heart valves are observed.\n\nMitral valve insufficiency Grade I.\n\n[Assessment]{.underline}: Dilated cardiomyopathy with slightly reduced\nleft ventricular function. MI I TII °, PAP 23 mm Hg + CVP. No more\npulmonary embolism detectable.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942 to us for echocardiographic follow-up on 06/15/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Echocardiography from 06/15/2016**: Good ultrasound conditions.\n\nThe left ventricle is dilated to approximately 65/57 mm (normal up to 56\nmm). The left atrium is dilated to 48 mm. Normal thickness of the left\nventricular myocardium. Ejection fraction is around 28%. Heart valves\nshow normal flow velocities.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing,\npotassium and creatinine levels were obtained. If EF remains this low,\nan ICD may be indicated.\n\n**Lab results from 06/15/2016:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.8 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n Platelet Count 280 K/µL 150-370 K/µL\n MC 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about Mr. David Romero, born on 02/16/1942, who\npresented himself at our Cardiology University Outpatient Clinic on\n06/30/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ---------------- ---------------\n Aspirin 100 mg/tablet 1-0-0\n Ramipril (Altace) 2.5 mg/tablet 1-0-1\n Carvedilol (Coreg) 12.5 mg/tablet 1-0-1\n Torasemide (Torem) 5 mg/tablet 1-0-0\n Spironolactone (Aldactone) 25 mg/tablet 1-0-0\n L-Thyroxine (Synthroid) 50 µg/tablet 1-0-0\n\n**Echocardiography on 06/30/2016:** In sinus rhythm. Adequate ultrasound\nwindow.\n\nModerately dilated left ventricle (LVDd 63mm). Significantly reduced\nsystolic LV function (EF biplane 29%). No LV hypertrophy.\n\n**ECG on 06/30/2016:** Sinus rhythm, regular tracing, heart rate 69/min,\ncomplete left bundle branch block, QRS 135 ms, ERBS with left bundle\nbranch block.\n\n**Assessment**: Mr. Romero presents himself for the follow-up assessment\nof known dilated cardiomyopathy. He currently reports minimal dyspnea.\nCoronary heart disease has been ruled out. No virus was detected\nbioptically. However, the recent echocardiography still shows severely\nimpaired LV function.\n\n**Current Recommendations:** Given the presence of left bundle branch\nblock, there is an indication for CRT-D implantation. For this purpose,\nwe have scheduled a pre-admission appointment, with the implantation\nplanned for 07/04/2016. We kindly request a referral letter. The\nLifeVest should continue to be worn until the implantation, despite the\npressure sores on the thorax.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was in our inpatient care from 07/04/2016 to\n07/06/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation:** The current admission was elective for CRT-D\nimplantation in dilated cardiomyopathy with severely impaired LV\nfunction despite full heart failure medication and complete left bundle\nbranch block. Please refer to previous medical records for a detailed\nhistory. On 07/05/2016, a CRT-ICD system was successfully implanted. The\nperi- and post-interventional course was uncomplicated. Pneumothorax was\nruled out post-interventionally. The wound conditions are\nirritation-free. The ICD card was given to the patient. We request\noutpatient follow-up on the above-mentioned date for wound inspection\nand CRT follow-up. Please adjust the known cardiovascular risk factors.\n\n**Findings:**\n\n**ECG upon Admission:** Sinus rhythm 66/min, PQ 176ms, QRS 126ms, QTc\n432ms, Complete left bundle branch block with corresponding excitation\nregression disorder.\n\n**Procedure**: Implantation of a CRT-D with left ventricular multipoint\npacing left pectoral. Smooth triple puncture of the lateral left\nsubclavian vein and implantation of an active single-coil electrode in\nthe RV apex with very good electrical values. Trouble-free probing of\nthe CS and direct venography using a balloon occlusion catheter.\nIdentification of a suitable lateral vein and implantation of a\nquadripolar electrode (Quartet, St. Jude Medical) with very good\nelectrical values. No phrenic stimulation up to 10 volts in all\npolarities. Finally, implantation of an active P/S electrode in the\nright atrial roof with equally very good electrical values. Connection\nto the device and submuscular implantation. Wound irrigation and layered\nwound closure with absorbable suture material. Finally, extensive\ntesting of all polarities of the LV electrode and activation of\nmultipoint pacing. Final setting of the ICD.\n\n**Chest X-ray on 07/05/2016:**\n\n[Clinical status, question, justifying indication:]{.underline} History\nof CRT-D implantation. Question about lead position, pneumothorax?\n\n**Findings**: New CRT-D unit left pectoral with leads projected onto the\nright ventricle, the right atrium, and the sinus coronarius. No\npneumothorax.\n\nNormal heart size. No pulmonary congestion. No diffuse infiltrates. No\npleural effusions.\n\n**ECG at Discharge:** Continuous ventricular PM stimulation, HR: 66/min.\n\n**Current Recommendations:**\n\n- We request a follow-up appointment in our Pacemaker Clinic. Please\n provide a referral slip.\n\n- We ask for the protection of the left arm and avoidance of\n elevations \\> 90 degrees. Self-absorbing sutures have been used.\n\n- We request regular wound checks.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942, who presented to our Cardiological University Outpatient\nClinic on 08/26/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation**: Slightly increasing exertional dyspnea, no\ncoronary heart disease.\n\n**Cardiovascular Risk Factors:**\n\n- Family history: No\n\n- Smoking: No\n\n- Hypertension: No\n\n- Diabetes: Yes\n\n- Dyslipidemia: Yes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Findings**:\n\n**Resting ECG:** Sinus rhythm, 83 bpm. Blood pressure: 120/70 mmHg.\n\n**Echocardiography: M-mode and 2-dimensional**\n\nLeft ventricle dimensions: Approximately 57/45 mm (normal up to 56 mm),\nmoderately dilated\n\n- Right atrium and right ventricle: Normal dimensions\n\n- Normal thickness of left ventricular muscle\n\n- Globally, mild reduction in contractility\n\n- Heart valves: Morphologically normal\n\n- Doppler-Echocardiography: No significant valve regurgitation\n\n**Assessment**: Mildly dilated cardiomyopathy with slightly reduced left\nventricular function. Ejection fraction at 45 - 50%. Mild diastolic\ndysfunction. Mild tricuspid regurgitation, pulmonary artery pressure 22\nmm Hg, and left ventricular filling pressure slightly increased.\n\n**Stress Echocardiography: Stress echocardiography with exercise test**\n\n- Stress test protocol: Treadmill exercise test\n\n- Reason for stress test: Exertional dyspnea\n\n- Quality of the ultrasound: Good\n\n- Initial workload: 50 watts\n\n- Maximum workload achieved: 150 Watt\n\n- Blood pressure response: Systolic BP increased from 112/80 mmHg to\n 175/90 mmHg\n\n- Heart rate response: Increased from 71bpm to 124bpm\n\n- Exercise terminated due to leg pain\n\n**Resting ECG:** Sinus rhythm**.** No significant changes during\nexercise\n\n**Echocardiography at rest:** Normokinesis of all left ventricular\nsegments EF: 45 - 50%\n\n**Echocardiography during exercise:** Increased contractility and wall\nthickening of all segments\n\n[Summary]{.underline}: No dynamic wall motion abnormalities. No evidence\nof exercise-induced myocardial ischemia\n\n**Carotid Doppler Ultrasound:** Both common carotid arteries are\nsmooth-walled**.** Intima-media thickness: 0.8 mm**.** Small plaque in\nthe carotid bulb on both sides**.** Normal flow in the internal and\nexternal carotid arteries**.** Normal dimensions and flow in the\nvertebral arteries\n\n**Summary:** Non-obstructive carotid plaques**.** Indicated to lower LDL\nto below 1.8 mmol/L\n\n**Summary:**\n\n- Stress echocardiography shows no evidence of ischemia, EF \\>45-50%\n\n- Carotid duplex shows minimal non-obstructive plaques\n\n- Increase Simvastatin to 20 mg, target LDL-C \\< 1.8 mmol/L\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about the results of the cardiac\ncatheterization of Mr. David Romero, born on 02/16/1942 performed by us\non 08/10/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Procedure:** Right femoral artery puncture. Left ventriculography with\na 5F pigtail catheter in the right anterior oblique projection. Coronary\nangiography with 5F JL4.0 and 5F JR 4.0 catheters. End-diastolic\npressure in the left ventricle within the normal range, measured in\nmmHg. No pathological pressure gradient across the aortic valve.\n\n**Coronary angiography:**\n\n- Unremarkable left main stem.\n\n- The left anterior descending (LAD) artery shows mild wall changes,\n with a maximum stenosis of 20-\\<30%.\n\n- The robust right coronary artery (RCA) is stenosed proximally by\n 30-40%, subsequently ectatic and then stenosed to 40-\\<50% distally.\n Slow contrast clearance. The right coronary artery is also stenosed\n up to 30%.\n\n- Left-dominant coronary circulation.\n\n**Assessment**: Diffuse coronary atherosclerosis with less than 50%\nstenosis in the RCA and evidence of endothelial dysfunction.\n\n**Current Recommendations:**\n\n- Initiation of Ranolazine\n\n- Additional stress myocardial perfusion scintigraphy\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about the results of the Myocardial\nPerfusion Scintigraphy performed on our patient, Mr. David Romero, born\non 02/16/1942, on 09/23/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Myocardial Perfusion Scintigraphy:**\n\nThe myocardial perfusion scintigraphy was conducted using 365 MBq of\n99m-Technetium MIBI during pharmacological stress and 383 MBq of\n99m-Technetium MIBI at rest.\n\n[Technique]{.underline}: Initially, the patient was pharmacologically\nstressed with the intravenous administration of 400 µg of Regadenoson\nover 20 seconds, accompanied by ergometer exercise at 50 W.\nSubsequently, the intravenous injection of the radiopharmaceutical was\nperformed. The maximum blood pressure achieved during the stress phase\nwas 143/84 mm Hg, and the maximum heart rate reached was 102 beats per\nminute.\n\nApproximately 60 minutes later, ECG-triggered acquisition of a\n360-degree SPECT study was conducted with reconstructions of short and\nlong-axis slices.\n\nDue to inhomogeneities in the myocardial wall segments during stress,\nrest images were acquired on another examination day. Following the\nintravenous injection of the radiopharmaceutical, ECG-triggered\nacquisition of a 360-degree SPECT study was performed, including\nshort-axis and long-axis slices, approximately 60 minutes later.\n\n[Clinical Information:]{.underline} Known coronary heart disease (RCA\n50%). ICD/CRT pacemaker.\n\n[Findings]{.underline}: No clear perfusion defects are seen in the\nscintigraphic images acquired after pharmacologic exposure to\nRegadenoson. This finding remains unchanged in the scintigraphic images\nacquired at rest.\n\nQuantitative analysis shows a normal-sized ventricle with a normal left\nventricular ejection fraction (LVEF) of 53% under exercise conditions\nand 47% at rest (EDV 81 mL). There are no clear wall motion\nabnormalities. In the gated SPECT analysis, there are no definite wall\nmotion abnormalities observed in both stress and rest conditions.\n\n**Quantitative Scoring:**\n\n- SSS (Summed Stress Score): 3 (4.4%)\n\n- SRS (Summed Rest Score): 0 (0.0%)\n\n- SDS (Summed Difference Score): 3 (4.4%)\n\n**Assessment**: No evidence of myocardial perfusion defects with\nRegadenoson stress or at rest. Normal ventricular size and function with\nno significant wall motion abnormalities.\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nWe would like to report on our patient, Mr. David Romero, born on\n02/16/1942, who was under our inpatient care from 05/20/2023 to\n05/21/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medical History:** The patient was admitted for device replacement due\nand upgrading to a CRT-P pacemaker. At admission, the patient reported\nno complaints of fever, cough, dyspnea, chest pain, or melena.\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Medication upon Admission**\n\n **Medication** **Dosage** **Frequency**\n --------------------------- -------------- ----------------------\n Insulin glargine (Lantus) 450 E/1.5 ml 0-0-0-6-8 IU\n Insulin lispro (Humalog) 300 E/3 ml 5-8 IU-5-8 IU-5-8 IU\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Colecalciferol 12.5 mcg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n\n**Therapy and Progression:** The patient\\'s current admission was\nelective for the implantation of a 3-chamber CRT-D device due to device\ndepletion. The procedure was performed without complications on\n05/20/2023. The post-interventional course was uneventful. The\nimplantation site showed no irritation or significant hematoma at the\ntime of discharge, and no pneumothorax was detected on X-ray.\n\nTo protect the surgical wound, we request dry wound dressing for the\nnext 10 days and clinical wound checks. Suture removal is not necessary\nwith absorbable suture material. We advise against arm elevation for the\nnext 4 weeks, avoiding heavy lifting on the side of the device pocket\nand gradual, pain-adapted full range of motion after 4 weeks.\n\n**Current Recommendations:** We kindly request an outpatient follow-up\nappointment in our Pacemaker Clinic.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage ** **Frequency**\n ----------------------------- --------------- -----------------------\n Insulin glargine (Lantus) 450 E./1.5 ml 0-0-0-/6-8 IU\n Insulin lispro (Humalog) 300 E./3 ml 5-8 IU/-5-8 IU/5-8 IU\n Levothyroxine (Synthroid) 100 µg 1-0-0-0\n Colecalciferol (Vitamin D3) 12.5 µg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Colecalciferol 12.5 µg 2-0-0-0\n\n**Addition: Findings:**\n\n**ECG at Discharge:** Sinus rhythm, ventricular pacing, QRS 122ms, QTc\n472ms\n\n**Rhythm Examination on 05/20/2023:**\n\n[Results:]{.underline} Replacement of a 3-chamber CRT-D device (new:\nSJM/Abbott Quadra Assura) due to impending battery depletion:\nUncomplicated replacement. Tedious freeing of the submuscular device and\nproximal lead portions using a plasma blade. Extraction of the old\ndevice. Connection to the new device. Avoidance of device fixation in\nthe submuscular position. Hemostasis by electrocauterization. Layered\nwound closure. Skin closure with absorbable intracutaneous sutures. End\nadjustment of the CRT-D device is complete. [Procedure]{.underline}:\nCompression of the wound with a sandbag and local cooling. First\noutpatient follow-up in 8 weeks through our pacemaker clinic (please\nschedule an appointment before discharge). Postoperative chest X-ray is\nnot necessary. Cefuroxime 1.5 mg again tonight.\n\n**Transthoracic Echocardiography on 05/18/2023**\n\n**Results:** Globally mildly impaired systolic LV function. Diastolic\ndysfunction Grade 1 (LV relaxation disorder).\n\n- Right Ventricle: Normal-sized right ventricle. Normal RV function.\n Pulmonary arterial pressure is normal.\n\n- Left Atrium: Slightly dilated left atrium.\n\n- Right Atrium: Normal-sized right atrium.\n\n- Mitral Valve: Morphologically unremarkable. Minimal mitral valve\n regurgitation.\n\n- Aortic Valve: Mildly sclerotic aortic valve cusps. No aortic valve\n insufficiency. No aortic valve stenosis (AV PGmax 7 mmHg).\n\n- Tricuspid Valve: Delicate tricuspid valve leaflets. Minimal\n tricuspid valve regurgitation (TR Pmax 26 mmHg).\n\n- Pulmonary Valve: No pulmonary valve insufficiency. Pericardium: No\n pericardial effusion.\n\n**Assessment**: Examination in sinus rhythm with bundle branch block.\nModerate ultrasound windows. Normal-sized left ventricle (LVED 54 mm)\nwith mildly reduced systolic LV function (EF biplan 55%) with mildly\nreduced contractility without regional emphasis. Mild LV hypertrophy,\npredominantly septal, without obstruction. Diastolic dysfunction Grade 1\n(E/A 0.47) with a normal LV filling index (E/E\\' mean 3.5). Slightly\nsclerotic aortic valve without stenosis, no AI. Slightly dilated left\natrium (LAVI 31 ml/m²). Minimal MI. Normal-sized right ventricle with\nnormal function. Normal-sized right atrium (RAVI 21 ml/m²). Minimal TI.\nAs far as assessable, systolic PA pressure is within the normal range.\nThe IVC cannot be viewed from the subcostal angle. No thrombi are\nvisible. As far as assessable, no pericardial effusion is visible.\n\n**Chest X-ray in two planes on 05/20/2023: **\n\n[Clinical Information, Question, Justification:]{.underline} Post CRT\ndevice replacement. Inquiry about position, pneumothorax.\n\n[Findings]{.underline}: No pneumothorax following CRT device\nreplacement.\n\n", "title": "text_9" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mr. David Romero, born on\n02/16/1942, who presented at our Rhythm Clinic on 09/29/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ------------------ ---------------\n Lantus (Insulin glargine) 450 Units/1.5 mL 0-0-0-/6-8\n Humalog (Insulin lispro) 300 Units/3 mL 5-8/0/5-8/5-8\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n Lipitor (Atorvastatin) 21.7 mg 0-0-1-0\n Norvasc (Amlodipine) 6.94 mg 1-0-0-0\n Altace (Ramipril) 5 mg 1-0-0-0\n Demadex (Torasemide) 5 mg 0-0-0.5-0\n Coreg (Carvedilol) 25 mg 0.5-0-0.5-0\n Zocor (Simvastatin) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n\n**Measurement Results:**\n\nBattery/Capacitor: Status: OK, Voltage: 8.4V\n\n- Right Atrial: 375 Ohms 3.80 mV 0.375 V 0.50 ms\n\n- Right Ventricular: 388 Ohms 11.80 mV 0.750 V 0.50 ms\n\n- Left Ventricular: 350 Ohms 0.625 V 0.50 ms\n\n- Defibrillation Impedance: Right Ventricular: 48 Ohms\n\n**Implant Settings:**\n\n- Bradycardia Setting: Mode: DDD\n\n- Tachycardia Settings: Zone Detection Interval (ms) Detection Beats\n ATP Shocks Details Status\n\n - VFVF 260 ms 30 /\n\n - VTVT1 330 ms 55 /\n\n<!-- -->\n\n- Probe Settings: Lead Sensitivity Sensing Polarity/Vector\n Amplification/Pulse Width Stimulation Polarity/Vector Auto Amplitude\n Control\n\n - Right Atrial: 0.30 mV Bipolar/ 1.375 V/0.50 ms Bipolar/\n\n - Right Ventricular: Bipolar/ 2.000 V/0.50 ms Bipolar/\n\n - Left Ventricular: 2.000 V/0.50 ms tip 1 - RV Coil\n\n**Assessment:**\n\n- Routine visit with normal device function.\n\n- Normal sinus rhythm with a heart rate of 65/min.\n\n- Balanced heart rate histogram with a plateau at 60-70 bpm.\n\n- Wound conditions are unremarkable.\n\n- Battery status: OK.\n\n- Atrial probe: Intact\n\n- Right ventricular probe: Intact\n\n- Left ventricular probe: Intact\n\n- A follow-up appointment for the patient is requested in 6 months.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.8 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 5.9 mg/L \\< 5.0 mg/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n MCV 92.7 fL 80.0-99.0 fL\n MCH 31.8 pg 27.0-33.5 pg\n MCHC 33.9 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.2% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n", "title": "text_10" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n\n\n\n\nHere is the query:\nWhat pathological finding was indicated in Mr. Rudolph's internal cytological report?\n\nChoose the correct answer from the following options:\nA. Benign Urothelial Proliferation\nB. Altered nuclear plasma ratios\nC. Inflammation\nD. Necrosis\nE. Fibrosis\n\n\nYour response:\n", "role": "user" }, { "content": "Altered nuclear plasma ratios", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\n\nWe are writing to report on the outpatient treatment of Mrs. Laura\nMiller, born on 04/03/1967, on 05/22/2020.\n\n**Diagnosis**: Osteoporotic vertebral body sintering (lumbar vertebra 2\nand thoracic vertebra 8).\n\n**Medical History**: Mrs. Miller presents with pain in her back, legs\nradiating, after fall on the back 6 weeks ago. The complaints were\nprogressive with intermittent paresthesia in both legs.\n\n**Other Diagnoses** (not fully collectible):\n\n- Status post apoplexy\n\n**Current Medication (**not ascertainable):\n\n- Blood pressure medication\n\n- Osteoporosis medication\n\n- No anticoagulation.\n\n**Physical Examination: Lumbar spine:** Skin without pathological\nfindings. No redness, no evidence of infection.\n\nTapping pain over thoracic spine/lumbar spine, no compression pain, no\ntorsion pain, no pressure pain over spinous process.\n\nRadiation of pain into the right and left leg, paravertebral muscle\nhardness.\n\nNo paresthesias in the genital area, no breech anesthesia, no peripheral\nneurologic deficits, No bladder or rectal dysfunction.\n\nPeripheral Circulation/Motor function/Sensitivity intact.\n\nStrength grade on all sides: Hip Flex/Ex: 5/5, Knee Flex/Ex: 5/5,\n\nFoot extensor muscles of the lower leg/flexor muscles of the lower leg:\n3/5.\n\nBig toe extensor muscles of the lower leg/big toe flexor muscles of the\nlower leg: 2/5.\n\n**Thoracic Spine 2 levels from 05/22/2020, Lumbar spine in 2 planes from\n05/22/2020:**\n\nClinical indication: Status post fall\n\nQuestion: new fracture?\n\nPreliminary images: none comparable\n\n**Findings**\n\n1\\) [Thoracic Spine]{.underline}: Multiple thoracic vertebral bodies\nexhibit decreased height, most notably at the central region where a\nmeasurement of approximately 17 mm suggests significant height loss and\npotential acute fracture. Additionally, there are endplate impressions\nin individual vertebrae of the lower thoracic spine. Aortic sclerosis is\npresent, along with degenerative changes throughout the thoracic\nvertebrae. The osseous structure presents osteoporotic features. A\nsuspected hemangioma is identified in a vertebral body of the lower\nthoracic spine.\n\n2\\) [Lumbar Spine]{.underline}: In a presumed five-segment lumbar spine,\nthe L1 vertebra shows a subtle reduction in height with a questionable\nendplate impression. Osteoporotic features are evident in the bony\nstructure.\n\n**Assessment:** Multiple fractures are evident in both thoracic\nvertebrae and the first lumbar vertebra, some of which may be acute. MRI\nis recommended for further evaluation. Osseous structure displays\npronounced osteoporotic features.\n\nGrade III esophageal varices present without definitive high-risk\nstigmata. Varices also noted at the gastroesophageal junction,\nclassified as GOV 1 according to Sarin\\'s classification. Band ligation\nof the varices is not performed, as no unambiguous source of bleeding is\nidentifiable and a significant portion of the stomach remains outside\nthe field of view.\n\n**Recommendation**: Terlipressin, monitor surveillance, Erythromycin\n\n**Computed Tomography Thoracic spine from 05/22/2020:**\n\nFracture at the base plate of lumbar vertebra 2 with involvement of the\nposterior margin. Left lateral, no significant reduction in height of\nthe vertebral body. No tension of the spine.\n\nSuspicion of new small fracture also at the cover plate at thoracic\nvertebra 8.\n\nMultiple, older, osteoporotic compression fractures at the thoracic\nspine and\n\nupper lumbar spine.\n\n**Additional Finding:**\n\nLiver cirrhosis with multiple nodules, low ascites, and portal vein\ncongestion. Splenomegaly. If not already known, further workup of liver\nlesions is recommended. Hydrops of the gallbladder.\n\n**Current Recommendations**: There is a general indication for admission\nof the patient and further diagnostics before surgical treatment of the\nfractures. Mrs. Miller is generally opposed to surgical care. She was\nthoroughly informed about the risks (progression, cross-section, death).\n\nRe-presentation with current bone densitometry and update of\nosteoporosis medication, as well as current holospinal MRI. In the\nmeantime, analgesia as needed using Acetaminophen 500mg 1-1-1 under\ngastric protection.\n\n**Esophagogastroduodenoscopy from 05/22/2020:**\n\n[Esophagus]{.underline}: Unobstructed intubation of the esophageal\nopening was achieved under direct visualization. In the upper third of\nthe esophagus, multiple prominent varices protrude into the lumen,\nunaltered by air insufflation. In the middle third, there are areas with\nwhitish overlying material that do not resemble the typical white nipple\nsign. Despite meticulous inspection, no active bleeding sites were\nidentified. The Z-line reveals isolated minor erosions. Cardiac\nsphincter closure is complete.\n\n[Stomach]{.underline}: Full distension of the gastric lumen was\naccomplished with air insufflation. The major curvature of the stomach\ncontained food mixed with hematin. The mucosal surface was similarly\ncoated with hematin, but no active bleeding was discernible in the\nvisualized areas. Peristaltic movement was widespread. Upon\nretroflexion, pronounced varices were noted near the cardiac region on\nthe lesser curvature. The pylorus was unremarkable and easily\ntraversable.\n\n[Duodenum]{.underline}: Adequate distension of the duodenal bulb was\nachieved, providing a clear view up to the descending part of the\nduodenum. Overall, the mucosa appeared normal with minor remnants of\nhematin, and no source of bleeding was identified.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about Mrs. Laura Miller, born on 04/03/1967, who was in\nour inpatient treatment from 05/27/2020 to 06/22/2020.\n\n**Diagnoses**: Initial diagnosis of hepatocellular carcinoma.\n\n- MRI liver: disseminated HCC foci in all segments, the largest foci\n is localized in segments 5 / 7 / 8\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: sophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: Residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Physical Examination:** Patient in mildly reduced general and normal\nnutritional status (BMI 20.3).\n\n- Lungs: Vesicular breath sound, no pathological secondary sounds.\n SpO2 96%.\n\n- Heart: Pure, rhythmic. Systolic with maximum at Erb\\'s point and\n continuation into the carotids. HR: 87/min. BP: 124/54mmHg\n\n- Abdomen: Lively bowel sounds, no tenderness, no guarding, no\n resistance, no peritonism. Soft abdomen. Liver not enlarged,\n palpable. Renal bed not palpable.\n\n- Extremities: Edema of the lower extremities on both sides, foot\n pulses bilaterally well palpable.\n\n- Spine: No tap pain.\n\n- Orienting neurological examination: Right leg weakness, known\n paresis of the extensor muscles of the lower leg/flexor muscles of\n the lower leg.\n\n**Therapy and Progression:** Mrs. Miller was taken over for suspected\nupper GI bleeding. Initially, the patient had presented with increasing\nback pain since approximately 6 weeks at status post fall in the Park\nClinic on 04/26/2020. The patient was known there for her stroke in\n2016. On the day of admission to the Park Clinic, normochromic\nnormocytic anemia (Hemoglobin 3 g/dL) was noticed, which is why the\ntransfer to our clinic was made.\n\nOn inpatient admission, the patient presented in slightly reduced\ngeneral condition. She reported having black stools once. In addition,\nMs. Miller had coffee ground-like emesis once. Dyspnea, angina pectoris\ncomplaints, and B symptoms were denied. There were no problems with\nmicturition. Recently, there were no abnormalities in bowel movements.\nSo far, no colonoscopy has been performed. There were no known\nintestinal diseases in the family.\n\n[Noxae]{.underline}: Ex-nicotine use (since 1996, previously cumulative\nca. 3 PY), occasional alcohol consumption (probably abstinent for about\n5 years).\n\nLaboratory results showed that the patient had elevated infectious\nparameters. The\n\nurinalysis was unremarkable. X-ray chest showed no clear picture of\npneumonia. In a first emergency esophagogastroduodenoscopy on\n05/28/2020, esophageal varices °III were found without clear signs of\nrisk. Furthermore, varices in the area of the cardia (GOV 1 after Sarin)\nwere seen. When the source of bleeding was inconclusive, it was referred\nto a banding initially waived. In a renewed esophagogastroduodenoscopy\nin the morning of 05/30/2020, 2 ampoules of Histoacryl were applied to\nthe cardia varices. In addition, the picture of an incipient\nportal-hypertensive gastropathy. Antibiotic intravenous therapy with\nceftriaxone was initiated. At 06/13/2020, a\nre-esophagogastroduodenoscopy took place, during which a renewed twofold\nbanding of the esophageal varices was performed with injection of 0.5 ml\nHistoacryl. Abdominal ultrasound showed a picture of liver cirrhosis\nwith splenomegaly and perihepatic ascites. In addition, the liver showed\nmultiple echo-poor nodes in the right lobe and a suspicious\n2.4x3.6x4.4cm echo-poor area with a halo in SII. This was followed by an\nMRI of the liver, in which the HCC in segment II was confirmed by\nimaging.\n\nMultiple additional arterial hypervascularized areas/round foci in all\nliver lobes without definite washout. There is no evidence of suspicious\nnodular changes on CT chest/abdomen/pelvis. At an in-house liver\nconference, systemic therapy (Lenvatinib or Sorafenib in Child B7) was\nrecommended.\n\nDue to the back pain, a holospinal MRI was performed, which showed a\nsubacute cover plate compression fracture in the thoracic vertebra 8 as\nwell as multiple older compression fractures of the thoracic spine and\nupper lumbar spine. The colleagues of neurosurgery were consulted, who\ngave the indication for surgery. On 06/14/2020, the planned surgery with\nkyphoplasty thoracic vertebra 8 under C-arm fluoroscopy could be\nperformed without complications. Postoperatively, the patient remained\ncirculatory stable.\n\nDue to auscultatory suspicion of aortic valve stenosis, further\nclarification was performed by cardiac echography, showing no\nhigher-grade valvular vitiation.\n\nWe are transferring Mrs. Miller in improved general condition to the\nSenior Citizens\\' Residence Seaview. If you have any questions, please\ndo not hesitate to contact us.\n\n**Addition:**\n\n**Ultrasound of the upper abdomen on 05/27/2020:**\n\nLimited assessable due to meteorism.\n\n**Liver**: Liver dimensions are within normal limits, measuring 15.9 cm\nin the craniocaudal axis. Echotexture demonstrates inhomogeneous\ngranularity. There is hepatic margin convexity and nodular surface\nappearance. Rarification of hepatic veins. Segment III reveals two\nhypoechoic lesions measuring 3 cm and 1 cm in diameter. Portal vein\ndemonstrates orthograde flow with a maximum velocity of 17 cm/s.\n\n**Gallbladder:** Gallbladder is partially contracted; its wall appears\nunremarkable without sonographic evidence of cholecystitis. No\ntenderness elicited upon sonographic examination.\n\n**Biliary Tract**: Intrahepatic bile ducts are patent. Common hepatic\nduct measures 6 mm in diameter. Common bile duct appears transiently\ndilated up to 9 mm and is otherwise unremarkable as far as can be\nvisualized prepapillary.\n\n**Pancreas**: Limited visualization of the pancreas; however, the\nvisible parenchyma appears homogeneously echoic.\n\n**Spleen**: Spleen is enlarged, measuring 13 x 4 cm, with homogeneous\nparenchyma.\n\n**Kidneys**: Kidneys are morphologically unremarkable, without evidence\nof pelvicalyceal system dilation.\n\n**Abdominal Vessels**: Aorta is partially visualized and appears within\nnormal calibers.\n\nIntestinal/Peritoneal Cavity: No evidence of free intraperitoneal fluid.\n\nUrinary Bladder/Genitalia: Urinary bladder is adequately distended,\nappearing unremarkable upon limited assessment. Uterus is not\nvisualized.\n\n**Virology from 05/28/2020:**\n\n- SARS CoV-2 PCR PCR negative Geq/ml\n\n- Findings: No detection of SARS-CoV-2 by PCR in the submitted\n material.\n\n**Chest X-ray a.p. from 05/28/2020:**\n\nLimited assessability in supine position, malrotation. The diaphragmatic\ncrests are smooth. The marginal sinuses are free of effusions and\ncalluses. Heart and mediastinum lie cryptically. The aorta is sclerosed.\nCranialization of the vessels as well as slightly elevated vascular\nmarkings in the supine position, especially in the right upper field.\nDystelectasis on the right. Sharply defined vertical shadowing in the\nleft upper field. The upper mediastinum is narrow, the trachea is in the\nmidline and is not constricted. Degenerative changes in the cervical\nspine. Overlying foreign material.\n\n**Assessment**: Sharply defined vertical shadowing in the left upper\nfield. Dystelectasis on the right side. Conventional radiographic\nexamination No evidence of a mass. No effusion.\n\n**Esophagogastroduodenoscopy of 05/28/2020:**\n\n**Esophagus**: Successful intubation of the esophageal orifice under\ndirect visualization. Multiple intraluminal protrusions noted in the\nupper third of the esophagus. Non-collapsible variceal strands observed\nupon air insufflation, beginning from the middle third. Whitish\nproliferations seen at multiple sites, not consistent with typical white\nnipple signs. No evidence of active bleeding on close inspection. Z-line\nobserved with isolated minor erosions. Cardiac sphincter fully\ncompetent.\n\n**Stomach**: Gastric lumen fully distended under air insufflation.\nCorpus predominantly contains hematin-laden food remnants. Mucosal\nsurface also stained with hematin but without visible active bleeding.\nPeristalsis noted throughout. Distinct coronary vasculature observed on\nthe lesser curvature. Pylorus unremarkable, offering no resistance to\npassage.\n\n**Duodenum**: Bulbus duodeni well-formed. Pars descendens duodeni\nvisualized clearly. Overall mucosa appears unremarkable, with scattered\nhematin remnants observed without an identifiable bleeding source.\n\n**Assessment**: Esophageal varices graded as °III, with no definitive\nhigh-risk stigmata. Varices also noted in the cardia, classified as GOV\n1 according to Sarin\\'s classification. Ligation of varices was not\nperformed due to the absence of an identifiable bleeding source and\nincomplete visualization of the gastric lumen.\n\n**Ultrasound of the abdomen on 05/29/2020:**\n\n**Quality of Exam**: Limited due to patient non-cooperation and\nmeteorism.\n\n**Liver**: Liver size is paradoxically reported both as normal at 15.9\ncm and enlarged at 18.7 cm. Margins are rounded. Echotexture is markedly\ninhomogeneous with nodular surface. Multiple hypoechoic nodules are\npresent in the right lobe, along with a suspicious hypoechoic area\nmeasuring 2.4 x 3.6 x 4.4 cm with peripheral halo in segment II. Hepatic\nveins are rarified. Portal vein shows orthograde flow with a vmax of 28\ncm/s.\n\n**Gallbladder**: Morphologically unremarkable with no wall thickening.\nCholelithiasis noted with concretions measuring at least 2 to 1.6 cm.\n\n**Biliary Tract:** Intrahepatic bile ducts are not dilated; Common\nhepatic duct measures up to 8.5 mm and common bile duct measures 6.6 mm\nin diameter.\n\n**Pancreas**: Partially visualized; adequacy of assessment is\ncompromised.\n\n**Spleen**: Enlarged with homogeneous internal echotexture.\n\n**Kidneys**: Morphologically unremarkable; no evidence of\nhydronephrosis.\n\n**Abdominal Vessels:** Aorta is not dilated.\n\n**Gastrointestinal**: Perihepatic ascites noted. Both small and large\nintestines appear unremarkable upon limited assessment.\n\n**Urinary Bladder/Genitalia:** Bladder is moderately filled and\nunremarkable in shape and size.\n\n**Assessment**: Limited study due to patient non-cooperation and\nmeteorism. Findings are suggestive of liver cirrhosis and grade I\nascites. Additional findings include suspected hepatic space-occupying\nlesions, splenomegaly, and cholelithiasis. Mild dilation of DHC and DC\nobserved without signs of intrahepatic cholestasis.\n\n**Virology from 06/01/2020:**\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HAV IgG 0.73 negative\n Anti HAV IgM \\<0.1 negative\n\n**Interpretation:** Serologically no evidence of fresh or expired\ninfection with\n\nHepatitis A virus, no immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n HBs antigen 0.21 negative\n Anti HBs \\<0.1 negative\n Anti HBc 0.1 negative\n\n**Interpretation:** Serologically no evidence of acute, chronic or\nexpired Hepatitis B virus infection. No immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HCV 0.06 negative\n\n**Interpretation:** Serologically no evidence of hepatitis C virus\ninfection. At possible fresh infection resubmission in 2-4 weeks and HCV\nPCR recommended.\n\n**MRI total spine plain from 06/04/2020:**\n\n**Technique**: T2 Dixon Sagittal and T2 Axial MRI Sequences. Coverage\nextends from the craniocervical junction to the sacrum.\n\n**Findings:**\n\n**General Spine:** Full extent from craniocervical junction to sacrum\nvisualized. Conus medullaris appropriately located at T12-L1 level.\nMyelon demonstrates uniform width and homogeneous signal. Evaluation of\nthoracolumbar transition and lumbar spine is compromised by artifact\nsuperimposition from ascites.\n\n**Cervical Spine:** Irregular alignment of the posterior vertebral body\nmargins noted, with evidence of disc protrusions and ligamentum flavum\nhypertrophy. Focal T2 hyperintensity observed at C5 level. No evidence\nof prevertebral soft tissue proliferation.\n\n**Thoracic Spine**: Maintained alignment of the posterior vertebral body\nmargins. Multiple anterior endplate compression fractures noted at T5,\nT8, T9, T11, T12 levels. Focal T2 hyperintensity near the anterior\nendplate of T8 involving the posterior margin, indicative of a\nnon-displaced fracture without spinal canal compromise. Hypertrophic\nfacet joint arthrosis at T10-T11 levels resulting in relative spinal\nnarrowing. Bilateral pleural effusions noted, more pronounced on the\nright, with a maximum width of approximately 2 cm. No evidence of\nsignificant neuroforaminal stenosis.\n\n**Lumbar Spine:** Maintained alignment of posterior vertebral body\nmargins. Known anterior endplate compression fractures at L1 and\nbaseplate compression fracture at L2. No evidence of pathological T2\nedema within the vertebral bodies, although assessment is limited due to\nsuperimposed artifacts from ascites. Spinal canal dimensions appear\nadequate throughout. Moderate fatty degeneration of sacral bone noted.\n\n**Assessment**: Evaluation limited due to ascites-related artifacts.\nSubacute anterior endplate compression fracture at T8, along with\nseveral other likely older compression fractures in the thoracic and\nupper lumbar spine. Bilateral pleural effusions observed. Multiple\nneuroforaminal narrowings as detailed above.\n\n**MR Liver plain + contast agent from 06/06/2020**\n\n**Findings:**\n\n1) [Lesion 1]{.underline}\n\n- Size of the lesion 41 mm\n\n- Segment 2\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: yes\n\n- Pseudocapsule: yes\n\n- Behavior delayed leaching: yes\n\n- pseudocapsule macrovascular invasion: no\n\n2) [Lesion 2]{.underline}\n\n- Size of the lesion 104 mm\n\n- Segment 5 / 7 / 8\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: no\n\n- Pseudocapsule: no\n\n- Behavior delayed washing out: no\n\n- Pseudocapsule: no\n\n- Macrovascular invasion: yes\n\n**Comments:**\n\n- MRI with Gadovist intravenous.\n\n- Multiple other satellite foci in all liver segments.\n\n- Signs of liver cirrhosis with nodular liver parenchyma and\n hypertrophy of the left lobe.\n\n- Cholecystolithiasis and gallbladder hydrops. No cholestasis.\n\n- Varices of the esophagus and fundus. Splenomegaly. Ascites. Pleural\n effusions on both sides.\n\n- Lymph node (approximately 8 mm) between the small curvature of the\n Stomach and S1 of the liver.\n\n- Axial hernia.\n\n**Assessment:** Milan fulfilled**.** Dissiminated HCC foci in all\nsegments, the largest foci being in segments 5 / 7 / 8 localized. Portal\nhypertension with bypass circulation and splenomegaly. Ascites and\npleural effusions.\n\n**Microbiology from 06/09/2020:**\n\n[Material]{.underline}: Ascites in blood culture bottles\n\n[Microscopic]{.underline}: No cells, no germs\n\n- Anaerobic culture negative after 48 hours\n\n- So far, no growth in the anaerobic cultures. The cultures are\n incubated for a total of 5 days. In case of growth of anaerobes we\n will send you a follow-up report.\n\n- No growth after 48 hours\n\n**Esophagogastroduodenoscopy of 06/11/2020:**\n\n**Esophagus**: In the distal esophagus, multiple band-like ulcerations\nas well as residual varices with risk signs that may not completely pass\nair insufflation. Z-line without erosions.\n\n**Stomach**: Mosaic-like occupancy of the gastric mucosa. With inversion\nthe\n\nknown small-curved lateral cardiavarii, which is hard on palpation with\nclosed forceps after histoacryl injection. Directly next to it, another\ncardiavarice can now be seen, which has not yet been injected with\nhistoacryl and is soft on palpation.\n\n**Duodenum**: Endoscopic therapy: Injection of 0.5 mL Histoacryl (+0.5\nmL Lipoidol) in the new cardiavarice. Application of 3 rubber band\nligatures to the residual varices in the esophagus.\n\n**Assessment:** Residual varices in the esophagus, application of 3\nrubber band ligations; portal hypertensive gastropathy\n\n**Spine-whole: 2 planes from 06/13/2020**\n\nThe perpendicular of C7 protrudes about 15 mm laterally to the left of\nsacral vertebra 1 in the anterior-posterior image and about 9.3 cm in\nfront of sacral vertebra 1 in the lateral ray path. Slight left convex\nscoliosis thoracolumbally with thoracic counter-swing (Cobb angle \\< 10°\nin each case). The lungs are unremarkable as far as technically\nassessable.\n\n**Assessment**: decompensated positive sagittal spinal imbalance. There\nis no relevant lateral trunk overhang.\n\n**Critical Findings Report:**\n\nA conspicuous single cell population of cells with partial signet ring\ncell character is detected in the smears. A cell block is prepared from\nthe remaining liquid material for further typing of these cells. A\nfollow-up report will follow.\n\n**Thoracic spine in 2 planes from 06/15/2020:**\n\n**Findings**: Thoracic vertebra 8: Post-kyphoplasty status with notable\nimprovement in vertebral height, now measuring 21 mm compared to a\npreoperative height of 13 mm. Mild straightening of the vertebral column\nobserved at this level.\n\nThoracic vertebra 9: Known older anterior endplate collapse.\n\nThoracolumbar spine: Multisegmental height reduction in vertebral bodies\nconsistent with osteoporotic changes. No signs of contrast\nextravasation.\n\nAdditional Finding: Pre-existing calcified structure projecting onto the\nleft upper abdomen; likely unrelated to current surgical site.\n\n**Assessment**: Unremarkable postoperative imaging following kyphoplasty\nof T8. No evidence of postoperative sintering or newly identifiable\nfractures. Overall, the surgical intervention appears successful in\nincreasing vertebral height and stabilizing the fracture site.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 06/18/2020:**\n\n**Technique**: Multislice spiral CT of the chest, abdomen, and pelvis\nwas performed post-bolus intravenous injection of 120 ml of Imeron 400.\nImaging conducted in arterial, portal venous, and venous phases. Oral\ncontrast agent administered with Micropaque 1:7 in water and Gastrolux\n1:33 in water. Thin-slice reconstructions and secondary coronal and\nsagittal reformats were performed.\n\n**Chest**: Presence of struma nodosa. Bilateral minor pleural effusions\nwith adjacent atelectasis, more pronounced on the right and extending\ninto the interlobar region. No signs of infiltrative changes. Isolated\nsmall nodular opacities in the right lung. Few small bullae noted.\nMediastinal lymph nodes mildly enlarged up to 0.5 cm; axillary and hilar\nnodes are not enlarged. No pericardial effusion observed.\n\n**Abdomen/Pelvis**: Known esophageal and fundal varices present. Liver\ndemonstrates nodular changes in the context of known Child-Pugh B stage\ncirrhosis. A solid hepatic cellular carcinoma lesion in segment II and\ndiffuse HCC nodules in segments V/VII/VIII visualized, corroborating\nprior MRI findings. They show pronounced arterial enhancement and\ncentral washout. Splenomegaly noted. Adrenal glands unremarkable. Renal\nand urinary systems are inconspicuous. No intestinal motility\nabnormalities detected. Marked ascites present; no pathologically\nenlarged abdominal lymph nodes noted upon limited assessment.\n\n**Skeletal**: Moderate coxarthrosis bilaterally. An old, minimally\ndisplaced fracture of the right 7th rib noted. Advanced degenerative\nchanges in thoracic vertebrae 10, 12, and lumbar spine.\nPost-vertebroplasty status at thoracic vertebra 9. Hemangioma at\nthoracic vertebra 11.\n\n**Assessment**:\n\n- Marked ascites in the setting of liver cirrhosis with multifocal HCC\n lesions, as corroborated by prior MRI. No evidence of extrahepatic\n or lymphatic spread.\n\n- Bilateral minor pleural effusions with associated atelectasis.\n\n- Skeletal findings include moderate coxarthrosis and degenerative\n changes in the spine.\n\nOverall, the scan provides vital information that aligns with and\nelaborates upon existing clinical and imaging data.\n\n**Histology**:\n\n**Pathology from 06/19/2020:**\n\n[Clinical Data:]{.underline} Hepatocellular carcinoma, hydropic\ndecompensated liver cirrhosis Child B,\n\n[Extraction date:]{.underline} 06/13/2020\n\n[Material:]{.underline} 1 Liquid material 7 ml light yellow\n\n[Editing]{.underline}: Papanicolaou and MGG staining\n\n\\+ Protein precipitation\n\n\\+ Erythrocytes\n\n\\+ Lymphocytes\n\n(+) Granulocytes Eosinophils\n\n\\+ Histiocytic cell forms\n\n\\+ Mesothelium\n\n\\+ Active mesothelium\n\n**Other**: Single mononuclear cells with large, eccentric nuclei with\nnucleoli and a narrow cytoplasmic space, partly with signet ring cells.\n\n**Supplementary findings from 06/19/2020**\n\n[Processing]{.underline}: Cell block, HE\n\n**Microscopic:**\n\nAs announced, from the remaining liquid material a cell block was\nprepared. In the HE stain only isolated evidence of mononuclear Cells\nand some blood. No cell atypia.\n\n**Critical Findings Report:** After examination of the remaining liquid\nmaterial in the cell block no Extension of the initial findings in the\nabsence of further diagnostic cell material. The finding is thus based\nexclusively on the Smear material:\n\n- Detection of a single-cell population consisting of cells with\n partial signet ring cell character. Differentially it could be The\n mesothelium may be a reactive change of the approaching mesothelium.\n Cells of an epithelial neoplasia are not visible on the present\n material. to be ruled out with certainty.\n\n**Diagnostic classification:** Suspicious\n\n**Current Recommendations:**\n\n- An appointment at our outpatient clinic to start therapy was\n organized for 06/26/2020.\n\n- An appointment for a health department check-up with varicose vein\n status survey and, if necessary, repeat rubber band ligation has\n been scheduled for 07/22/2020. Please come to the endoscopy on this\n day at 08:30 am fasting with current lab results. incl. coagulation,\n signed consent form as well as SARS-CoV-2 PCR not older than 48h.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report to you on Mrs. Laura Miller, born 04/03/1967, whom we examined\non 06/08/2020 in the course of a consultation.\n\n**Consilar Request:**\n\n- Liver cirrhosis, Child-Pugh B, ethyltoxic genesis\n\n- HCC\n\n- Laboratory albumin: 2.6\n\n- Nutritional advice requested\n\n**Nutritional counseling in cirrhosis of the liver:**\n\n- Albumin at 2.6\n\n- 70kg at admission (stable weight in recent years).\n\n- Height: 1.72m\n\n- BMI falsified by ascites\n\n- Patient reports that she always a \\\"bad eater\\\"\n\n- She reports to eat less due to numerous medication intake\n\n- Patient is noticeably overwhelmed and seems very burdened by\n diagnosis\n\n**Assessment:**\n\n- Protein malnutrition with inadequate oral nutrition\n\n- Patient appears desperate and overwhelmed, questionable compliance\n\n**Recommendations: **\n\n- High-calorie food for more choices (already ordered)\n\n- High-calorie drinks (contains more protein)\n\n- Incorporate protein-rich snacks such as yogurt, sippy cups,\n crispbread\n\n- with cheese.\n\n- A high-energy, high-protein food choice was made with the patient\\'s\n discussed in detail\n\n- Contact details were handed out\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 08/21/2020 to\n08/23/2020.\n\n**Diagnoses**:\n\n- MRI of the liver: disseminated HCC foci in all segments, the largest\n foci is localized in segments 5 / 7 / 8\n\n<!-- -->\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: esophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Current Presentation:** Mrs. Miller presented electively for\ngastroscopy for variceal screening with continuation of banding therapy\ndue to esophageal variceal bleeding.\n\n**Medical History**: For a detailed medical history, we refer to\nprevious reports from our department. In summary, we present a liver\ncirrhosis due to ethyl toxicity leading to the development of multifocal\nHCC. Similar to the liver board decision of 06/13/20, a recommendation\nfor systemic therapy with Lenvatinib or Sorafenib was made in the\nsetting of partially compensated Child B7 cirrhosis with multifocal HCC\nin both lobes of the liver.\n\n**Therapy and Course:** Upon admission, the patient was in\nage-appropriate general condition and largely symptom-free. There were\nno signs of acute infection, jaundice, encephalopathic symptoms, or GI\nbleeding. No irregularities in bowel movements or urination were\nreported. The patient denied abdominal pain and dyspnea. There were no\nknown allergies.\n\nOn the day of admission, an uncomplicated gastroscopy was performed,\nincluding the application of 4 rubber band ligations for residual\nesophageal varices. Post-interventional pain was adequately controlled\nwith double-standard doses of Pantoprazole and intravenous analgesic\ntherapy. The further inpatient course was uneventful, and the patient\ntolerated the post-interventional diet without signs of GI bleeding.\n\nBased on laboratory findings and clinical evaluation, particularly with\nregressed ascites, a compensated Child A6 cirrhosis was confirmed.\nTherefore, a re-presentation at our interdisciplinary liver board was\ninitiated for discussion of potential treatment options in the context\nof compensated liver function.\n\nAs per the consensus recommendation from the liver board, a follow-up\ngastroscopy is scheduled within the next two weeks. Depending on the\nvariceal status, systemic therapy with Atezolizumab/Bevacizumab or\nLenvatinib will follow.\n\nThroughout the monitoring period, the patient remained stable in terms\nof circulation and hemoglobin levels. Therefore, on 08/23/20, we\ndischarged Mrs. Miller for outpatient follow-up care. The patient was\nthoroughly informed about reasons that necessitate immediate\nre-presentation. Please note the listed procedural appointments.\n\n**Physical Examination:** Awake, alert, oriented\n\n- Heart: Regular heart tones, no murmurs\n\n- Lungs: Clear vesicular breath sounds, no crackles or wheezes\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, palpable firm liver edge under the rib cage, no palpable\n spleen enlargement, non-painful renal angle\n\n- Extremities: Good peripheral pulses, no edema\n\n- Neurology: No focal neurological deficits.\n\n**EGD on 08/21/2020:**\n\n**Findings:**\n\n**Esophagus**: Unobstructed intubation of the esophagus under direct\nvision. Multiple variceal cords and scarring changes due to banding were\nobserved in the lower half of the esophagus. Z-line at 35 cm\ndiaphragmatic passage at 39 cm. Two variceal cords extend along the\nsmall curve into the stomach, two of the varices show alarm signs (red\nspots). 4 rubber band ligations were performed.\n\n**Stomach**: In the proximal corpus a picture of portal hypertensive\ngastropathy, otherwise unremarkable. No fundus varices.\n\n**Duodenum**: Good unfolding of the duodenal bulb, contact-sensitive\nmucosa. Good insight into the descending part of the duodenum. Overall,\nunremarkable mucosa.\n\n**Assessment:** Esophageal varices, Gastroesophageal varices Type I.\nBanding therapy.\n\n**Current Recommendations:**\n\n- Regular clinical and laboratory checks by the primary care\n physician.\n\n- In case of fever, acute deterioration of the general condition, or\n clinical signs of bleeding such as melena or hematemesis, we request\n immediate re-presentation, even at night and on weekends, through\n our interdisciplinary emergency department.\n\n- Decision of the liver board: Improvement of liver function with\n alcohol abstinence, but also progression of multifocal HCC over 2\n months without tumor-specific therapy. Consensus: Repeat EGD in 7-14\n days, depending on variceal status, Atezolizumab/Bevacizumab, or\n Lenvatinib.\n\n- Follow-up appointment on 09/11/20 in our HCC outpatient clinic for\n clinical control and explanation of the EGD.\n\n- Follow-up in our endoscopy for EGD to determine variceal status and\n possible banding -\\> Please bring a COVID PCR test (maximum 48 hours\n old) for inpatient admission.\n\nIf complaints persist or worsen, we recommend immediate re-presentation.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 09/18/2020 to\n09/20/2020.\n\n**Diagnoses:**\n\n- 4-time banding therapy with 4 rubber band ligations for residual\n esophageal varices without alarm signs\n\n- Hepatocellular Carcinoma (HCC)\n\n- MR Liver: Disseminated HCC lesions in all segments, with the largest\n lesion located in segments 5/7/8\n\n- Decompensated cirrhosis of the liver (Child B) since 05/20 due to\n ethyltoxic origin.\n\n- Transfusion-dependent anemia due to a history of variceal bleeding.\n\n- Osteoporotic thoracic vertebral fracture of vertebra BWK8 (OF3) with\n kyphoplasty.\n\n- Portal hypertension with portosystemic collaterals\n\n- Splenomegaly\n\n- Cholelithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- History of stroke (2016)\n\n- Allergies: Amalgam\n\n**Presentation:** Mrs. Miller\\'s elective presentation was for a\nfollow-up examination for known esophageal varices.\n\n**Medical History:** For a detailed medical history, please refer to\nprevious reports from our department. In summary, in June 2020, the\npatient was diagnosed with decompensated liver cirrhosis attributed to\nethyltoxicity. MR imaging showed multifocal HCC. According to the liver\nboard decision on 06/15/20, initial therapy was recommended with\nLenvatinib or Sorafenib for partially compensated Child B7 cirrhosis\nwith multifocal HCC in both liver lobes. Despite improvement in liver\nfunction with alcohol cessation, there was a short-term progression of\nmultifocal HCC without tumor-specific therapy, leading to a\nrecommendation for a repeat variceal screening on 08/28/20. Depending on\nthe findings, therapy with Atezolizumab/Bevacizumab or Lenvatinib was\nadvised. The last EGD was performed on 08/21/20, revealing esophageal\nvarices with alarm signs, and a 4-time banding was performed.\n\n**Physical Examination upon Admission:** Blood pressure: 80/150 mmHg,\nheart rate 88/min, temperature 36.4°C, SpO2 97% in room air.\n\nPatient in good general condition and normal mental status. Mrs. Miller\nis fully oriented. Pupils are equal and reactive.\n\n- Cardiovascular: Clear heart sounds, no murmurs.\n\n- Lungs: Equal breath sounds bilaterally, no crackles, resonant\n percussion.\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, liver and spleen not palpable.\n\n- Extremities: No edema, good peripheral pulses. No focal neurological\n deficits.\n\n**Course and Therapy:** On the day of admission, the EGD was performed\nwithout complications. Residual varices without warning signs were\nobserved, and a 4-time rubber band ligation was performed. Portal\nhypertensive gastropathy was also diagnosed. After the procedure, the\npatient was transferred to our gastroenterological normal ward.\n\nThe post-interventional course was uneventful. There were no clinical or\nlaboratory signs of post-interventional bleeding. The diet was\nreintroduced without any issues. Therefore, on 09/20/2020, we discharged\nMrs. Miller for outpatient care. We request a follow-up appointment at\nour in-house HCC outpatient clinic. Additionally, we request a follow-up\nEGD with variceal control.\n\n\n\n\nHere is the query:\nWhat was the classification of Laura Miller’s esophageal varices according to Sarin’s classification?\n\nChoose the correct answer from the following options:\nA. GOV1\nB. GOV2\nC. IGV1\nD. IGV2\nE. Not classified\n\n\nYour response:\n", "role": "user" }, { "content": "GOV1", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\n\nWe are writing to report on the outpatient treatment of Mrs. Laura\nMiller, born on 04/03/1967, on 05/22/2020.\n\n**Diagnosis**: Osteoporotic vertebral body sintering (lumbar vertebra 2\nand thoracic vertebra 8).\n\n**Medical History**: Mrs. Miller presents with pain in her back, legs\nradiating, after fall on the back 6 weeks ago. The complaints were\nprogressive with intermittent paresthesia in both legs.\n\n**Other Diagnoses** (not fully collectible):\n\n- Status post apoplexy\n\n**Current Medication (**not ascertainable):\n\n- Blood pressure medication\n\n- Osteoporosis medication\n\n- No anticoagulation.\n\n**Physical Examination: Lumbar spine:** Skin without pathological\nfindings. No redness, no evidence of infection.\n\nTapping pain over thoracic spine/lumbar spine, no compression pain, no\ntorsion pain, no pressure pain over spinous process.\n\nRadiation of pain into the right and left leg, paravertebral muscle\nhardness.\n\nNo paresthesias in the genital area, no breech anesthesia, no peripheral\nneurologic deficits, No bladder or rectal dysfunction.\n\nPeripheral Circulation/Motor function/Sensitivity intact.\n\nStrength grade on all sides: Hip Flex/Ex: 5/5, Knee Flex/Ex: 5/5,\n\nFoot extensor muscles of the lower leg/flexor muscles of the lower leg:\n3/5.\n\nBig toe extensor muscles of the lower leg/big toe flexor muscles of the\nlower leg: 2/5.\n\n**Thoracic Spine 2 levels from 05/22/2020, Lumbar spine in 2 planes from\n05/22/2020:**\n\nClinical indication: Status post fall\n\nQuestion: new fracture?\n\nPreliminary images: none comparable\n\n**Findings**\n\n1\\) [Thoracic Spine]{.underline}: Multiple thoracic vertebral bodies\nexhibit decreased height, most notably at the central region where a\nmeasurement of approximately 17 mm suggests significant height loss and\npotential acute fracture. Additionally, there are endplate impressions\nin individual vertebrae of the lower thoracic spine. Aortic sclerosis is\npresent, along with degenerative changes throughout the thoracic\nvertebrae. The osseous structure presents osteoporotic features. A\nsuspected hemangioma is identified in a vertebral body of the lower\nthoracic spine.\n\n2\\) [Lumbar Spine]{.underline}: In a presumed five-segment lumbar spine,\nthe L1 vertebra shows a subtle reduction in height with a questionable\nendplate impression. Osteoporotic features are evident in the bony\nstructure.\n\n**Assessment:** Multiple fractures are evident in both thoracic\nvertebrae and the first lumbar vertebra, some of which may be acute. MRI\nis recommended for further evaluation. Osseous structure displays\npronounced osteoporotic features.\n\nGrade III esophageal varices present without definitive high-risk\nstigmata. Varices also noted at the gastroesophageal junction,\nclassified as GOV 1 according to Sarin\\'s classification. Band ligation\nof the varices is not performed, as no unambiguous source of bleeding is\nidentifiable and a significant portion of the stomach remains outside\nthe field of view.\n\n**Recommendation**: Terlipressin, monitor surveillance, Erythromycin\n\n**Computed Tomography Thoracic spine from 05/22/2020:**\n\nFracture at the base plate of lumbar vertebra 2 with involvement of the\nposterior margin. Left lateral, no significant reduction in height of\nthe vertebral body. No tension of the spine.\n\nSuspicion of new small fracture also at the cover plate at thoracic\nvertebra 8.\n\nMultiple, older, osteoporotic compression fractures at the thoracic\nspine and\n\nupper lumbar spine.\n\n**Additional Finding:**\n\nLiver cirrhosis with multiple nodules, low ascites, and portal vein\ncongestion. Splenomegaly. If not already known, further workup of liver\nlesions is recommended. Hydrops of the gallbladder.\n\n**Current Recommendations**: There is a general indication for admission\nof the patient and further diagnostics before surgical treatment of the\nfractures. Mrs. Miller is generally opposed to surgical care. She was\nthoroughly informed about the risks (progression, cross-section, death).\n\nRe-presentation with current bone densitometry and update of\nosteoporosis medication, as well as current holospinal MRI. In the\nmeantime, analgesia as needed using Acetaminophen 500mg 1-1-1 under\ngastric protection.\n\n**Esophagogastroduodenoscopy from 05/22/2020:**\n\n[Esophagus]{.underline}: Unobstructed intubation of the esophageal\nopening was achieved under direct visualization. In the upper third of\nthe esophagus, multiple prominent varices protrude into the lumen,\nunaltered by air insufflation. In the middle third, there are areas with\nwhitish overlying material that do not resemble the typical white nipple\nsign. Despite meticulous inspection, no active bleeding sites were\nidentified. The Z-line reveals isolated minor erosions. Cardiac\nsphincter closure is complete.\n\n[Stomach]{.underline}: Full distension of the gastric lumen was\naccomplished with air insufflation. The major curvature of the stomach\ncontained food mixed with hematin. The mucosal surface was similarly\ncoated with hematin, but no active bleeding was discernible in the\nvisualized areas. Peristaltic movement was widespread. Upon\nretroflexion, pronounced varices were noted near the cardiac region on\nthe lesser curvature. The pylorus was unremarkable and easily\ntraversable.\n\n[Duodenum]{.underline}: Adequate distension of the duodenal bulb was\nachieved, providing a clear view up to the descending part of the\nduodenum. Overall, the mucosa appeared normal with minor remnants of\nhematin, and no source of bleeding was identified.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about Mrs. Laura Miller, born on 04/03/1967, who was in\nour inpatient treatment from 05/27/2020 to 06/22/2020.\n\n**Diagnoses**: Initial diagnosis of hepatocellular carcinoma.\n\n- MRI liver: disseminated HCC foci in all segments, the largest foci\n is localized in segments 5 / 7 / 8\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: sophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: Residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Physical Examination:** Patient in mildly reduced general and normal\nnutritional status (BMI 20.3).\n\n- Lungs: Vesicular breath sound, no pathological secondary sounds.\n SpO2 96%.\n\n- Heart: Pure, rhythmic. Systolic with maximum at Erb\\'s point and\n continuation into the carotids. HR: 87/min. BP: 124/54mmHg\n\n- Abdomen: Lively bowel sounds, no tenderness, no guarding, no\n resistance, no peritonism. Soft abdomen. Liver not enlarged,\n palpable. Renal bed not palpable.\n\n- Extremities: Edema of the lower extremities on both sides, foot\n pulses bilaterally well palpable.\n\n- Spine: No tap pain.\n\n- Orienting neurological examination: Right leg weakness, known\n paresis of the extensor muscles of the lower leg/flexor muscles of\n the lower leg.\n\n**Therapy and Progression:** Mrs. Miller was taken over for suspected\nupper GI bleeding. Initially, the patient had presented with increasing\nback pain since approximately 6 weeks at status post fall in the Park\nClinic on 04/26/2020. The patient was known there for her stroke in\n2016. On the day of admission to the Park Clinic, normochromic\nnormocytic anemia (Hemoglobin 3 g/dL) was noticed, which is why the\ntransfer to our clinic was made.\n\nOn inpatient admission, the patient presented in slightly reduced\ngeneral condition. She reported having black stools once. In addition,\nMs. Miller had coffee ground-like emesis once. Dyspnea, angina pectoris\ncomplaints, and B symptoms were denied. There were no problems with\nmicturition. Recently, there were no abnormalities in bowel movements.\nSo far, no colonoscopy has been performed. There were no known\nintestinal diseases in the family.\n\n[Noxae]{.underline}: Ex-nicotine use (since 1996, previously cumulative\nca. 3 PY), occasional alcohol consumption (probably abstinent for about\n5 years).\n\nLaboratory results showed that the patient had elevated infectious\nparameters. The\n\nurinalysis was unremarkable. X-ray chest showed no clear picture of\npneumonia. In a first emergency esophagogastroduodenoscopy on\n05/28/2020, esophageal varices °III were found without clear signs of\nrisk. Furthermore, varices in the area of the cardia (GOV 1 after Sarin)\nwere seen. When the source of bleeding was inconclusive, it was referred\nto a banding initially waived. In a renewed esophagogastroduodenoscopy\nin the morning of 05/30/2020, 2 ampoules of Histoacryl were applied to\nthe cardia varices. In addition, the picture of an incipient\nportal-hypertensive gastropathy. Antibiotic intravenous therapy with\nceftriaxone was initiated. At 06/13/2020, a\nre-esophagogastroduodenoscopy took place, during which a renewed twofold\nbanding of the esophageal varices was performed with injection of 0.5 ml\nHistoacryl. Abdominal ultrasound showed a picture of liver cirrhosis\nwith splenomegaly and perihepatic ascites. In addition, the liver showed\nmultiple echo-poor nodes in the right lobe and a suspicious\n2.4x3.6x4.4cm echo-poor area with a halo in SII. This was followed by an\nMRI of the liver, in which the HCC in segment II was confirmed by\nimaging.\n\nMultiple additional arterial hypervascularized areas/round foci in all\nliver lobes without definite washout. There is no evidence of suspicious\nnodular changes on CT chest/abdomen/pelvis. At an in-house liver\nconference, systemic therapy (Lenvatinib or Sorafenib in Child B7) was\nrecommended.\n\nDue to the back pain, a holospinal MRI was performed, which showed a\nsubacute cover plate compression fracture in the thoracic vertebra 8 as\nwell as multiple older compression fractures of the thoracic spine and\nupper lumbar spine. The colleagues of neurosurgery were consulted, who\ngave the indication for surgery. On 06/14/2020, the planned surgery with\nkyphoplasty thoracic vertebra 8 under C-arm fluoroscopy could be\nperformed without complications. Postoperatively, the patient remained\ncirculatory stable.\n\nDue to auscultatory suspicion of aortic valve stenosis, further\nclarification was performed by cardiac echography, showing no\nhigher-grade valvular vitiation.\n\nWe are transferring Mrs. Miller in improved general condition to the\nSenior Citizens\\' Residence Seaview. If you have any questions, please\ndo not hesitate to contact us.\n\n**Addition:**\n\n**Ultrasound of the upper abdomen on 05/27/2020:**\n\nLimited assessable due to meteorism.\n\n**Liver**: Liver dimensions are within normal limits, measuring 15.9 cm\nin the craniocaudal axis. Echotexture demonstrates inhomogeneous\ngranularity. There is hepatic margin convexity and nodular surface\nappearance. Rarification of hepatic veins. Segment III reveals two\nhypoechoic lesions measuring 3 cm and 1 cm in diameter. Portal vein\ndemonstrates orthograde flow with a maximum velocity of 17 cm/s.\n\n**Gallbladder:** Gallbladder is partially contracted; its wall appears\nunremarkable without sonographic evidence of cholecystitis. No\ntenderness elicited upon sonographic examination.\n\n**Biliary Tract**: Intrahepatic bile ducts are patent. Common hepatic\nduct measures 6 mm in diameter. Common bile duct appears transiently\ndilated up to 9 mm and is otherwise unremarkable as far as can be\nvisualized prepapillary.\n\n**Pancreas**: Limited visualization of the pancreas; however, the\nvisible parenchyma appears homogeneously echoic.\n\n**Spleen**: Spleen is enlarged, measuring 13 x 4 cm, with homogeneous\nparenchyma.\n\n**Kidneys**: Kidneys are morphologically unremarkable, without evidence\nof pelvicalyceal system dilation.\n\n**Abdominal Vessels**: Aorta is partially visualized and appears within\nnormal calibers.\n\nIntestinal/Peritoneal Cavity: No evidence of free intraperitoneal fluid.\n\nUrinary Bladder/Genitalia: Urinary bladder is adequately distended,\nappearing unremarkable upon limited assessment. Uterus is not\nvisualized.\n\n**Virology from 05/28/2020:**\n\n- SARS CoV-2 PCR PCR negative Geq/ml\n\n- Findings: No detection of SARS-CoV-2 by PCR in the submitted\n material.\n\n**Chest X-ray a.p. from 05/28/2020:**\n\nLimited assessability in supine position, malrotation. The diaphragmatic\ncrests are smooth. The marginal sinuses are free of effusions and\ncalluses. Heart and mediastinum lie cryptically. The aorta is sclerosed.\nCranialization of the vessels as well as slightly elevated vascular\nmarkings in the supine position, especially in the right upper field.\nDystelectasis on the right. Sharply defined vertical shadowing in the\nleft upper field. The upper mediastinum is narrow, the trachea is in the\nmidline and is not constricted. Degenerative changes in the cervical\nspine. Overlying foreign material.\n\n**Assessment**: Sharply defined vertical shadowing in the left upper\nfield. Dystelectasis on the right side. Conventional radiographic\nexamination No evidence of a mass. No effusion.\n\n**Esophagogastroduodenoscopy of 05/28/2020:**\n\n**Esophagus**: Successful intubation of the esophageal orifice under\ndirect visualization. Multiple intraluminal protrusions noted in the\nupper third of the esophagus. Non-collapsible variceal strands observed\nupon air insufflation, beginning from the middle third. Whitish\nproliferations seen at multiple sites, not consistent with typical white\nnipple signs. No evidence of active bleeding on close inspection. Z-line\nobserved with isolated minor erosions. Cardiac sphincter fully\ncompetent.\n\n**Stomach**: Gastric lumen fully distended under air insufflation.\nCorpus predominantly contains hematin-laden food remnants. Mucosal\nsurface also stained with hematin but without visible active bleeding.\nPeristalsis noted throughout. Distinct coronary vasculature observed on\nthe lesser curvature. Pylorus unremarkable, offering no resistance to\npassage.\n\n**Duodenum**: Bulbus duodeni well-formed. Pars descendens duodeni\nvisualized clearly. Overall mucosa appears unremarkable, with scattered\nhematin remnants observed without an identifiable bleeding source.\n\n**Assessment**: Esophageal varices graded as °III, with no definitive\nhigh-risk stigmata. Varices also noted in the cardia, classified as GOV\n1 according to Sarin\\'s classification. Ligation of varices was not\nperformed due to the absence of an identifiable bleeding source and\nincomplete visualization of the gastric lumen.\n\n**Ultrasound of the abdomen on 05/29/2020:**\n\n**Quality of Exam**: Limited due to patient non-cooperation and\nmeteorism.\n\n**Liver**: Liver size is paradoxically reported both as normal at 15.9\ncm and enlarged at 18.7 cm. Margins are rounded. Echotexture is markedly\ninhomogeneous with nodular surface. Multiple hypoechoic nodules are\npresent in the right lobe, along with a suspicious hypoechoic area\nmeasuring 2.4 x 3.6 x 4.4 cm with peripheral halo in segment II. Hepatic\nveins are rarified. Portal vein shows orthograde flow with a vmax of 28\ncm/s.\n\n**Gallbladder**: Morphologically unremarkable with no wall thickening.\nCholelithiasis noted with concretions measuring at least 2 to 1.6 cm.\n\n**Biliary Tract:** Intrahepatic bile ducts are not dilated; Common\nhepatic duct measures up to 8.5 mm and common bile duct measures 6.6 mm\nin diameter.\n\n**Pancreas**: Partially visualized; adequacy of assessment is\ncompromised.\n\n**Spleen**: Enlarged with homogeneous internal echotexture.\n\n**Kidneys**: Morphologically unremarkable; no evidence of\nhydronephrosis.\n\n**Abdominal Vessels:** Aorta is not dilated.\n\n**Gastrointestinal**: Perihepatic ascites noted. Both small and large\nintestines appear unremarkable upon limited assessment.\n\n**Urinary Bladder/Genitalia:** Bladder is moderately filled and\nunremarkable in shape and size.\n\n**Assessment**: Limited study due to patient non-cooperation and\nmeteorism. Findings are suggestive of liver cirrhosis and grade I\nascites. Additional findings include suspected hepatic space-occupying\nlesions, splenomegaly, and cholelithiasis. Mild dilation of DHC and DC\nobserved without signs of intrahepatic cholestasis.\n\n**Virology from 06/01/2020:**\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HAV IgG 0.73 negative\n Anti HAV IgM \\<0.1 negative\n\n**Interpretation:** Serologically no evidence of fresh or expired\ninfection with\n\nHepatitis A virus, no immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n HBs antigen 0.21 negative\n Anti HBs \\<0.1 negative\n Anti HBc 0.1 negative\n\n**Interpretation:** Serologically no evidence of acute, chronic or\nexpired Hepatitis B virus infection. No immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HCV 0.06 negative\n\n**Interpretation:** Serologically no evidence of hepatitis C virus\ninfection. At possible fresh infection resubmission in 2-4 weeks and HCV\nPCR recommended.\n\n**MRI total spine plain from 06/04/2020:**\n\n**Technique**: T2 Dixon Sagittal and T2 Axial MRI Sequences. Coverage\nextends from the craniocervical junction to the sacrum.\n\n**Findings:**\n\n**General Spine:** Full extent from craniocervical junction to sacrum\nvisualized. Conus medullaris appropriately located at T12-L1 level.\nMyelon demonstrates uniform width and homogeneous signal. Evaluation of\nthoracolumbar transition and lumbar spine is compromised by artifact\nsuperimposition from ascites.\n\n**Cervical Spine:** Irregular alignment of the posterior vertebral body\nmargins noted, with evidence of disc protrusions and ligamentum flavum\nhypertrophy. Focal T2 hyperintensity observed at C5 level. No evidence\nof prevertebral soft tissue proliferation.\n\n**Thoracic Spine**: Maintained alignment of the posterior vertebral body\nmargins. Multiple anterior endplate compression fractures noted at T5,\nT8, T9, T11, T12 levels. Focal T2 hyperintensity near the anterior\nendplate of T8 involving the posterior margin, indicative of a\nnon-displaced fracture without spinal canal compromise. Hypertrophic\nfacet joint arthrosis at T10-T11 levels resulting in relative spinal\nnarrowing. Bilateral pleural effusions noted, more pronounced on the\nright, with a maximum width of approximately 2 cm. No evidence of\nsignificant neuroforaminal stenosis.\n\n**Lumbar Spine:** Maintained alignment of posterior vertebral body\nmargins. Known anterior endplate compression fractures at L1 and\nbaseplate compression fracture at L2. No evidence of pathological T2\nedema within the vertebral bodies, although assessment is limited due to\nsuperimposed artifacts from ascites. Spinal canal dimensions appear\nadequate throughout. Moderate fatty degeneration of sacral bone noted.\n\n**Assessment**: Evaluation limited due to ascites-related artifacts.\nSubacute anterior endplate compression fracture at T8, along with\nseveral other likely older compression fractures in the thoracic and\nupper lumbar spine. Bilateral pleural effusions observed. Multiple\nneuroforaminal narrowings as detailed above.\n\n**MR Liver plain + contast agent from 06/06/2020**\n\n**Findings:**\n\n1) [Lesion 1]{.underline}\n\n- Size of the lesion 41 mm\n\n- Segment 2\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: yes\n\n- Pseudocapsule: yes\n\n- Behavior delayed leaching: yes\n\n- pseudocapsule macrovascular invasion: no\n\n2) [Lesion 2]{.underline}\n\n- Size of the lesion 104 mm\n\n- Segment 5 / 7 / 8\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: no\n\n- Pseudocapsule: no\n\n- Behavior delayed washing out: no\n\n- Pseudocapsule: no\n\n- Macrovascular invasion: yes\n\n**Comments:**\n\n- MRI with Gadovist intravenous.\n\n- Multiple other satellite foci in all liver segments.\n\n- Signs of liver cirrhosis with nodular liver parenchyma and\n hypertrophy of the left lobe.\n\n- Cholecystolithiasis and gallbladder hydrops. No cholestasis.\n\n- Varices of the esophagus and fundus. Splenomegaly. Ascites. Pleural\n effusions on both sides.\n\n- Lymph node (approximately 8 mm) between the small curvature of the\n Stomach and S1 of the liver.\n\n- Axial hernia.\n\n**Assessment:** Milan fulfilled**.** Dissiminated HCC foci in all\nsegments, the largest foci being in segments 5 / 7 / 8 localized. Portal\nhypertension with bypass circulation and splenomegaly. Ascites and\npleural effusions.\n\n**Microbiology from 06/09/2020:**\n\n[Material]{.underline}: Ascites in blood culture bottles\n\n[Microscopic]{.underline}: No cells, no germs\n\n- Anaerobic culture negative after 48 hours\n\n- So far, no growth in the anaerobic cultures. The cultures are\n incubated for a total of 5 days. In case of growth of anaerobes we\n will send you a follow-up report.\n\n- No growth after 48 hours\n\n**Esophagogastroduodenoscopy of 06/11/2020:**\n\n**Esophagus**: In the distal esophagus, multiple band-like ulcerations\nas well as residual varices with risk signs that may not completely pass\nair insufflation. Z-line without erosions.\n\n**Stomach**: Mosaic-like occupancy of the gastric mucosa. With inversion\nthe\n\nknown small-curved lateral cardiavarii, which is hard on palpation with\nclosed forceps after histoacryl injection. Directly next to it, another\ncardiavarice can now be seen, which has not yet been injected with\nhistoacryl and is soft on palpation.\n\n**Duodenum**: Endoscopic therapy: Injection of 0.5 mL Histoacryl (+0.5\nmL Lipoidol) in the new cardiavarice. Application of 3 rubber band\nligatures to the residual varices in the esophagus.\n\n**Assessment:** Residual varices in the esophagus, application of 3\nrubber band ligations; portal hypertensive gastropathy\n\n**Spine-whole: 2 planes from 06/13/2020**\n\nThe perpendicular of C7 protrudes about 15 mm laterally to the left of\nsacral vertebra 1 in the anterior-posterior image and about 9.3 cm in\nfront of sacral vertebra 1 in the lateral ray path. Slight left convex\nscoliosis thoracolumbally with thoracic counter-swing (Cobb angle \\< 10°\nin each case). The lungs are unremarkable as far as technically\nassessable.\n\n**Assessment**: decompensated positive sagittal spinal imbalance. There\nis no relevant lateral trunk overhang.\n\n**Critical Findings Report:**\n\nA conspicuous single cell population of cells with partial signet ring\ncell character is detected in the smears. A cell block is prepared from\nthe remaining liquid material for further typing of these cells. A\nfollow-up report will follow.\n\n**Thoracic spine in 2 planes from 06/15/2020:**\n\n**Findings**: Thoracic vertebra 8: Post-kyphoplasty status with notable\nimprovement in vertebral height, now measuring 21 mm compared to a\npreoperative height of 13 mm. Mild straightening of the vertebral column\nobserved at this level.\n\nThoracic vertebra 9: Known older anterior endplate collapse.\n\nThoracolumbar spine: Multisegmental height reduction in vertebral bodies\nconsistent with osteoporotic changes. No signs of contrast\nextravasation.\n\nAdditional Finding: Pre-existing calcified structure projecting onto the\nleft upper abdomen; likely unrelated to current surgical site.\n\n**Assessment**: Unremarkable postoperative imaging following kyphoplasty\nof T8. No evidence of postoperative sintering or newly identifiable\nfractures. Overall, the surgical intervention appears successful in\nincreasing vertebral height and stabilizing the fracture site.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 06/18/2020:**\n\n**Technique**: Multislice spiral CT of the chest, abdomen, and pelvis\nwas performed post-bolus intravenous injection of 120 ml of Imeron 400.\nImaging conducted in arterial, portal venous, and venous phases. Oral\ncontrast agent administered with Micropaque 1:7 in water and Gastrolux\n1:33 in water. Thin-slice reconstructions and secondary coronal and\nsagittal reformats were performed.\n\n**Chest**: Presence of struma nodosa. Bilateral minor pleural effusions\nwith adjacent atelectasis, more pronounced on the right and extending\ninto the interlobar region. No signs of infiltrative changes. Isolated\nsmall nodular opacities in the right lung. Few small bullae noted.\nMediastinal lymph nodes mildly enlarged up to 0.5 cm; axillary and hilar\nnodes are not enlarged. No pericardial effusion observed.\n\n**Abdomen/Pelvis**: Known esophageal and fundal varices present. Liver\ndemonstrates nodular changes in the context of known Child-Pugh B stage\ncirrhosis. A solid hepatic cellular carcinoma lesion in segment II and\ndiffuse HCC nodules in segments V/VII/VIII visualized, corroborating\nprior MRI findings. They show pronounced arterial enhancement and\ncentral washout. Splenomegaly noted. Adrenal glands unremarkable. Renal\nand urinary systems are inconspicuous. No intestinal motility\nabnormalities detected. Marked ascites present; no pathologically\nenlarged abdominal lymph nodes noted upon limited assessment.\n\n**Skeletal**: Moderate coxarthrosis bilaterally. An old, minimally\ndisplaced fracture of the right 7th rib noted. Advanced degenerative\nchanges in thoracic vertebrae 10, 12, and lumbar spine.\nPost-vertebroplasty status at thoracic vertebra 9. Hemangioma at\nthoracic vertebra 11.\n\n**Assessment**:\n\n- Marked ascites in the setting of liver cirrhosis with multifocal HCC\n lesions, as corroborated by prior MRI. No evidence of extrahepatic\n or lymphatic spread.\n\n- Bilateral minor pleural effusions with associated atelectasis.\n\n- Skeletal findings include moderate coxarthrosis and degenerative\n changes in the spine.\n\nOverall, the scan provides vital information that aligns with and\nelaborates upon existing clinical and imaging data.\n\n**Histology**:\n\n**Pathology from 06/19/2020:**\n\n[Clinical Data:]{.underline} Hepatocellular carcinoma, hydropic\ndecompensated liver cirrhosis Child B,\n\n[Extraction date:]{.underline} 06/13/2020\n\n[Material:]{.underline} 1 Liquid material 7 ml light yellow\n\n[Editing]{.underline}: Papanicolaou and MGG staining\n\n\\+ Protein precipitation\n\n\\+ Erythrocytes\n\n\\+ Lymphocytes\n\n(+) Granulocytes Eosinophils\n\n\\+ Histiocytic cell forms\n\n\\+ Mesothelium\n\n\\+ Active mesothelium\n\n**Other**: Single mononuclear cells with large, eccentric nuclei with\nnucleoli and a narrow cytoplasmic space, partly with signet ring cells.\n\n**Supplementary findings from 06/19/2020**\n\n[Processing]{.underline}: Cell block, HE\n\n**Microscopic:**\n\nAs announced, from the remaining liquid material a cell block was\nprepared. In the HE stain only isolated evidence of mononuclear Cells\nand some blood. No cell atypia.\n\n**Critical Findings Report:** After examination of the remaining liquid\nmaterial in the cell block no Extension of the initial findings in the\nabsence of further diagnostic cell material. The finding is thus based\nexclusively on the Smear material:\n\n- Detection of a single-cell population consisting of cells with\n partial signet ring cell character. Differentially it could be The\n mesothelium may be a reactive change of the approaching mesothelium.\n Cells of an epithelial neoplasia are not visible on the present\n material. to be ruled out with certainty.\n\n**Diagnostic classification:** Suspicious\n\n**Current Recommendations:**\n\n- An appointment at our outpatient clinic to start therapy was\n organized for 06/26/2020.\n\n- An appointment for a health department check-up with varicose vein\n status survey and, if necessary, repeat rubber band ligation has\n been scheduled for 07/22/2020. Please come to the endoscopy on this\n day at 08:30 am fasting with current lab results. incl. coagulation,\n signed consent form as well as SARS-CoV-2 PCR not older than 48h.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report to you on Mrs. Laura Miller, born 04/03/1967, whom we examined\non 06/08/2020 in the course of a consultation.\n\n**Consilar Request:**\n\n- Liver cirrhosis, Child-Pugh B, ethyltoxic genesis\n\n- HCC\n\n- Laboratory albumin: 2.6\n\n- Nutritional advice requested\n\n**Nutritional counseling in cirrhosis of the liver:**\n\n- Albumin at 2.6\n\n- 70kg at admission (stable weight in recent years).\n\n- Height: 1.72m\n\n- BMI falsified by ascites\n\n- Patient reports that she always a \\\"bad eater\\\"\n\n- She reports to eat less due to numerous medication intake\n\n- Patient is noticeably overwhelmed and seems very burdened by\n diagnosis\n\n**Assessment:**\n\n- Protein malnutrition with inadequate oral nutrition\n\n- Patient appears desperate and overwhelmed, questionable compliance\n\n**Recommendations: **\n\n- High-calorie food for more choices (already ordered)\n\n- High-calorie drinks (contains more protein)\n\n- Incorporate protein-rich snacks such as yogurt, sippy cups,\n crispbread\n\n- with cheese.\n\n- A high-energy, high-protein food choice was made with the patient\\'s\n discussed in detail\n\n- Contact details were handed out\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 08/21/2020 to\n08/23/2020.\n\n**Diagnoses**:\n\n- MRI of the liver: disseminated HCC foci in all segments, the largest\n foci is localized in segments 5 / 7 / 8\n\n<!-- -->\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: esophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Current Presentation:** Mrs. Miller presented electively for\ngastroscopy for variceal screening with continuation of banding therapy\ndue to esophageal variceal bleeding.\n\n**Medical History**: For a detailed medical history, we refer to\nprevious reports from our department. In summary, we present a liver\ncirrhosis due to ethyl toxicity leading to the development of multifocal\nHCC. Similar to the liver board decision of 06/13/20, a recommendation\nfor systemic therapy with Lenvatinib or Sorafenib was made in the\nsetting of partially compensated Child B7 cirrhosis with multifocal HCC\nin both lobes of the liver.\n\n**Therapy and Course:** Upon admission, the patient was in\nage-appropriate general condition and largely symptom-free. There were\nno signs of acute infection, jaundice, encephalopathic symptoms, or GI\nbleeding. No irregularities in bowel movements or urination were\nreported. The patient denied abdominal pain and dyspnea. There were no\nknown allergies.\n\nOn the day of admission, an uncomplicated gastroscopy was performed,\nincluding the application of 4 rubber band ligations for residual\nesophageal varices. Post-interventional pain was adequately controlled\nwith double-standard doses of Pantoprazole and intravenous analgesic\ntherapy. The further inpatient course was uneventful, and the patient\ntolerated the post-interventional diet without signs of GI bleeding.\n\nBased on laboratory findings and clinical evaluation, particularly with\nregressed ascites, a compensated Child A6 cirrhosis was confirmed.\nTherefore, a re-presentation at our interdisciplinary liver board was\ninitiated for discussion of potential treatment options in the context\nof compensated liver function.\n\nAs per the consensus recommendation from the liver board, a follow-up\ngastroscopy is scheduled within the next two weeks. Depending on the\nvariceal status, systemic therapy with Atezolizumab/Bevacizumab or\nLenvatinib will follow.\n\nThroughout the monitoring period, the patient remained stable in terms\nof circulation and hemoglobin levels. Therefore, on 08/23/20, we\ndischarged Mrs. Miller for outpatient follow-up care. The patient was\nthoroughly informed about reasons that necessitate immediate\nre-presentation. Please note the listed procedural appointments.\n\n**Physical Examination:** Awake, alert, oriented\n\n- Heart: Regular heart tones, no murmurs\n\n- Lungs: Clear vesicular breath sounds, no crackles or wheezes\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, palpable firm liver edge under the rib cage, no palpable\n spleen enlargement, non-painful renal angle\n\n- Extremities: Good peripheral pulses, no edema\n\n- Neurology: No focal neurological deficits.\n\n**EGD on 08/21/2020:**\n\n**Findings:**\n\n**Esophagus**: Unobstructed intubation of the esophagus under direct\nvision. Multiple variceal cords and scarring changes due to banding were\nobserved in the lower half of the esophagus. Z-line at 35 cm\ndiaphragmatic passage at 39 cm. Two variceal cords extend along the\nsmall curve into the stomach, two of the varices show alarm signs (red\nspots). 4 rubber band ligations were performed.\n\n**Stomach**: In the proximal corpus a picture of portal hypertensive\ngastropathy, otherwise unremarkable. No fundus varices.\n\n**Duodenum**: Good unfolding of the duodenal bulb, contact-sensitive\nmucosa. Good insight into the descending part of the duodenum. Overall,\nunremarkable mucosa.\n\n**Assessment:** Esophageal varices, Gastroesophageal varices Type I.\nBanding therapy.\n\n**Current Recommendations:**\n\n- Regular clinical and laboratory checks by the primary care\n physician.\n\n- In case of fever, acute deterioration of the general condition, or\n clinical signs of bleeding such as melena or hematemesis, we request\n immediate re-presentation, even at night and on weekends, through\n our interdisciplinary emergency department.\n\n- Decision of the liver board: Improvement of liver function with\n alcohol abstinence, but also progression of multifocal HCC over 2\n months without tumor-specific therapy. Consensus: Repeat EGD in 7-14\n days, depending on variceal status, Atezolizumab/Bevacizumab, or\n Lenvatinib.\n\n- Follow-up appointment on 09/11/20 in our HCC outpatient clinic for\n clinical control and explanation of the EGD.\n\n- Follow-up in our endoscopy for EGD to determine variceal status and\n possible banding -\\> Please bring a COVID PCR test (maximum 48 hours\n old) for inpatient admission.\n\nIf complaints persist or worsen, we recommend immediate re-presentation.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 09/18/2020 to\n09/20/2020.\n\n**Diagnoses:**\n\n- 4-time banding therapy with 4 rubber band ligations for residual\n esophageal varices without alarm signs\n\n- Hepatocellular Carcinoma (HCC)\n\n- MR Liver: Disseminated HCC lesions in all segments, with the largest\n lesion located in segments 5/7/8\n\n- Decompensated cirrhosis of the liver (Child B) since 05/20 due to\n ethyltoxic origin.\n\n- Transfusion-dependent anemia due to a history of variceal bleeding.\n\n- Osteoporotic thoracic vertebral fracture of vertebra BWK8 (OF3) with\n kyphoplasty.\n\n- Portal hypertension with portosystemic collaterals\n\n- Splenomegaly\n\n- Cholelithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- History of stroke (2016)\n\n- Allergies: Amalgam\n\n**Presentation:** Mrs. Miller\\'s elective presentation was for a\nfollow-up examination for known esophageal varices.\n\n**Medical History:** For a detailed medical history, please refer to\nprevious reports from our department. In summary, in June 2020, the\npatient was diagnosed with decompensated liver cirrhosis attributed to\nethyltoxicity. MR imaging showed multifocal HCC. According to the liver\nboard decision on 06/15/20, initial therapy was recommended with\nLenvatinib or Sorafenib for partially compensated Child B7 cirrhosis\nwith multifocal HCC in both liver lobes. Despite improvement in liver\nfunction with alcohol cessation, there was a short-term progression of\nmultifocal HCC without tumor-specific therapy, leading to a\nrecommendation for a repeat variceal screening on 08/28/20. Depending on\nthe findings, therapy with Atezolizumab/Bevacizumab or Lenvatinib was\nadvised. The last EGD was performed on 08/21/20, revealing esophageal\nvarices with alarm signs, and a 4-time banding was performed.\n\n**Physical Examination upon Admission:** Blood pressure: 80/150 mmHg,\nheart rate 88/min, temperature 36.4°C, SpO2 97% in room air.\n\nPatient in good general condition and normal mental status. Mrs. Miller\nis fully oriented. Pupils are equal and reactive.\n\n- Cardiovascular: Clear heart sounds, no murmurs.\n\n- Lungs: Equal breath sounds bilaterally, no crackles, resonant\n percussion.\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, liver and spleen not palpable.\n\n- Extremities: No edema, good peripheral pulses. No focal neurological\n deficits.\n\n**Course and Therapy:** On the day of admission, the EGD was performed\nwithout complications. Residual varices without warning signs were\nobserved, and a 4-time rubber band ligation was performed. Portal\nhypertensive gastropathy was also diagnosed. After the procedure, the\npatient was transferred to our gastroenterological normal ward.\n\nThe post-interventional course was uneventful. There were no clinical or\nlaboratory signs of post-interventional bleeding. The diet was\nreintroduced without any issues. Therefore, on 09/20/2020, we discharged\nMrs. Miller for outpatient care. We request a follow-up appointment at\nour in-house HCC outpatient clinic. Additionally, we request a follow-up\nEGD with variceal control.\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n\n\n\n\nHere is the query:\nWhat type of heart murmur was noted in Mr. Nilsson's physical examination in January 2005?\n\nChoose the correct answer from the following options:\nA. 3/6 systolic murmur auscultated on the left parasternal side\nB. 1/6 diastolic murmur\nC. 4/6 pansystolic murmur\nD. 2/6 ejection murmur\nE. Continuous murmur\n\n\nYour response:\n", "role": "user" }, { "content": "3/6 systolic murmur auscultated on the left parasternal side", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953, who\nreceived an MRI of the right proximal thigh for further clarification of\na potential tumor.\n\n**MRI of the right thigh, plain and with contrast agent, on\n02/19/2017:**\n\n[Technique]{.underline}: Surface coil, localization scan, coronal T1 SE,\ntransverse, coronal, sagittal T2 TSE with fat suppression. After\nintravenous contrast administration, T1-TSE transverse and T1-TSE FS\n(coronal, T2 TSE FS coronal as an additional fat-saturated sequence in\nthe same section level for exploring relevant edema).\n\n[Findings]{.underline}: Normal bone marrow signal consistent with age.\nNo signs of fractures. Coexistence of moderate degenerative changes in\nthe hip joints, more pronounced on the right than on the left. Mild\nactivation of the muscles in the left proximal adductor region. Ventral\nto the gracilis muscle and dorsal to the sartorius muscle at the level\nof the middle third of the right thigh is a subfascial intermuscular\noval mass lesion with a high-signal appearance on T2-weighted images and\na low-signal appearance on T1-weighted images. It is partially septated,\nwell-demarcated, and shows strong contrast enhancement. No evidence of\nblood degradation products. Dimensions are 35 x 45 x 40 mm. No evidence\nof suspiciously enlarged lymph nodes. Other assessed soft tissues are\nunremarkable for the patient\\'s age.\n\n[Assessment]{.underline}: Overall, a high suspicion of a mucinous mass\nlesion in the region of the right adductor compartment. Differential\nDiagnosis: Mucinous liposarcoma. Further histological evaluation is\nstrongly recommended.\n\n**Current Recommendations:** Presentation at the clinic for surgery for\nfurther differential diagnostic clarification.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953. He was\nunder our inpatient care from 03/10/2017 to 03/12/2017.\n\n**Diagnosis:** Soft tissue tumor of the right proximal thigh\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Treatment**: Incisional biopsy on 03/10/2017\n\n**Histology:**\n\n[Microscopy]{.underline}: (Hematoxylin and Eosin staining):\nHistologically, an infiltrate of a mesenchymal neoplasm is evident in a\nsection prepared by us and stained with HE. There are areas with an\nestimated tumor percentage of approximately 90% that were selected and\nlabeled for molecular pathology analysis.\n\n[Molecular Pathology]{.underline}: After macrodissection of labeled\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused next-generation sequencing technology. The\nanalysis was performed using FusioPlex Sarcoma v2 assays, allowing\ndetection of fusions in 63 genes.\n\n**Medical History:** We may kindly assume that you are familiar with Mr.\nHavers's medical history. The patient presented to our surgery clinic\ndue to a mass in the right proximal thigh. The swelling was first\nnoticed approximately 3 months ago and has shown significant enlargement\nsince. The patient subsequently consulted a general surgeon, who\nreferred him to our center after performing an MRI, suspecting an\nintramuscular liposarcoma. After presenting the case to our\ninterdisciplinary tumor board, the decision was made to perform an\nincisional biopsy. The patient was admitted for the above procedure on\n03/10/2017.\n\n**Physical Examination:** On clinical examination, a patient in slightly\nreduced general and nutritional status was observed. Approximately 6 x 7\nx 4 cm-sized tumor in the right proximal thigh, well mobile,\nintramuscular. Numbness in both legs at L5/S1.\n\nNo change in skin color. No fluctuation or redness. The rest of the\nclinical examination was unremarkable.\n\n**Treatment and Progression:** Following routine preoperative\npreparations and informed consent, the above-mentioned procedure was\nperformed under general anesthesia on 03/10/2017. The intraoperative and\npostoperative courses were uncomplicated.\n\nInitial mild swelling regressed over time. The inserted drainage was\nremoved on the second postoperative day. The patient mobilized\nindependently on the ward. Pain management was provided as needed.\n\nWith the patient\\'s subjective well-being and inconspicuous wound\nconditions, we were able to discharge Mr. Havers on 03/12/2017 for\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- Suture material to be shortened on the 14th postoperative day.\n\n- Follow-up appointments in our outpatient clinic\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin Calcium (Lipitor) 21.7 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole Sodium (Protonix) 22.6 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Urea 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Complete Blood Count \\- \\-\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n Erythrocytes 5.2 M/µL 4.3-5.8 M/µL\n Leukocytes 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n INR 0.94 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n\n**Addition: Histology Report:**\n\n[Microscopy:]{.underline} (Hematoxylin and Eosin staining):\nHistologically, infiltrates of a mesenchymal neoplasm can be seen in a\nsection we prepared. Below this are areas estimated to contain 90%\ntumor, which have been selected and labeled for molecular pathological\nanalysis.\n\n[Molecular Pathology:]{.underline} After macrodissection of the marked\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused Next-Generation Sequencing technology. The\nexamination was performed using the FusioPlex Sarcoma v2 Assays, that\nallows for the detection of fusions involving 63 genes.\n\n[Diagnosis:]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma, Grade 1 according to\n FNCLCC (Sum score 2 + 0 + 1 = 3), with the detection of a FUS: DDIT3\n fusion transcript (right adductor compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue.\n\n- In addition to previous reports, myxoid neoplasm is characterized by\n minimal cell density/round cell areas, here less than 25%, according\n to FNCLCC (=2 points for tumor differentiation).\n\n- No evidence of necrosis (=0 points).\n\n- 2 mitotic figures in 10 high-power fields (=1 point).\n\n- Total score is 2 + 0 + 1 = 3, corresponding to Grade 1 according to\n FNCLCC.\n\n[Diagnosis]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma (right adductor\n compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue\n (subcutaneous).\n\n[Comment]{.underline}: The present biopsy material corresponds to Grade\n1 according to FNCLCC. A supplementary report follows.\n\n**Supplementary Report from: 03/29/2017:**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh. Encapsulated subfascial tumor, palpably indurated.\nAdipose tissue adjacent to the tumor, macroscopically lighter and finer\nthan the subcutaneous adipose tissue towards the skin.\n\n[Material]{.underline}: Microscopy and Molecular Pathology Interphase\nFISH analysis using a two-color break-apart probe to examine a\nchromosomal break in the FUS gene (chromosome 16p11.2) and in the DDIT3\ngene (chromosome 12q13.3-q14.1).\n\nInterphase FISH analysis reveals a specific break event in the FUS gene\n(FUS-FISH positive). This indicates the presence of a FUS translocation.\nSimilarly, in interphase FISH analysis, a specific break event is\ndetectable in the DDIT3 gene (DDIT3-FISH positive), indicating the\npresence of a DDIT3 translocation.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n[Comment]{.underline}: The cytogenetic findings are indicative of a\nmyxoid liposarcoma. Technical validation by RNA sequencing will be\nprovided in a supplemental report. This does not affect the above\ndiagnosis.\n\n**Supplementary Report from: 03/18/2017:**\n\n[Microscopy: MDM2, S100:]{.underline} Partial weak expression of S100\nprotein by the lesional cells, occasionally including pre-existing\nadipocytes. No abnormal expression of MDM2. No abnormal expression of\nMDM2 in mature adipose tissue.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n**Main Report from: 03/18/2017**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh, as per MRI 02/19/2017. Encapsulated subfascial tumor,\npalpably indurated located in the right adductor compartment. Adipose\ntissue adjacent to the tumor, macroscopically lighter and finer than the\nsubcutaneous adipose tissue towards the skin.\n\n[Macroscopy:]{.underline}\n\nTumor: Brown, nodular piece of tissue, 20 x 14 x 10 mm, with smooth and\nrough surface. Cut surface shiny and mottled, sometimes gray, sometimes\nbrown.\n\nSubcutaneous adipose tissue: A piece of adipose tissue, 25 x 20 x 5 mm.\n\n[Microscopy:]{.underline}\n\nModerately cell dense mesenchymal proliferation with a myxoid matrix.\nPredominantly round nuclei, moderately dense nuclear chromatin, slight\npleomorphism. Occasional adipocytic cells with univacuolar cytoplasm.\n\nPartially dense, ribbon-like connective tissue as well as mature\nunivacuolar adipose tissue.\n\n[Diagnosis:]{.underline}\n\nIncisional biopsy suspected of a myxoid liposarcoma. Predominantly\nmature fatty tissue as well as fascial tissue.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe would like to inform you about our patient Mr. John Havers, born on\n05/29/1953, who was admitted to our hospital from 03/29/2017 to\n04/05/2017.\n\n**Diagnoses**:\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n- Incisional biopsy on 03/10/2017\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Current Presentation**: Neoplasm of uncertain or unknown behavior.\n\n**Treatment**: On 04/01/2017, en bloc tumor excision with removal of the\nold biopsy scar, partial resection of the M. gracilis, fibers of the M.\nsartorius and M. adductor longus, and ligation of the V. saphena magna\nwas performed.\n\n**Histology from 04/11/2017**\n\nClinical Information: Myxoid liposarcoma, localized in the right thigh.\n\n[Macroscopy Tumor, right thigh]{.underline}: A triple surgical resection\nwas performed, removing skin and subcutaneous tissue and the underlying\nsoft tissue and muscle. The size of the excised skin spindle was 130 x\n45 mm with a resection depth of up to 48 mm. A wound 25 mm long and 6 mm\nwide was noted on the skin surface. The muscle attached\nlaterally/dorsally measured 75 x 25 x 6 mm. Two nodules were noted on\nthe cut surface. The larger nodule, located in the subcutaneous tissue,\nmeasured 33 mm (proximal/distal) x 36 mm (anterior/dorsal) x 30 mm. Its\ndistance from the proximal preparation cap was 26 mm, from the distal\npreparation cap more than 60 mm, from the ventral soft tissue 20 mm, and\nfrom the dorsal soft tissue 3 mm, with less than 1 mm basal extension.\nSuperficially, it was surrounded by a delicate capsule. A separate\nnodule measuring 20 mm (proximal/distal) x 24 mm (ventral/dorsal) x 20\nmm was found immediately ventro-distal to the first nodule. This nodule\nwas located more than 40 mm from the proximal preparation cap, more than\n50 mm from the distal preparation cap, 12 mm ventrally, 11 mm dorsally,\nand 5 mm basally. Consequently, the maximum size of the tumor from\nproximal to distal was 53 mm. No macroscopic necrotic areas were evident\non the cut surface of the nodule. However, partial necrosis of the\nsubcutaneous fatty tissue in the vicinity of the described wound was\nobserved.\n\n[Microscopy HE, PAS:]{.underline} Histomorphologically, there is a\nmoderately cell-dense proliferation with a significant myxoid matrix in\nthe area of the two confluent nodules, with a maximum diameter of 53 mm.\nThere are also areas with relative cell poverty. Within the myxoid\nmatrix, there are blood vessels with a distinct growth pattern referred\nto as the \\\"chicken wire pattern.\\\" No clear tumor necroses are evident.\nThe tumor cell nuclei have a round configuration with moderately dense\nchromatin. Apoptotic figures are increased. The number of mitoses is\nlow.The lesion was completely removed with a minimal margin of 0.5 mm\nfrom the posterior resection edge. In the superficial subcutaneous\ntissue, there is a band-like necrosis directly related to superficial\ngranulation tissue. The included skin spindle shows regular epidermal\ncovering and a largely unremarkable dermis.\n\n[Diagnosis]{.underline}: Skin/subcutaneous excision with a maximum 53 mm\nmyxoid liposarcoma that was completely removed (minimum distance to\nposterior cutoff plane 0.5 mm).\n\n[Comment]{.underline}: In view of the present morphology and knowledge\nof the molecular pathological examination results with proven break\nevents in the FUS gene and DDIT3 gene as part of interphase FISH\nanalysis, the diagnosed condition is myxoid liposarcoma.\n\nAccording to the FNCLCC grading scheme, this corresponds to grade 1:\nHistological type: 2 points + mitotic index 1 point + necrosis index 0\npoints = 3 points.\n\nICD-O-3 tumor classification: Myxoid liposarcoma TNM (8th edition): pT2\npNX L0 V0 Pn0 G1 R0\n\n**Medical History:** We assume that you are familiar with Mr. Havers's\nmedical history, and we refer to our previous correspondence.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds.\n\nHeart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys.\n\nNormal peripheral pulses; joints freely movable. Strength, motor\nfunction, and sensation are unremarkable.\n\n**Therapy and Progression**: The patient presented to our surgical\nclinic because of a mass in the right proximal thigh. The swelling was\nfirst noticed about 3 months ago and has increased significantly in size\nsince then. MRI findings raised suspicion of a liposarcoma. After\nconsultation in the interdisciplinary tumor board, the indication for\nincisional biopsy was performed on 03/10/2017. The histopathological\nexamination confirmed the presence of a myxoid liposarcoma, leading to\nthe decision for en bloc excision. The patient was extensively informed\nabout the procedure and the risks and gave his consent. The patient was\nadmitted for the procedure on 03/29/2017.\n\nUpon clinical examination, a patient in good general and nutritional\ncondition was noted. Other general clinical findings were unremarkable.\nA wound healing disorder of 2 cm was observed in the area of the wound\nafter incisional biopsy.\n\n**Sarcoma Tumor Board Recommendation dated 03/11/2017:** R0 G1 finding,\nstandard sarcoma follow-up.\n\n**Procedure**: Following standard preoperative preparations and informed\nconsent, the aforementioned procedure was performed on 03/01/2017 under\ngeneral anesthesia. The intraoperative and postoperative course was\nuneventful.\n\nOn the first postoperative day, there was slight swelling in the\naffected area, which gradually subsided. Analgesia was sufficient with\nAcetaminophen as needed. Thrombosis prophylaxis was administered with\nsubcutaneous Enoxaparin 0.4 mL. The patient mobilized independently on\nthe ward. The inserted drainage could not be removed so far due to\nexcessive drainage output. During the hospital stay, a staging CT of the\nchest and abdomen was performed. No thoracoabdominal metastases were\ndetected.\n\n**Summary**: With a good subjective well-being and unremarkable wound\nconditions, Mr. Havers was discharged on 04/05/2017 for further\noutpatient care. Clinical examination reveals slight swelling of the\nwound area. The wound is not dehiscent and shows no signs of irritation.\nThe patient is mobilizing independently.\n\n**CT Chest/Abdomen/Pelvis from 04/01/2017: **\n\n[Clinical Information, Question, Justification]{.underline}: Liposarcoma\nof the thigh. Staging.\n\n[Technique]{.underline}: Digital overview radiographs. Following\nintravenous contrast agent administration (100 ml Xenetix), CT of the\nchest and entire abdomen in the venous contrast phase. Reconstruction of\nthe primary dataset with a slice thickness of 0.625 mm. Multiplanar\nreconstruction. Total DLP: 885 mGy\\*cm.\n\n[Findings]{.underline}: There are no prior images available for\ncomparison.\n\n[Chest]{.underline}: Lungs are evenly ventilated and normally developed\nbilaterally. No pneumothorax on either side. Minimal right-sided pleural\neffusion. Mild basilar hypoventilation, particularly in the right lower\nlobe. Calcified granuloma in the apical right lower lobe. No suspicious\npulmonary nodules.\n\nHeart shows enlargement of the left ventricle and left atrium. Coronary\nartery sclerosis. Atherosclerosis of the aortic arch. No pericardial\neffusion. Aorta and pulmonary trunk have normal diameters. No central\npulmonary artery embolism. No pathologically enlarged mediastinal or\nhilar lymph nodes. Symmetric appearance of the neck soft tissues.\nThyroid gland without focal lesions. Axillary lymph nodes are of normal\nsize.\n\n[Abdomen]{.underline}: Liver is of normal size and has a smooth contour.\nNo signs of cholestasis. No portal vein thrombosis. No suspicious\nintrahepatic lesions. Gallbladder appears normal. Common bile duct is\nnot dilated. Spleen is not enlarged. Pancreas shows regular lobulation,\nand there is no dilatation of the pancreatic duct. Both kidneys are free\nfrom urinary tract obstruction. No solid intrarenal masses. Few renal\ncysts. Adrenal glands appear unremarkable. Urinary bladder shows no\nfocal wall thickening. Prostate is not enlarged. Advanced\natherosclerosis of the abdominal aorta and pelvic vessels. History of\nstenting of the left external iliac artery with no reocclusion.\nMesenteric, para-aortic, and parailiac lymph nodes are not\npathologically enlarged. No free intraperitoneal fluid or air is\ndetected. Osseous Structures: Degenerative changes in the spine. No\nevidence of suspicious osseous destruction suggestive of tumors. Soft\ntissue mantle appears unremarkable.\n\n**Assessment**: No thoracoabdominal metastases.\n\n**Current Recommendations**:\n\n- Regular wound inspections and dressing changes.\n\n- Documentation of drainage output and removal if the output is \\<20\n ml/24 hours, expected removal on 04/23/2017 at our outpatient\n clinic.\n\n- Removal of sutures is not required for absorbable sutures.\n\n- According to the tumor board decision dated 04/11/2017, we recommend\n regular follow-up according to the schedule.\n\n**Sarcoma Follow-up Schedule Stage I**\n\n- Local Follow-up:\n\n 1. MRI right thigh: Years 1-5: every 6 months\n\n 2. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 3. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 4. Years 6-10: every 12 months in alternation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ -------------------\n Aspirin 100 mg 1-0-0-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Enoxaparin (Lovenox) Variable 0-0-1-0\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Acetaminophen (Tylenol) 500 mg 2-2-2-2 if needed\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------- ---------------------\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.74 mg/dL 0.70-1.20 mg/dL\n Blood Urea Nitrogen 33 mg/dL 17-48 mg/dL\n C-Reactive Protein 1.7 mg/dL \\< 5.0 mg/dL\n Thyroid-Stimulating Hormone 3.58 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 16.5 g/dL 13.5-17.0 g/dL\n Hematocrit 49.3% 39.5-50.5%\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.63 K/µL 3.90-10.50 K/µL\n Platelets 301 K/µL 150-370 K/µL\n Mean Corpuscular Volume 95.7 fL 80.0-99.0 fL\n Mean Corpuscular Hemoglobin 32.0 pg 27.0-33.5 pg\n Mean Corpuscular Hemoglobin Concentration 33.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.4 fL 7.0-12.0 fL\n Red Cell Distribution Width 12.1% 11.6-14.4%\n Activated Partial Thromboplastin Time 32.4 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented to our outpatient surgery clinic on\n04/23/2017.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Medical History:** We kindly assume that you are familiar with the\npatient\\'s detailed medical history and refer to our previous discharge\nletter.\n\n**Current Presentation:** The patient presented today for a follow-up\nvisit in our clinic. He reported no complaints. The Redon drain has not\nproduced any secretions in the last 2 days.\n\nClinical examination revealed uneventful wound conditions with applied\nSteri-strips. There is no evidence of infection. The Redon drain\ncontains serous wound secretions.\n\nProcedure: The Redon drain is being removed today. With nearly fully\nhealed wound conditions, we recommend initiating scar massage with fatty\ntopical products in the near future.\n\n**MRI of the Right Thigh on** 04/23/2017**:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB. Recurrence? Regional behavior? Lymph nodes?\n\n[Technique]{.underline}: 3 Tesla MRI of the right thigh, both plain and\nafter the administration of 8 ml of Gadovist intravenously. Supine\nposition, surface coil.\n\nSequences: TIRM coronal and axial, T2-TSE coronal and axial, T1 VIBE\nDixon axial, EPI-DWI with ADC map axial, T1-Starvibe vascular images\nplain and post-contrast axial with subtraction images, T1-TSE FS\npost-contrast coronal.\n\n[Findings]{.underline}: Minor FLAIR hyperintense streaky signal\nalteration in the surgical area, most likely scar-related, with slight\ndiffusion restriction and streaky contrast enhancement. No evidence of a\nrecurrent suspicious substrate. No nodular contrast enhancement.\nSlightly accentuated inguinal lymph nodes on the right, most likely\nreactive. Unremarkable visualization of the remaining soft tissue.\nNormal bone marrow signal. Bladder filled. Unremarkable representation\nof the imaged pelvic organs.\n\n[Assessment]{.underline}: Following the resection of a myxoid\nliposarcoma on the right medial thigh, there is a regular postoperative\nfinding. No indication of local recurrence.\n\n**Chest X-ray in Two Planes on 04/23/2017: **\n\n[Clinical Background, Question, Justification]{.underline}: Myxoid\nliposarcoma of the right thigh, initial diagnosis in 2022. Follow-up.\nMetastases?\n\n[Findings]{.underline}: No corresponding prior images for comparison.\nThe upper mediastinum is centrally located and not widened. Hila are\nfree. No acute congestion. No confluent pneumonic infiltrate. No\nevidence of larger intrapulmonary lesions. A 7 mm spot shadow is noted\nright suprahilar, primarily representing a vascular structure. No\neffusions. No pneumothorax.\n\n**Current Recommendations:** The patient would like to continue\nfollow-up care with us, so we scheduled an MRI control appointment to\nassess the possibility of local recurrence. On this day, a two-view\nchest X-ray is also required.\n\n**We recommend the following follow-up schedule:**\n\n- Local Follow-up:\n\n 5. MRI right thigh: Years 1-5: every 6 months\n\n 6. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 7. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 8. Years 6-10: every 12 months in alternation\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented for tumor follow-up on 02/10/2018, in our\noutpatient surgery clinic for a discussion of findings.\n\n**Diagnosis**: Myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a regular postoperative finding on the\nright thigh.\n\nThe control MRI with contrast of the right thigh on 04/23/2017 revealed\nmorphologically:\n\n- No evidence of a local-regional recurrence.\n\n- In pulmonary follow-up using conventional chest X-ray on 04/23/2017,\n no signs of pulmonary metastasis were detected.\n\n**Current Recommendations:** Sarcoma Follow-up Schedule Stage I\n\n- Local Follow-up:\n\n 9. MRI right thigh: Years 1-5: every 6 months\n\n 10. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 11. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 12. Years 6-10: every 12 months in alternation\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting to you on our patient Mr. John Havers, born on\n05/29/1953, who presented himself on **08/01/2018** at our outpatient\nsurgery clinic for a discussion of findings as part of tumor follow-up.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a normal postoperative condition in\nthe right thigh.\n\n**MRI of the Right Thigh on 08/01/2018:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh. Progress\nassessment.\n\n[Method]{.underline}: 1.5 Tesla. Localization sequences. TIRM and T2 TSE\ncoronal. TIRM, T2 TSE, VIBE DIXON, and RESOLVE-DWI axial. StarVIBE FS\nbefore and after contrast + subtraction. T1 TSE FS coronal after\ncontrast.\n\n[Findings]{.underline}: Comparison with MRI from 04/23/2017.\nPost-resection of a myxoid liposarcoma in the proximal medial right\nthigh soft tissue. In the surgical area, there is no evidence of a\nsuspicious nodular, contrast-affine lesion, and no evidence of\nmalignancy-suspected diffusion restriction. Slight scar-related changes\nin the access path. Otherwise, unremarkable presentation of soft tissues\nand included bony structures. No inguinal lymphadenopathy. Assessment:\nFor myxoid liposarcoma, there has been consistent evidence since\n02/2018:\n\n**Chest CT on 08/01/2018**:\n\n[Clinical Background, Question, Justification: Liposarcoma on the thigh.\nStaging.]{.underline} After risk history assessment, oral and written\nexplanation of contrast agent application and examination procedure, as\nwell as potential risks of the examination (see also informed consent\nform). Written patient consent.\n\n[Method]{.underline}: Digital overview radiographs. After intravenous\ncontrast agent administration (80 ml of Imeron), CT of the chest in\nvenous contrast phase, reconstruction of the primary dataset with a\nslice thickness of 0.625 mm. Total DLP 185 mGy\\*cm.\n\n[Findings]{.underline}: For comparison, there is a CT of the\nchest/abdomen/pelvis from 04/01/2018. No evidence of suspicious\npulmonary nodules. Several partly calcified micronodules bipulmonary,\nespecially in the right lower lobe (ex. S303/IMA179). Partial\nunderventilation bipulmonary. No pleural effusion. No evidence of\npathologically enlarged lymph nodes. Constant calcified right hilar\nlymph nodes. Calcifying aortic sclerosis along with coronary sclerosis.\nHepatic steatosis. Individual renal cysts. Slightly shrunken left\nadrenal gland. Degenerative changes of the axial skeleton without\nevidence of a malignancy-suspected osseous lesion.\n\n[Assessment]{.underline}: No evidence of a new thoracic tumor\nmanifestation.\n\n**Recommendations:** Sarcoma Follow-up\n\n- Local Follow-up:\n\n 13. MRI right thigh: Years 1-5: every 6 months\n\n 14. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 15. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 16. Years 6-10: every 12 months in alternation\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n RBC 5.2 M/µL 4.3-5.8 M/µL\n WBC 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n International Normalized Ratio (INR) 0.94 0.90-1.25\n Activated Partial Thromboplastin Time (aPTT) 30.1 sec 25.0-38.0 sec\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who was admitted to our clinic from 08/14/2023 to\n09/02/2023.\n\n**Diagnosis:** Pulmonary Metastasis from Myxoid Liposarcoma\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n<!-- -->\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Medical History:** Mr. Havers has been under our care for myxoid\nliposarcoma, which was previously excised from his right medial thigh.\nHe had a stable postoperative course and was scheduled for regular\nfollow-up to monitor for any potential recurrence or metastasis.\n\n**Current Presentation:** During a follow-up appointment on 08/14/2023,\nMr. Havers complained of mild shortness of breath, occasional coughing,\nand intermittent chest discomfort. He reported no significant weight\nloss but noted a decrease in his overall energy levels. Physical\nexamination revealed decreased breath sounds in the right lung base.\n\n**Physical Examination:** Patient in adequate general condition.\nOriented in all aspects. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable. Lungs: Normal chest shape, moderately\nmobile, decreased breath sounds in the right lung base. Heart: Regular\nheart action, normal rate; heart sounds clear, no pathological sounds.\nAbdomen: Peristalsis and bowel sounds normal in all quadrants; soft\nabdomen, markedly obese, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation is unremarkable.\n\n**Chest X-ray (08/14/2023):** A chest X-ray was performed, which\nrevealed a suspicious opacity in the right lower lung field.\n\n**CT Chest (08/16/2023):** In light of the chest X-ray findings, a\ncontrast-enhanced CT scan of the chest was conducted to obtain more\ndetailed information. The CT imaging demonstrated a well-defined,\nirregularly shaped lesion in the right lower lobe of the lung, measuring\napproximately 2.5 cm in diameter. The lesion exhibited characteristics\nhighly suggestive of a metastatic deposit. There were no other\nsignificant abnormalities noted in the chest.\n\n**Histology (08/21/2023):** Based on the CT findings, a CT-guided core\nneedle biopsy of the pulmonary lesion was performed to confirm the\nnature of the lesion. Histopathological examination of the biopsy\nspecimen confirmed the presence of myxoid liposarcoma cells in the\npulmonary lesion. Immunohistochemical staining for MDM2 and CDK4\nsupported the diagnosis of metastatic myxoid liposarcoma.\n\n**Treatment Discussion:** Given the diagnosis of a pulmonary metastasis\nfrom myxoid liposarcoma, the case was reviewed in the interdisciplinary\ntumor board. The consensus decision was to pursue surgical resection of\nthe pulmonary metastasis, as it remained localized and resectable. The\npatient and his family were informed of the treatment options and\nassociated risks, and they provided informed consent for the procedure.\n\n**Surgery Report (08/29/2023):** Mr. Havers underwent a right lower\nlobectomy with lymph node dissection to remove the pulmonary metastasis.\nThe procedure was performed by our thoracic surgery team and was\ncompleted without any immediate complications. Intraoperative frozen\nsection analysis confirmed the presence of metastatic myxoid liposarcoma\nin the resected lung tissue.\n\n**Postoperative Course:** Mr. Havers postoperative course was\nuneventful, and he demonstrated good respiratory recovery. He was\nmanaged with adequate pain control and underwent chest physiotherapy to\nprevent postoperative complications. Pathological examination of the\nresected lung tissue confirmed the presence of metastatic myxoid\nliposarcoma, with clear surgical margins.\n\n**Current Recommendations:**\n\n1. **Follow-up:** A strict follow-up plan should be established for Mr.\n Havers to monitor for any potential recurrence or new metastatic\n lesions. This should include regular clinical assessments, chest\n imaging, and other relevant investigations.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n --------------------- ------------- ---------------------\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 39 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.5 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.6 g/dL 13.5-17.0 g/dL\n Hematocrit 49.4 % 39.5-50.5 %\n RBC 5.1 M/µL 4.3-5.8 M/µL\n WBC 10.04 K/µL 3.90-10.50 K/µL\n Platelets 166 K/µL 150-370 K/µL\n MCV 95.2 fL 80.0-99.0 fL\n MCH 32.6 pg 27.0-33.5 pg\n MCHC 33.2 g/dL 31.5-36.0 g/dL\n MPV 11.4 fL 7.0-12.0 fL\n RDW-CV 12.5 % 11.5-15.0 %\n Prothrombin Time 122 % 78-123 %\n INR 0.99 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n\n\n\n\nHere is the query:\nWhich of the following medications was NOT part of Mr. Havers' discharge prescription after tumor excision surgery in March 2017?\n\nChoose the correct answer from the following options:\nA. Empagliflozin\nB. Metformin Hydrochloride\nC. Atorvastatin Calcium\nD. Metoprolol Tartrate\nE. Acetaminophen\n\n\nYour response:\n", "role": "user" }, { "content": "Acetaminophen", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953, who\nreceived an MRI of the right proximal thigh for further clarification of\na potential tumor.\n\n**MRI of the right thigh, plain and with contrast agent, on\n02/19/2017:**\n\n[Technique]{.underline}: Surface coil, localization scan, coronal T1 SE,\ntransverse, coronal, sagittal T2 TSE with fat suppression. After\nintravenous contrast administration, T1-TSE transverse and T1-TSE FS\n(coronal, T2 TSE FS coronal as an additional fat-saturated sequence in\nthe same section level for exploring relevant edema).\n\n[Findings]{.underline}: Normal bone marrow signal consistent with age.\nNo signs of fractures. Coexistence of moderate degenerative changes in\nthe hip joints, more pronounced on the right than on the left. Mild\nactivation of the muscles in the left proximal adductor region. Ventral\nto the gracilis muscle and dorsal to the sartorius muscle at the level\nof the middle third of the right thigh is a subfascial intermuscular\noval mass lesion with a high-signal appearance on T2-weighted images and\na low-signal appearance on T1-weighted images. It is partially septated,\nwell-demarcated, and shows strong contrast enhancement. No evidence of\nblood degradation products. Dimensions are 35 x 45 x 40 mm. No evidence\nof suspiciously enlarged lymph nodes. Other assessed soft tissues are\nunremarkable for the patient\\'s age.\n\n[Assessment]{.underline}: Overall, a high suspicion of a mucinous mass\nlesion in the region of the right adductor compartment. Differential\nDiagnosis: Mucinous liposarcoma. Further histological evaluation is\nstrongly recommended.\n\n**Current Recommendations:** Presentation at the clinic for surgery for\nfurther differential diagnostic clarification.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953. He was\nunder our inpatient care from 03/10/2017 to 03/12/2017.\n\n**Diagnosis:** Soft tissue tumor of the right proximal thigh\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Treatment**: Incisional biopsy on 03/10/2017\n\n**Histology:**\n\n[Microscopy]{.underline}: (Hematoxylin and Eosin staining):\nHistologically, an infiltrate of a mesenchymal neoplasm is evident in a\nsection prepared by us and stained with HE. There are areas with an\nestimated tumor percentage of approximately 90% that were selected and\nlabeled for molecular pathology analysis.\n\n[Molecular Pathology]{.underline}: After macrodissection of labeled\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused next-generation sequencing technology. The\nanalysis was performed using FusioPlex Sarcoma v2 assays, allowing\ndetection of fusions in 63 genes.\n\n**Medical History:** We may kindly assume that you are familiar with Mr.\nHavers's medical history. The patient presented to our surgery clinic\ndue to a mass in the right proximal thigh. The swelling was first\nnoticed approximately 3 months ago and has shown significant enlargement\nsince. The patient subsequently consulted a general surgeon, who\nreferred him to our center after performing an MRI, suspecting an\nintramuscular liposarcoma. After presenting the case to our\ninterdisciplinary tumor board, the decision was made to perform an\nincisional biopsy. The patient was admitted for the above procedure on\n03/10/2017.\n\n**Physical Examination:** On clinical examination, a patient in slightly\nreduced general and nutritional status was observed. Approximately 6 x 7\nx 4 cm-sized tumor in the right proximal thigh, well mobile,\nintramuscular. Numbness in both legs at L5/S1.\n\nNo change in skin color. No fluctuation or redness. The rest of the\nclinical examination was unremarkable.\n\n**Treatment and Progression:** Following routine preoperative\npreparations and informed consent, the above-mentioned procedure was\nperformed under general anesthesia on 03/10/2017. The intraoperative and\npostoperative courses were uncomplicated.\n\nInitial mild swelling regressed over time. The inserted drainage was\nremoved on the second postoperative day. The patient mobilized\nindependently on the ward. Pain management was provided as needed.\n\nWith the patient\\'s subjective well-being and inconspicuous wound\nconditions, we were able to discharge Mr. Havers on 03/12/2017 for\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- Suture material to be shortened on the 14th postoperative day.\n\n- Follow-up appointments in our outpatient clinic\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin Calcium (Lipitor) 21.7 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole Sodium (Protonix) 22.6 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Urea 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Complete Blood Count \\- \\-\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n Erythrocytes 5.2 M/µL 4.3-5.8 M/µL\n Leukocytes 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n INR 0.94 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n\n**Addition: Histology Report:**\n\n[Microscopy:]{.underline} (Hematoxylin and Eosin staining):\nHistologically, infiltrates of a mesenchymal neoplasm can be seen in a\nsection we prepared. Below this are areas estimated to contain 90%\ntumor, which have been selected and labeled for molecular pathological\nanalysis.\n\n[Molecular Pathology:]{.underline} After macrodissection of the marked\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused Next-Generation Sequencing technology. The\nexamination was performed using the FusioPlex Sarcoma v2 Assays, that\nallows for the detection of fusions involving 63 genes.\n\n[Diagnosis:]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma, Grade 1 according to\n FNCLCC (Sum score 2 + 0 + 1 = 3), with the detection of a FUS: DDIT3\n fusion transcript (right adductor compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue.\n\n- In addition to previous reports, myxoid neoplasm is characterized by\n minimal cell density/round cell areas, here less than 25%, according\n to FNCLCC (=2 points for tumor differentiation).\n\n- No evidence of necrosis (=0 points).\n\n- 2 mitotic figures in 10 high-power fields (=1 point).\n\n- Total score is 2 + 0 + 1 = 3, corresponding to Grade 1 according to\n FNCLCC.\n\n[Diagnosis]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma (right adductor\n compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue\n (subcutaneous).\n\n[Comment]{.underline}: The present biopsy material corresponds to Grade\n1 according to FNCLCC. A supplementary report follows.\n\n**Supplementary Report from: 03/29/2017:**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh. Encapsulated subfascial tumor, palpably indurated.\nAdipose tissue adjacent to the tumor, macroscopically lighter and finer\nthan the subcutaneous adipose tissue towards the skin.\n\n[Material]{.underline}: Microscopy and Molecular Pathology Interphase\nFISH analysis using a two-color break-apart probe to examine a\nchromosomal break in the FUS gene (chromosome 16p11.2) and in the DDIT3\ngene (chromosome 12q13.3-q14.1).\n\nInterphase FISH analysis reveals a specific break event in the FUS gene\n(FUS-FISH positive). This indicates the presence of a FUS translocation.\nSimilarly, in interphase FISH analysis, a specific break event is\ndetectable in the DDIT3 gene (DDIT3-FISH positive), indicating the\npresence of a DDIT3 translocation.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n[Comment]{.underline}: The cytogenetic findings are indicative of a\nmyxoid liposarcoma. Technical validation by RNA sequencing will be\nprovided in a supplemental report. This does not affect the above\ndiagnosis.\n\n**Supplementary Report from: 03/18/2017:**\n\n[Microscopy: MDM2, S100:]{.underline} Partial weak expression of S100\nprotein by the lesional cells, occasionally including pre-existing\nadipocytes. No abnormal expression of MDM2. No abnormal expression of\nMDM2 in mature adipose tissue.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n**Main Report from: 03/18/2017**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh, as per MRI 02/19/2017. Encapsulated subfascial tumor,\npalpably indurated located in the right adductor compartment. Adipose\ntissue adjacent to the tumor, macroscopically lighter and finer than the\nsubcutaneous adipose tissue towards the skin.\n\n[Macroscopy:]{.underline}\n\nTumor: Brown, nodular piece of tissue, 20 x 14 x 10 mm, with smooth and\nrough surface. Cut surface shiny and mottled, sometimes gray, sometimes\nbrown.\n\nSubcutaneous adipose tissue: A piece of adipose tissue, 25 x 20 x 5 mm.\n\n[Microscopy:]{.underline}\n\nModerately cell dense mesenchymal proliferation with a myxoid matrix.\nPredominantly round nuclei, moderately dense nuclear chromatin, slight\npleomorphism. Occasional adipocytic cells with univacuolar cytoplasm.\n\nPartially dense, ribbon-like connective tissue as well as mature\nunivacuolar adipose tissue.\n\n[Diagnosis:]{.underline}\n\nIncisional biopsy suspected of a myxoid liposarcoma. Predominantly\nmature fatty tissue as well as fascial tissue.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient Mr. John Havers, born on\n05/29/1953, who was admitted to our hospital from 03/29/2017 to\n04/05/2017.\n\n**Diagnoses**:\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n- Incisional biopsy on 03/10/2017\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Current Presentation**: Neoplasm of uncertain or unknown behavior.\n\n**Treatment**: On 04/01/2017, en bloc tumor excision with removal of the\nold biopsy scar, partial resection of the M. gracilis, fibers of the M.\nsartorius and M. adductor longus, and ligation of the V. saphena magna\nwas performed.\n\n**Histology from 04/11/2017**\n\nClinical Information: Myxoid liposarcoma, localized in the right thigh.\n\n[Macroscopy Tumor, right thigh]{.underline}: A triple surgical resection\nwas performed, removing skin and subcutaneous tissue and the underlying\nsoft tissue and muscle. The size of the excised skin spindle was 130 x\n45 mm with a resection depth of up to 48 mm. A wound 25 mm long and 6 mm\nwide was noted on the skin surface. The muscle attached\nlaterally/dorsally measured 75 x 25 x 6 mm. Two nodules were noted on\nthe cut surface. The larger nodule, located in the subcutaneous tissue,\nmeasured 33 mm (proximal/distal) x 36 mm (anterior/dorsal) x 30 mm. Its\ndistance from the proximal preparation cap was 26 mm, from the distal\npreparation cap more than 60 mm, from the ventral soft tissue 20 mm, and\nfrom the dorsal soft tissue 3 mm, with less than 1 mm basal extension.\nSuperficially, it was surrounded by a delicate capsule. A separate\nnodule measuring 20 mm (proximal/distal) x 24 mm (ventral/dorsal) x 20\nmm was found immediately ventro-distal to the first nodule. This nodule\nwas located more than 40 mm from the proximal preparation cap, more than\n50 mm from the distal preparation cap, 12 mm ventrally, 11 mm dorsally,\nand 5 mm basally. Consequently, the maximum size of the tumor from\nproximal to distal was 53 mm. No macroscopic necrotic areas were evident\non the cut surface of the nodule. However, partial necrosis of the\nsubcutaneous fatty tissue in the vicinity of the described wound was\nobserved.\n\n[Microscopy HE, PAS:]{.underline} Histomorphologically, there is a\nmoderately cell-dense proliferation with a significant myxoid matrix in\nthe area of the two confluent nodules, with a maximum diameter of 53 mm.\nThere are also areas with relative cell poverty. Within the myxoid\nmatrix, there are blood vessels with a distinct growth pattern referred\nto as the \\\"chicken wire pattern.\\\" No clear tumor necroses are evident.\nThe tumor cell nuclei have a round configuration with moderately dense\nchromatin. Apoptotic figures are increased. The number of mitoses is\nlow.The lesion was completely removed with a minimal margin of 0.5 mm\nfrom the posterior resection edge. In the superficial subcutaneous\ntissue, there is a band-like necrosis directly related to superficial\ngranulation tissue. The included skin spindle shows regular epidermal\ncovering and a largely unremarkable dermis.\n\n[Diagnosis]{.underline}: Skin/subcutaneous excision with a maximum 53 mm\nmyxoid liposarcoma that was completely removed (minimum distance to\nposterior cutoff plane 0.5 mm).\n\n[Comment]{.underline}: In view of the present morphology and knowledge\nof the molecular pathological examination results with proven break\nevents in the FUS gene and DDIT3 gene as part of interphase FISH\nanalysis, the diagnosed condition is myxoid liposarcoma.\n\nAccording to the FNCLCC grading scheme, this corresponds to grade 1:\nHistological type: 2 points + mitotic index 1 point + necrosis index 0\npoints = 3 points.\n\nICD-O-3 tumor classification: Myxoid liposarcoma TNM (8th edition): pT2\npNX L0 V0 Pn0 G1 R0\n\n**Medical History:** We assume that you are familiar with Mr. Havers's\nmedical history, and we refer to our previous correspondence.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds.\n\nHeart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys.\n\nNormal peripheral pulses; joints freely movable. Strength, motor\nfunction, and sensation are unremarkable.\n\n**Therapy and Progression**: The patient presented to our surgical\nclinic because of a mass in the right proximal thigh. The swelling was\nfirst noticed about 3 months ago and has increased significantly in size\nsince then. MRI findings raised suspicion of a liposarcoma. After\nconsultation in the interdisciplinary tumor board, the indication for\nincisional biopsy was performed on 03/10/2017. The histopathological\nexamination confirmed the presence of a myxoid liposarcoma, leading to\nthe decision for en bloc excision. The patient was extensively informed\nabout the procedure and the risks and gave his consent. The patient was\nadmitted for the procedure on 03/29/2017.\n\nUpon clinical examination, a patient in good general and nutritional\ncondition was noted. Other general clinical findings were unremarkable.\nA wound healing disorder of 2 cm was observed in the area of the wound\nafter incisional biopsy.\n\n**Sarcoma Tumor Board Recommendation dated 03/11/2017:** R0 G1 finding,\nstandard sarcoma follow-up.\n\n**Procedure**: Following standard preoperative preparations and informed\nconsent, the aforementioned procedure was performed on 03/01/2017 under\ngeneral anesthesia. The intraoperative and postoperative course was\nuneventful.\n\nOn the first postoperative day, there was slight swelling in the\naffected area, which gradually subsided. Analgesia was sufficient with\nAcetaminophen as needed. Thrombosis prophylaxis was administered with\nsubcutaneous Enoxaparin 0.4 mL. The patient mobilized independently on\nthe ward. The inserted drainage could not be removed so far due to\nexcessive drainage output. During the hospital stay, a staging CT of the\nchest and abdomen was performed. No thoracoabdominal metastases were\ndetected.\n\n**Summary**: With a good subjective well-being and unremarkable wound\nconditions, Mr. Havers was discharged on 04/05/2017 for further\noutpatient care. Clinical examination reveals slight swelling of the\nwound area. The wound is not dehiscent and shows no signs of irritation.\nThe patient is mobilizing independently.\n\n**CT Chest/Abdomen/Pelvis from 04/01/2017: **\n\n[Clinical Information, Question, Justification]{.underline}: Liposarcoma\nof the thigh. Staging.\n\n[Technique]{.underline}: Digital overview radiographs. Following\nintravenous contrast agent administration (100 ml Xenetix), CT of the\nchest and entire abdomen in the venous contrast phase. Reconstruction of\nthe primary dataset with a slice thickness of 0.625 mm. Multiplanar\nreconstruction. Total DLP: 885 mGy\\*cm.\n\n[Findings]{.underline}: There are no prior images available for\ncomparison.\n\n[Chest]{.underline}: Lungs are evenly ventilated and normally developed\nbilaterally. No pneumothorax on either side. Minimal right-sided pleural\neffusion. Mild basilar hypoventilation, particularly in the right lower\nlobe. Calcified granuloma in the apical right lower lobe. No suspicious\npulmonary nodules.\n\nHeart shows enlargement of the left ventricle and left atrium. Coronary\nartery sclerosis. Atherosclerosis of the aortic arch. No pericardial\neffusion. Aorta and pulmonary trunk have normal diameters. No central\npulmonary artery embolism. No pathologically enlarged mediastinal or\nhilar lymph nodes. Symmetric appearance of the neck soft tissues.\nThyroid gland without focal lesions. Axillary lymph nodes are of normal\nsize.\n\n[Abdomen]{.underline}: Liver is of normal size and has a smooth contour.\nNo signs of cholestasis. No portal vein thrombosis. No suspicious\nintrahepatic lesions. Gallbladder appears normal. Common bile duct is\nnot dilated. Spleen is not enlarged. Pancreas shows regular lobulation,\nand there is no dilatation of the pancreatic duct. Both kidneys are free\nfrom urinary tract obstruction. No solid intrarenal masses. Few renal\ncysts. Adrenal glands appear unremarkable. Urinary bladder shows no\nfocal wall thickening. Prostate is not enlarged. Advanced\natherosclerosis of the abdominal aorta and pelvic vessels. History of\nstenting of the left external iliac artery with no reocclusion.\nMesenteric, para-aortic, and parailiac lymph nodes are not\npathologically enlarged. No free intraperitoneal fluid or air is\ndetected. Osseous Structures: Degenerative changes in the spine. No\nevidence of suspicious osseous destruction suggestive of tumors. Soft\ntissue mantle appears unremarkable.\n\n**Assessment**: No thoracoabdominal metastases.\n\n**Current Recommendations**:\n\n- Regular wound inspections and dressing changes.\n\n- Documentation of drainage output and removal if the output is \\<20\n ml/24 hours, expected removal on 04/23/2017 at our outpatient\n clinic.\n\n- Removal of sutures is not required for absorbable sutures.\n\n- According to the tumor board decision dated 04/11/2017, we recommend\n regular follow-up according to the schedule.\n\n**Sarcoma Follow-up Schedule Stage I**\n\n- Local Follow-up:\n\n 1. MRI right thigh: Years 1-5: every 6 months\n\n 2. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 3. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 4. Years 6-10: every 12 months in alternation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ -------------------\n Aspirin 100 mg 1-0-0-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Enoxaparin (Lovenox) Variable 0-0-1-0\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Acetaminophen (Tylenol) 500 mg 2-2-2-2 if needed\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------- ---------------------\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.74 mg/dL 0.70-1.20 mg/dL\n Blood Urea Nitrogen 33 mg/dL 17-48 mg/dL\n C-Reactive Protein 1.7 mg/dL \\< 5.0 mg/dL\n Thyroid-Stimulating Hormone 3.58 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 16.5 g/dL 13.5-17.0 g/dL\n Hematocrit 49.3% 39.5-50.5%\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.63 K/µL 3.90-10.50 K/µL\n Platelets 301 K/µL 150-370 K/µL\n Mean Corpuscular Volume 95.7 fL 80.0-99.0 fL\n Mean Corpuscular Hemoglobin 32.0 pg 27.0-33.5 pg\n Mean Corpuscular Hemoglobin Concentration 33.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.4 fL 7.0-12.0 fL\n Red Cell Distribution Width 12.1% 11.6-14.4%\n Activated Partial Thromboplastin Time 32.4 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented to our outpatient surgery clinic on\n04/23/2017.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Medical History:** We kindly assume that you are familiar with the\npatient\\'s detailed medical history and refer to our previous discharge\nletter.\n\n**Current Presentation:** The patient presented today for a follow-up\nvisit in our clinic. He reported no complaints. The Redon drain has not\nproduced any secretions in the last 2 days.\n\nClinical examination revealed uneventful wound conditions with applied\nSteri-strips. There is no evidence of infection. The Redon drain\ncontains serous wound secretions.\n\nProcedure: The Redon drain is being removed today. With nearly fully\nhealed wound conditions, we recommend initiating scar massage with fatty\ntopical products in the near future.\n\n**MRI of the Right Thigh on** 04/23/2017**:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB. Recurrence? Regional behavior? Lymph nodes?\n\n[Technique]{.underline}: 3 Tesla MRI of the right thigh, both plain and\nafter the administration of 8 ml of Gadovist intravenously. Supine\nposition, surface coil.\n\nSequences: TIRM coronal and axial, T2-TSE coronal and axial, T1 VIBE\nDixon axial, EPI-DWI with ADC map axial, T1-Starvibe vascular images\nplain and post-contrast axial with subtraction images, T1-TSE FS\npost-contrast coronal.\n\n[Findings]{.underline}: Minor FLAIR hyperintense streaky signal\nalteration in the surgical area, most likely scar-related, with slight\ndiffusion restriction and streaky contrast enhancement. No evidence of a\nrecurrent suspicious substrate. No nodular contrast enhancement.\nSlightly accentuated inguinal lymph nodes on the right, most likely\nreactive. Unremarkable visualization of the remaining soft tissue.\nNormal bone marrow signal. Bladder filled. Unremarkable representation\nof the imaged pelvic organs.\n\n[Assessment]{.underline}: Following the resection of a myxoid\nliposarcoma on the right medial thigh, there is a regular postoperative\nfinding. No indication of local recurrence.\n\n**Chest X-ray in Two Planes on 04/23/2017: **\n\n[Clinical Background, Question, Justification]{.underline}: Myxoid\nliposarcoma of the right thigh, initial diagnosis in 2022. Follow-up.\nMetastases?\n\n[Findings]{.underline}: No corresponding prior images for comparison.\nThe upper mediastinum is centrally located and not widened. Hila are\nfree. No acute congestion. No confluent pneumonic infiltrate. No\nevidence of larger intrapulmonary lesions. A 7 mm spot shadow is noted\nright suprahilar, primarily representing a vascular structure. No\neffusions. No pneumothorax.\n\n**Current Recommendations:** The patient would like to continue\nfollow-up care with us, so we scheduled an MRI control appointment to\nassess the possibility of local recurrence. On this day, a two-view\nchest X-ray is also required.\n\n**We recommend the following follow-up schedule:**\n\n- Local Follow-up:\n\n 5. MRI right thigh: Years 1-5: every 6 months\n\n 6. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 7. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 8. Years 6-10: every 12 months in alternation\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented for tumor follow-up on 02/10/2018, in our\noutpatient surgery clinic for a discussion of findings.\n\n**Diagnosis**: Myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a regular postoperative finding on the\nright thigh.\n\nThe control MRI with contrast of the right thigh on 04/23/2017 revealed\nmorphologically:\n\n- No evidence of a local-regional recurrence.\n\n- In pulmonary follow-up using conventional chest X-ray on 04/23/2017,\n no signs of pulmonary metastasis were detected.\n\n**Current Recommendations:** Sarcoma Follow-up Schedule Stage I\n\n- Local Follow-up:\n\n 9. MRI right thigh: Years 1-5: every 6 months\n\n 10. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 11. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 12. Years 6-10: every 12 months in alternation\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting to you on our patient Mr. John Havers, born on\n05/29/1953, who presented himself on **08/01/2018** at our outpatient\nsurgery clinic for a discussion of findings as part of tumor follow-up.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a normal postoperative condition in\nthe right thigh.\n\n**MRI of the Right Thigh on 08/01/2018:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh. Progress\nassessment.\n\n[Method]{.underline}: 1.5 Tesla. Localization sequences. TIRM and T2 TSE\ncoronal. TIRM, T2 TSE, VIBE DIXON, and RESOLVE-DWI axial. StarVIBE FS\nbefore and after contrast + subtraction. T1 TSE FS coronal after\ncontrast.\n\n[Findings]{.underline}: Comparison with MRI from 04/23/2017.\nPost-resection of a myxoid liposarcoma in the proximal medial right\nthigh soft tissue. In the surgical area, there is no evidence of a\nsuspicious nodular, contrast-affine lesion, and no evidence of\nmalignancy-suspected diffusion restriction. Slight scar-related changes\nin the access path. Otherwise, unremarkable presentation of soft tissues\nand included bony structures. No inguinal lymphadenopathy. Assessment:\nFor myxoid liposarcoma, there has been consistent evidence since\n02/2018:\n\n**Chest CT on 08/01/2018**:\n\n[Clinical Background, Question, Justification: Liposarcoma on the thigh.\nStaging.]{.underline} After risk history assessment, oral and written\nexplanation of contrast agent application and examination procedure, as\nwell as potential risks of the examination (see also informed consent\nform). Written patient consent.\n\n[Method]{.underline}: Digital overview radiographs. After intravenous\ncontrast agent administration (80 ml of Imeron), CT of the chest in\nvenous contrast phase, reconstruction of the primary dataset with a\nslice thickness of 0.625 mm. Total DLP 185 mGy\\*cm.\n\n[Findings]{.underline}: For comparison, there is a CT of the\nchest/abdomen/pelvis from 04/01/2018. No evidence of suspicious\npulmonary nodules. Several partly calcified micronodules bipulmonary,\nespecially in the right lower lobe (ex. S303/IMA179). Partial\nunderventilation bipulmonary. No pleural effusion. No evidence of\npathologically enlarged lymph nodes. Constant calcified right hilar\nlymph nodes. Calcifying aortic sclerosis along with coronary sclerosis.\nHepatic steatosis. Individual renal cysts. Slightly shrunken left\nadrenal gland. Degenerative changes of the axial skeleton without\nevidence of a malignancy-suspected osseous lesion.\n\n[Assessment]{.underline}: No evidence of a new thoracic tumor\nmanifestation.\n\n**Recommendations:** Sarcoma Follow-up\n\n- Local Follow-up:\n\n 13. MRI right thigh: Years 1-5: every 6 months\n\n 14. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 15. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 16. Years 6-10: every 12 months in alternation\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n RBC 5.2 M/µL 4.3-5.8 M/µL\n WBC 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n International Normalized Ratio (INR) 0.94 0.90-1.25\n Activated Partial Thromboplastin Time (aPTT) 30.1 sec 25.0-38.0 sec\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who was admitted to our clinic from 08/14/2023 to\n09/02/2023.\n\n**Diagnosis:** Pulmonary Metastasis from Myxoid Liposarcoma\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n<!-- -->\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Medical History:** Mr. Havers has been under our care for myxoid\nliposarcoma, which was previously excised from his right medial thigh.\nHe had a stable postoperative course and was scheduled for regular\nfollow-up to monitor for any potential recurrence or metastasis.\n\n**Current Presentation:** During a follow-up appointment on 08/14/2023,\nMr. Havers complained of mild shortness of breath, occasional coughing,\nand intermittent chest discomfort. He reported no significant weight\nloss but noted a decrease in his overall energy levels. Physical\nexamination revealed decreased breath sounds in the right lung base.\n\n**Physical Examination:** Patient in adequate general condition.\nOriented in all aspects. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable. Lungs: Normal chest shape, moderately\nmobile, decreased breath sounds in the right lung base. Heart: Regular\nheart action, normal rate; heart sounds clear, no pathological sounds.\nAbdomen: Peristalsis and bowel sounds normal in all quadrants; soft\nabdomen, markedly obese, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation is unremarkable.\n\n**Chest X-ray (08/14/2023):** A chest X-ray was performed, which\nrevealed a suspicious opacity in the right lower lung field.\n\n**CT Chest (08/16/2023):** In light of the chest X-ray findings, a\ncontrast-enhanced CT scan of the chest was conducted to obtain more\ndetailed information. The CT imaging demonstrated a well-defined,\nirregularly shaped lesion in the right lower lobe of the lung, measuring\napproximately 2.5 cm in diameter. The lesion exhibited characteristics\nhighly suggestive of a metastatic deposit. There were no other\nsignificant abnormalities noted in the chest.\n\n**Histology (08/21/2023):** Based on the CT findings, a CT-guided core\nneedle biopsy of the pulmonary lesion was performed to confirm the\nnature of the lesion. Histopathological examination of the biopsy\nspecimen confirmed the presence of myxoid liposarcoma cells in the\npulmonary lesion. Immunohistochemical staining for MDM2 and CDK4\nsupported the diagnosis of metastatic myxoid liposarcoma.\n\n**Treatment Discussion:** Given the diagnosis of a pulmonary metastasis\nfrom myxoid liposarcoma, the case was reviewed in the interdisciplinary\ntumor board. The consensus decision was to pursue surgical resection of\nthe pulmonary metastasis, as it remained localized and resectable. The\npatient and his family were informed of the treatment options and\nassociated risks, and they provided informed consent for the procedure.\n\n**Surgery Report (08/29/2023):** Mr. Havers underwent a right lower\nlobectomy with lymph node dissection to remove the pulmonary metastasis.\nThe procedure was performed by our thoracic surgery team and was\ncompleted without any immediate complications. Intraoperative frozen\nsection analysis confirmed the presence of metastatic myxoid liposarcoma\nin the resected lung tissue.\n\n**Postoperative Course:** Mr. Havers postoperative course was\nuneventful, and he demonstrated good respiratory recovery. He was\nmanaged with adequate pain control and underwent chest physiotherapy to\nprevent postoperative complications. Pathological examination of the\nresected lung tissue confirmed the presence of metastatic myxoid\nliposarcoma, with clear surgical margins.\n\n**Current Recommendations:**\n\n1. **Follow-up:** A strict follow-up plan should be established for Mr.\n Havers to monitor for any potential recurrence or new metastatic\n lesions. This should include regular clinical assessments, chest\n imaging, and other relevant investigations.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n --------------------- ------------- ---------------------\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 39 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.5 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.6 g/dL 13.5-17.0 g/dL\n Hematocrit 49.4 % 39.5-50.5 %\n RBC 5.1 M/µL 4.3-5.8 M/µL\n WBC 10.04 K/µL 3.90-10.50 K/µL\n Platelets 166 K/µL 150-370 K/µL\n MCV 95.2 fL 80.0-99.0 fL\n MCH 32.6 pg 27.0-33.5 pg\n MCHC 33.2 g/dL 31.5-36.0 g/dL\n MPV 11.4 fL 7.0-12.0 fL\n RDW-CV 12.5 % 11.5-15.0 %\n Prothrombin Time 122 % 78-123 %\n INR 0.99 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/18/2018 to\n03/01/2018.\n\n**Diagnoses: **\n\n- Malignant melanoma of the left scapula, TD 16 mm, exophytic\n ulcerating, invasion stage - III, R0\n\n- **Mutation analysis:** BRAF status: mutated. PD-L1 status: PD-L1\n tumor proportion score (TPS): \\<1%. Immune cell infiltrate (IC): 2%\n of tumor area. PD-L1 combined-positive score (CPS): 2.\n\n- **History:** Ms. Done was admitted to the hospital with high grade\n suspicion of malignant melanoma of the back. The patient reported a\n skin lesion that had been present for approximately 4 weeks. The\n lesion had grown rapidly during this time and appeared to be oozing\n and bleeding. She presented to our outpatient clinic, where she was\n advised to undergo surgical excision in case of suspected\n malignancy.\n\n- Questions about B-symptoms, AP complaints, stool or urine\n abnormalities were negated.\n\n- System Therapy (Adjuvant Treatment for Stage III Melanoma): 1\n\n02/22/18: 1st dose pembrolizumab 200mg\n\n03/15/18: 2nd dose Pembrolizumab 200mg\n\n04/05/18: 3rd dose Pembrolizumab 200mg\n\n04/26/18: 4th dose Pembrolizumab 200mg\n\n05/17/18: 5th dose Pembrolizumab 200mg\n\n06/07/18: 6th dose Pembrolizumab 200mg\n\n06/28/18: 7th dose Pembrolizumab 200mg\n\n07/19/18: 8th dose Pembrolizumab 200mg\n\n08/09/18: 9th dose Pembrolizumab 200mg i.v.\n\n**Physical examination findings:** 52-year-old female patient in normal\ngeneral condition, nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement normal. Pupils are equal and\nreactive to light and accommodation. Regular, normocardial heart rate\nduring recording. Cor and pulmo auscultatory and percutaneously\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall, liver\nand spleen not enlarged, no pain to palpation, no resistance to\npalpation, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged cervical, submandibular, supra- and infraclavicular, axillary\nand inguinal lymph nodes palpable. inguinal lymph nodes palpable.\nFurther internal and orienting neurological examination neurological\nexamination remained without pathological findings.\n\n**Skin findings:** In the area of the left scapula, a table tennis-ball\nsized area with a slightly fissured, oozing, pink-black pigmented\nsurface. On the cranial side an irregularly black-brown pigmented macula\nof about 3.2x1.2 cm is visible.\n\n**PET/CT with 203 MBq (F-18)-Fluorodeoxyglucose from 02/18/2018: **\n\nWeight: 66 kg, blood glucose: 118 mg/dL. 20 mg furosemide; acquisition\nstart 91 min after tracer injection; 821 mm scan length á () mm/s in\nflow technique (neck to proximal thigh); oral and i.v. contrast (1.5\nmL/kg, i.v., max. 120 mL). Quantitative analysis of\nattenuation-corrected image data using SUV calculation.\n\n**Findings:**\n\nCT: In case of known contrast agent allergy, premedication was performed\nwith one ampoule each of H1 and H2 antihistamine. The contrast-enhanced\nexamination proceeded without complications during the course.\n\nNeck: Symmetrical visualization of the soft tissues of the neck. No\nevidence of pathologically enlarged cervical lymph nodes. Struma nodosa\nwith several hypodense nodes on the right side up to max. approx. 1 cm.\n\nThorax: Cutaneous/subcutaneous irregular-shaped lesion caudal to the\nright scapula. Limited assessability in the lung window with motion\nartifacts and shallow inspiration depth. As far as assessable, no\nevidence of larger suspicious intrapulmonary pulmonary round foci. No\ninfiltrate. No pleural effusion. No evidence of pathologically enlarged\nlymph nodes mediastinal, hilar and axillary bilaterally.\n\nAbdomen/pelvis: Normal contrast of liver parenchyma without evidence of\nsuspicious focal liver lesions. Portal vein and hepatic veins perfused\nregularly. Gallbladder without irritation. Spleen with accessory spleen,\npancreas and adrenal glands bds. regular. Kidneys perfused at the same\nside. No urinary retention. Nephrolithiasis on the right side.\nVisualization of the parenchymatous upper abdominal organs. No evidence\nof pathologically enlarged coeliacal, mesenteric, retroperitoneal,\niliac, and inguinal lymph nodes. Inhomogeneously contrasted enlarged\nprostate. Urinary bladder wall, as far as assessable with low filling\ncircumferentially wall thickened.\n\nSkeleton: no evidence of suspicious osteodestructive lesions. Osteopenia\nwith degenerative skeletal changes.\n\nPET:\n\nIncreased tracer enhancement of the suspicious lesion caudal to left\nscapula, indicative of a melanoma (SUVmax 67). Focal intense tracer\nenhancement in the right thyroid lobe (SUVmax approximately 7.9).\nElongated intense tracer enhancement in the lower abdomen ventrally\nmedian without clear correlate, most consistent with contamination.\nOtherwise, unremarkable activity distribution in the study area.\n\nAssessment:\n\nNo evidence of metabolically active metastases in the study area.\n\n**Operation report from** **02/22/2018**:\n\nProcedure: Excision of malignant melanoma on the left upper back.\n\nPreoperative Diagnosis: Malignant melanoma, left upper back.\n\nPostoperative Diagnosis: Malignant melanoma, left upper back.\n\nAnesthesia: Local anesthesia using 70 mL tumescent solution comprising\n0.21% Lidocaine/Ropivacaine with epinephrine.\n\nProcedure Details: The surgical area was prepped using Betadine. The\narea was draped in a sterile fashion. Excision of the exophytic tumor\nwas performed, measuring 51 x 20 x 15 mm. A safety margin of 10 mm was\nmaintained in depth, with the excision extending slightly into the\nsubcutaneous tissue but not beyond the fascia. This resulted in a total\ndefect size of 75 x 45 mm. The defect could not be closed with a simple\nprimary suture. Perforator vessels were coagulated, and the defect was\nbridged using skin flaps. Additional resection of Burow triangles was\ndone according to aesthetic units. The wound was closed using an\nintracutaneous suture technique. A continuous overhand blocked suture\nwas used with 3-0 Vicryl. The patient was advised that the visible\nsuture material could be removed between postoperative days 14 and 16. A\ndressing was applied, followed by a pressure dressing to minimize\nswelling and promote healing. Comments: The patient tolerated the\nprocedure well and was provided postoperative care instructions.\n\nPlan: Follow up in clinic for suture removal and wound assessment\nbetween postoperative days 14 and 16.\n\n**Histology Dermatohistology:** **02/23/2018.**\n\n**Gross Examination:** A roughly oval excision specimen measuring 48 x\n36 x 14 mm. The specimen is serially sectioned into lamellar stages A\nthrough H (8 cassettes).\n\n**Microscopic Examination:**\n\nStage A: Displays a benign epidermis and dermis without evidence of\nmelanocytic tumor cells.\n\nStage B: Features an irregularly thickened epidermis. At the center of\nthe section, melanocytic tumor cells are observed at the dermoepidermal\njunction (positive for MelanA stain). Additionally, abundant\nmelanophages and pigment deposits are noted. The lateral safety margin\nmeasures at least 8 mm.\n\nStage C: Resembles stage B. Atypical melanocytic tumor cells are present\nat the dermoepidermal junction. Upper dermis displays fibrosis,\ninflammation, and numerous melanophages (confirmed by positive MelanA\nstaining). The lateral safety margin is at least 6 mm.\n\nStage D: Central region shows melanocytic tumor cells in both the\nepidermis and upper dermis. There is significant inflammation,\nmelanophages, and pigment deposition (confirmed by MelanA staining).\n\nThe maximum lateral safety margin here is approximately 8 mm. A small\nlymph node in the subcutaneous fat tissue is also seen, infiltrated by\nmelanocytic tumor cells.\n\nThe tumor shows stages E, F, G and H: Exophytic, bovist-like growing\nulcerated hemorrhagic tumor consisting of completely pleomorphic tumor\ncells. These cells vary in morphology, appearing both nested and\nspindle-shaped, with clear cytoplasm and conspicuous nucleoli. Notable\npigment production is observed, as are numerous atypical mitoses.\nControl staining in stage F with MelanA is completely positive. The\nsections are entirely excised.\n\n**Diagnosis:** Exophytic, ulcerated malignant melanoma with a tumor\nthickness of at least 15 mm. The tumor invasion is categorized as stage\nIII.\n\n**Medication upon discharge: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ----------------------------------------- --------------- -------------- ------------------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Oral Once daily in the morning\n Enoxaparin (Lovenox) 0.2 mL Subcutaneous In the evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Oral Morning and evening\n Leuprorelin (Lupron Depot) 3.75 mg Depot Subcutaneous Every 4 weeks\n Fentanyl Transdermal System (Duragesic) 12 μg/hr Transdermal Changed every 3 days\n Pantoprazole (Protonix) 40 mg Oral Once daily in the morning\n Sevelamer (Renagel) 800 mg Oral Once daily in the morning\n Multivitamin One tablet Oral Once daily in the morning\n Torsemide (Demadex) 200 mg Oral Once daily in the morning\n Cholecalciferol (Dekristol) 20,000 IU Oral Once weekly\n Sodium Bicarbonate (Bicanorm) One tablet Oral Once daily in the morning\n Calcitriol (Rocaltrol) 0.25 μg Oral Once daily in the morning\n Valacyclovir (Valtrex) 500 mg Oral Half-tablet daily in the morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Oral Mornings on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Oral In the morning on day 1 and day 2 following daratumumab administration\n\n\n\n### text_1\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 10/23/2020 to\n11/01/2020.\n\n- Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\n according to UICC.\n\n- Therapies to date:\n\n- Resection of primary tumor (malignant melanoma) on the left upper\n back (02/2018)\n\n- 01/20 Microsurgical resection right frontal tumor\n\n- 02/20 Excision of empyema\n\n- 02-03/20: Radiation therapy\n\n- 05/02/20: Start of immunotherapy with Nivolumab & 05/26/20: Start of\n combination immunotherapy 60 mg nivolumab, 200 mg ipilimumab (-\\>\n drug exanthema)\n\n**Physical examination findings: **\n\nOn admission, the patient was awake and adequately oriented. Height:\n166cm, weight: 56kg. Nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement regular. Pupils equal, pupillary\nreflex responsive to accommodation and light. Regular, normocardial\nheart rate on admission. Heart and lung: auscultatory and percutaneous\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall Liver\nand spleen are not enlarged, no tenderness, no rebound palpable.\nResistences palpable, loud bowel sounds. No enlarged No enlarged\ncervical, submandibular, supra- and infraclavicular lymph nodes\npalpable. **Skin findings:** Pronounced xerosis cutis, raised skin\nfolds, some with erythema and fine lamellar scale and fine lamellar\nscale, especially on the arms and face. **Microbiology:** Nasal swab:\nnormal flora, no MRSA. Throat swab: Normal flora, no MRSA Virology:\n10/23/2020: No detection of SARS-CoV-2 by PCR in the submitted material.\n\n**Therapy and Progression:**\n\n**Summary:** The patient presented with exsiccation eczema on the arms,\nlegs, and face.\n\n**Treatment Details:** Topical Treatment for Eczema: Applied Desonide\nCream once daily to the affected areas. For maintenance, applied Eucerin\nCream daily to the body and a moisturizing ointment like Cetaphil to the\nface.\n\n**Antipruritic Treatment:** Prescribed Benadryl tablets, to be taken as\nneeded.\n\n**Oncology Consultation:** The patient was educated by our oncologist,\nDr. Ex, regarding adjuvant therapy options. The potential benefits and\nrisks of a combination immunotherapy with Nivolumab and Ipilimumab were\ndiscussed. The patient had already started Nivolumab 200 mg therapy on\n05/26/2020.\n\n**Incident on 10/28/2020**: The patient had an unattended fall,\nresulting in a hematoma on the left forehead. An emergency CT scan\nshowed no new fractures or acute hemorrhage but confirmed the presence\nof previously known cystic metastasis.\n\n**Operation report (01/02/2020): **\n\n**Diagnosis:** Hemorrhaged right frontal metastasis from previously\ndiagnosed malignant melanoma (ID 2018)\n\n**Procedure:** Microsurgical resection of right frontal mass with\nintraoperative neuromonitoring (MEPs stable) and neuronavigation via a\nleft frontolateral craniotomy.\n\nTime: 10:34 am Closure Time: 1:04 pm. Total Duration: 2 hours 30 minutes\n\n**Preoperative Evaluation:** Imaging identified a hemorrhage in the\nright frontal lobe. Given the patient\\'s history of malignant melanoma,\na hemorrhagic melanoma metastasis was suspected. No other intracranial\nmetastases were detected. The patient and their family were informed of\nthe surgical benefits and risks. After ample time for consideration and\nquestions, written informed consent was obtained.\n\n**Procedure Details:** The patient was positioned supine and intubated.\nThe head was secured in a Mayfield clamp and rotated 60° to the right.\nThe navigation dataset was reviewed. Using the navigation system, a left\nfrontotemporal craniotomy was planned. An arcuate incision line was\ndrawn. The surgical area was shaved, cleaned, and sterilized.\nProphylactic antibiotics and mannitol were administered. A time-out was\nconducted preoperatively. The skin was incised, and Raney clips were\ninserted. The left temporal muscle was split. Using the navigation\nsystem for guidance, a left frontolateral craniotomy was performed. The\nbone flap was carefully removed and preserved in an antibiotic solution\nfor later reimplantation. The dura mater was opened, and the operating\nmicroscope was introduced. Upon inspection, the tumor was evident.\n\n**MRI brain report (01/04/2020): **\n\n**Clinical Information:** Postoperative assessment following\nmicrosurgical resection of a left frontal hemorrhaged metastasis from\npreviously diagnosed malignant melanoma.\n\n**Technique:** Multiplanar, multisequence MRI of the brain, including\nT1-weighted, T2-weighted, FLAIR, diffusion-weighted imaging (DWI), and\npost-contrast T1-weighted sequences.\n\n**Findings:** There is evidence of a right frontotemporal craniotomy\nwith associated post-surgical changes in the right frontal region.\nTitanium plates and screws are noted securing the bone flap, causing\nminimal artifact. The previous tumor site in the right frontal lobe\nshows post-surgical changes with a well-circumscribed cavity. There is\nno evidence of residual enhancing tumor within this cavity on\npost-contrast sequences, suggesting complete resection. Surrounding this\ncavity, there\\'s mild edema, consistent with expected post-operative\nchanges. No other intracranial metastases. The ventricles are of normal\nsize and symmetric. There is no evidence of hydrocephalus. No midline\nshift or mass effect is observed. There are scattered foci of\nsusceptibility artifact in the surgical bed on gradient echo sequences,\nconsistent with expected postoperative blood products. Major\nintracranial vessels appear patent with no evidence of vascular\nocclusion or significant stenosis. The remaining brain parenchyma\nappears normal in signal intensity and morphology on all sequences. No\nother significant abnormalities are identified.\n\n**Impression:** Post-surgical changes in the left frontal lobe\nconsistent with recent tumor resection. There is no evidence of residual\ntumor in the surgical bed. Expected postoperative edema and blood\nproducts adjacent to the resection site. No new metastatic foci\nidentified. No evidence of complications such as hydrocephalus, midline\nshift, or vascular abnormalities.\n\n**Operation report (02/04/2020): **\n\n**Diagnosis:** Subfascial, epidural, and subdural empyema following\nresection of right frontal metastasis for malignant melanoma.\n\n**Procedure:** Empyema removal (subfascial, epidural, subdural) S\nIncision Time: 15:23 Closure Time: 04:01 PM Total Duration: 2 hours 31\nminutes\n\n**Preoperative Evaluation:** The patient had a prior surgical resection\nof a right frontal metastasis due to known malignant melanoma. On a\nrecent outpatient visit, a cerebrospinal fluid (CSF) cushion was\nidentified and punctured, revealing the presence of pathogens. Imaging\nindicated deep and subcutaneous abscesses, necessitating revision\nsurgery. The patient was adequately informed about the procedure,\nunderstood the associated risks, and provided written consent.\n\n**Procedure Details:** The patient was positioned supine with the head\nrotated approximately 60° in a Mayfield clamp. The surgical area was\nwashed and sterilized, focusing on the pre-existing access point. A team\ntime-out was conducted. Perioperative antibiotics were withheld until\nall samples for microbiology were obtained. The skin was incised,\nrevealing multiple layers of muscle. These were carefully dissected,\nleading to the identification and evacuation of the subcutaneous\nepifascial abscess. Infected muscle tissue and abscess walls were\nresected. The skull flap appeared loosened. A miniplate was removed, and\nupon further inspection, the dura mater appeared strained. It was\nincised and revealed turbid fluid, indicating a deep abscess. The dura\nmater was mobilized, though adherence to the cortex was observed around\nthe resection cavity, suggesting possible tumor regrowth. Affected areas\nwere carefully resected. After thorough irrigation, a drainage system\nwas inserted into the resection cavity. A duraplasty was performed,\nfollowed by the reimplantation of the bone flap using a miniplate. The\npatient was also included in a bone flap study and was randomized for\nflap reimplantation. After further irrigation, the wound was\nmeticulously closed, and a subfascial drain was inserted. The final\nclosure was completed with single button sutures. Under the guidance of\nthe operating microscope, the tumor was meticulously dissected from the\nsurrounding healthy tissue. Special care was taken to minimize damage to\nthe surrounding brain structures. The intraoperative neuromonitoring\nindicated stable MEPs throughout, suggesting that motor pathways\nremained undisturbed during the procedure. Throughout the resection,\nperiodic hemostasis was achieved using bipolar electrocautery to control\nbleeding. Following the complete resection of the tumor, the surgical\ncavity was irrigated with sterile saline to remove any residual debris.\nThe integrity of the surrounding brain tissue was assessed, and no\nimmediate complications were observed. The dura mater was sutured,\nensuring a watertight closure. A synthetic dural graft was used to\nreinforce the suture line. The preserved bone flap was reimplanted and\nsecured in place using titanium plates and screws. The temporal muscle\nand soft tissues were reapproximated and sutured in layers. The skin was\nclosed using a combination of absorbable sutures for the subcutaneous\nlayer and non-absorbable sutures for the skin. Sterile dressings were\napplied to the incision site. Postoperative Assessment: The procedure\nwas completed without complications. Immediate postoperative\nneurological examination revealed no new deficits. The patient was\ntransferred to the recovery room in stable condition, awaiting\nextubation by the anesthesiology team.\n\n**Recommendations:** Close monitoring in the neurological intensive care\nunit (NICU) is advised for the first 24 hours. Postoperative imaging,\ntypically an MRI, should be scheduled within the next 48 hours to assess\nthe extent of tumor resection and to rule out any postoperative\ncomplications.\n\n**Summary:** Mrs. Done\\'s recent hospital course was complicated by the\ndetection and subsequent excision of a hemorrhagic metastasis from a\nknown history of malignant melanoma. She continues to be on targeted\ntherapy with close monitoring. No new metastasis or recurrence has been\ndetected as of the last evaluation. The interdisciplinary approach\ninvolving the neurosurgery and oncology teams has been pivotal in her\nmanagement. Given the aggressive nature of melanoma, regular\nsurveillance and immediate action upon detection of new\nlesions/metastasis are paramount for her prognosis.\n\n**02-03/20: Radiation therapy **\n\nDiagnosis: Metastatic malignant melanoma with a focus on the right\nfrontal metastasis. Technique: Stereotactic radiosurgery (SRS) using a\nlinear accelerator (LINAC). Fractionation: Given the aggressive nature\nof malignant melanoma, a hypofractionated regimen was adopted. The\npatient underwent five sessions, each delivering a dose of 6 Gy for a\ncumulative total dose of 30 Gy.\n\nTreatment Planning: A simulation CT scan with a 1mm slice thickness was\nperformed in the treatment position, with a thermoplastic mask for\nimmobilization. The treatment planning system utilized the simulation\nCT, along with MRI for better tumor delineation. The target volume and\ncritical structures like the eyes, optic nerves, chiasm, and brainstem\nwere contoured. The radiation plan was optimized to ensure maximal dose\nto the target while sparing the critical structures.\n\nProcedure: At each session, patient positioning was verified using\ncone-beam CT (CBCT) to ensure precise targeting. Real-time monitoring\nwas employed to account for any intrafraction motion.\n\nSide Effects: The patient tolerated the treatment well. She reported\ntransient fatigue and mild scalp irritation, which resolved with\nconservative measures. No acute radiation-induced neurotoxicity was\nobserved.\n\n**Patient History Update: Mrs. Jane Done (DOB: 01/01/1966)**\n\n**General Status (10/03/2020):**\n\nMrs. Done presented in stable condition with stable vital signs.\nNeurologically, she\\'s intact with no new focal deficits. The surgical\nscars in the frontal region from previous operations are not fully\nhealed and there is some dehiscence and swelling, indicative of\ninfection. This wound complication can be traced back to her previous\nhistory of an empyema which required surgical intervention.\n\n**Dermatological Assessment:**\n\nThe previous exsiccation eczema, prominent on her arms, legs, and face,\nhas improved markedly. The treatment regimen involving consistent\nmoisturization and targeted topical therapies seems effective.\nImportantly, there were no new suspicious skin lesions or nodules noted\nduring her most recent full-body skin check.\n\n**Oncology Status:**\n\nMrs. Done remains on her immunotherapy regimen, specifically the\ncombination of Nivolumab and Ipilimumab. Her response has been positive,\nwith no new metastatic sites identified in the latest assessments. She\nhas displayed commendable compliance with this regimen and regular\nfollow-up evaluations.\n\n**Recent MRI Brain (09/30/2020):**\n\nHer latest multiplanar, multisequence MRI revealed post-surgical\nalterations in the right frontal lobe, consistent with previous\nobservations. Encouragingly, there was no sign of any residual or\nrecurrent tumor activity. Moreover, the MRI did not show any new\nintracranial metastatic sites or other significant abnormalities.\n\n**Thoracic CT Scan (10/01/2020): **\n\nTechnique: Post complication-free bolus i.v. administration of Imeron\n400, a multiline spiral CT was performed through the thorax during the\nvenous contrast phase, supplemented with thin-section, coronary, and\nsagittal secondary reconstructions.\n\nFindings: Multiple roundish subsolid nodules found bipulmonary, notably\na 4mm nodule in the right upper lobe. Blurred subpleural condensations\nin the left upper lobe. Another blurred bronchus-associated\nconsolidation was observed in the left upper lobe and pleurally in the\nleft dorsal lower lobe. No evidence of pathologically enlarged lymph\nnodes in the hilar, mediastinal, or axillary regions. Unchanged\npresentation of the left adrenal gland from the preliminary examination.\nThickened imprinting of the gastric wall noted. Ventrally emphasized\nspondylophytic attachments observed in the thoracic spine. No\nosteodestructive processes detected.\n\n**Impression:** Presence of multiple subsolid pulmonary nodules;\nrecommended follow-up in 4-6 weeks for potential (post-) inflammatory or\nmalignant genesis. No evidence of pathologically enlarged lymph nodes.\n\n**Abdomen/Pelvis CT Scan (10/01/2023): **\n\nTechnique: A low dose CT scan was taken of the abdomen and pelvis.\n\n**Findings:** Regular visualization of the acquired basal lung sections.\nOrthotopic kidneys without urinary stasis. No evidence of urinary\ncalculi. Suspected uterine fibroids attached to the uterus wall.\nEnlarged right ovary with minor calcifications. Assessment: Absence of\nurinary calculi. Possible uterine fibroids and an enlarged right ovary,\nsuggesting a specialized gynecological examination.\n\n**PICC Line Installation (10/02/2020)**\n\n**Diagnosis:**\n\nHome antibiotics required for wound healing disorder following discharge\ndue to an empyema.\n\n**Type of Surgery:**\n\nInstallation of a PICC line in the left basilic vein.\n\n**Anesthesia:**\n\nLocal anesthesia\n\n**Procedure Details:**\n\nThe patient was presented for long-term antibiotic treatment due to a\nwound healing disturbance post the discharge of an epidural abscess. The\nprimary aim was to apply a PICC-line catheter for the antibiotic\nregimen. A written informed consent was duly obtained prior to the\nprocedure.\n\nThe standard procedure began with the washing off and draping of the\npatient. A preoperative sonography of the arm veins was conducted. Based\non the sonographic results, it was decided to insert the catheter via\nthe left basilica vein.\n\nUnder venous congestion and following local anesthesia with 2mL Mecain,\na 2mm skin incision was made. The sonographically guided puncture was\nperformed successfully. Post this, the peel-away sheath was inserted.\nWith the wire in place, the catheter was advanced with its tip\npositioned approximately 2cm below the carina. The wire was subsequently\nremoved. Following this, the catheter was aspirated and flushed with\nNaCl to ensure its patency. A sterile fixation was then applied, and the\nwound was dressed.\n\n**Notes:**\n\nNo complications were observed during the procedure. The patient was\nadvised on the care and maintenance of the PICC line. Regular follow-ups\nare recommended to monitor the wound healing and the effectiveness of\nthe antibiotic treatment.\n\nThe patient was discharged with instructions and is scheduled for a\nfollow-up in two weeks.\n\n**Additional Therapeutic Engagements:**\n\nFor her overall well-being and to counter the side effects of her\ntreatment journey, Mrs. Done has been actively involved in physical\ntherapy sessions. These sessions focus on enhancing her strength and\nbalance, especially given the previous incident of an unattended fall.\nTo address the inevitable psychological strains of her diagnosis, she\nhas also been attending counseling sessions.\n\n**Current Recommendations:**\n\n-Continue the ongoing immunotherapy without changes.\n\n-Dermatological check-ups every month are advised for early detection of\nany potential skin abnormalities.\n\n-Regular neurological evaluations are crucial to ensure no emergence of\nnew deficits.\n\n-Imaging should be scheduled every six months for proactive monitoring.\n\n-Her physical therapy regimen should be ongoing to maintain and improve\nmobility.\n\n-Continue counseling to support her emotional and psychological\nwell-being.\n\n**Summary and Notes:**\n\nMrs. Done\\'s resilience and adherence to her treatments are commendable.\nHer progress is a testament to the integrated care approach she has been\nreceiving. Maintaining a proactive surveillance stance will be essential\nfor her long-term prognosis and quality of life.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe wish to provide an update regarding our mutual patient, Mrs. Jane\nDone, born on 01.01.1966. She was admitted to our clinic from 11/23/2020\nto 12/01/2020.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done presented for a follow-up visit on 11/23/2020. Over the past\nfew months, she reported fatigue and intermittent bouts of nausea. Of\nsignificant concern were newly identified skin changes located on her\nright arm.\n\n**Clinical Findings:**\n\nSkin: Multiple macules and patches on the right arm, the largest\nmeasuring about 1.5cm in diameter, hyperpigmented with irregular\nborders.\n\n**US: **\n\nUltrasound imaging of the right arm revealed no deep extension or\ninvasion of underlying structures. This preliminary assessment was\ncrucial, suggesting that if malignancy is present, it might be in early\nstages.\n\n**Histology: **\n\nHistological examination: Gross Description: The sample consists of\nmultiple tan-pink soft tissue fragments, aggregating to 1.8 cm in the\ngreatest dimension.\n\nMicroscopic description: Sections show a proliferation of atypical\nmelanocytes arranged in nests and as single units at the dermoepidermal\njunction. Some of these cells infiltrate the papillary dermis.\n\nImmunohistochemistry: The atypical cells are positive for HMB-45 and\nS-100. Melan A is focally positive. Ki-67 proliferation index is about\n10%.\n\nFinal Diagnosis: Dysplastic nevus with severe atypia; margins appear\nclear. Further excision is recommended to ensure complete removal and to\nrule out invasive melanoma.\n\n**Lab results: **\n\nComplete Blood Count (CBC):\n\nHemoglobin: 12.3 g/dL (Normal range: 12-16 g/dL)\n\nWhite Blood Cell Count: 6,200 cells/µL (Normal range: 4,000-11,000\ncells/µL)\n\nPlatelet Count: 290,000 cells/µL (Normal range: 150,000-450,000\ncells/µL)\n\nDifferential:\n\nNeutrophils 65%, Lymphocytes 25%, Monocytes 8%, Eosinophils 2%. B.\n\nLiver Function Tests (LFTs):\n\nALT (Alanine Aminotransferase): 40 U/L (Normal range: 7-56 U/L)\n\nAST (Aspartate Aminotransferase): 38 U/L (Normal range: 10-40 U/L)\n\nALP (Alkaline Phosphatase): 90 U/L (Normal range: 44-147 U/L)\n\nTotal Bilirubin: 1.0 mg/dL (Normal range: 0.1-1.2 mg/dL)\n\nAlbumin: 4.2 g/dL (Normal range: 3.4-5.4 g/dL)\n\nAssessment/Recommendations:\n\nGiven her history and the suspicious nature of the new skin changes, we\nhave decided to send the biopsy for urgent histological assessment.\n\nFurthermore, considering her reported symptoms, we have conducted a\nthorough internal check-up, including blood tests and liver function\ntests, to rule out any systemic side effects of the immunotherapy.\n\nWe recommend continuous monitoring of Mrs. Done's condition and kindly\nrequest your valuable input in managing her case optimally. A\nmultidisciplinary approach, given her complicated medical history, will\nbe most beneficial for the patient.\n\nPlease find attached the detailed examination and investigative reports\nfor your reference.\n\nWith kind regards,\n\n\n\n### text_3\n**Dear colleague, **\n\nWe wish to provide a comprehensive update regarding our mutual patient,\nMrs. Jane Done, born on 01.01.1966. She has had a history of various\nmedical conditions and treatments, which we believe is essential to\ndiscuss for her optimal management and was admitted to our clinical from\n01/01/2021 to 01/28/2021.\n\n**Previous Diagnoses and Therapies:**\n\nMetastatic malignant melanoma (presumed ID 2018); M1, stage IV according\nto UICC. Resection of primary tumor (malignant melanoma) on the left\nupper back (02/2018)\n\n01/20 Microsurgical resection right frontal tumor\n\n02/20 Excision of empyema\n\n02-03/20: Radiation therapy\n\n05/02/20: Start of immunotherapy with Nivolumab\n\n05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\nImaging 01/02/2021: PET/CT: Cervical lymph node metastasis;\n\ncMRI: no evidence of metastases. Contrast-enhancing meninges.\n\n**Virology: **\n\nUpon Admission: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load\nof 7,000 Geq/mL and a Ct value of 32.\n\nAt Discharge: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load of\n2,350 Geq/mL and a Ct value of 32.\n\n**Microbiology: **\n\nMRSA Screening Upon Admission: Nasal Swab: Normal flora detected; MRSA\nnot present. Throat Swab: Normal flora detected; MRSA not present.\n\nProcedures:\n\n\\- Presentation to neurology for CSF puncture (e.g., exclude\nmeningeosis)\n\n\\- Panel sequencing complement\n\n\\- Surgery/therapy: Neck dissection followed by adjuvant therapy with\npembrolizumab.\n\nClinical examination:\n\nExamination findings: Patient in normal general and nutritional\ncondition, consciousness unremarkable. Cranial mobility free, ocular\nmobility normal. Pupils are isocor, pupillary reflex prompt to\naccommodation and light. Regular, normocardial heart rate on admission.\nNo typical heart murmurs. Abdomen: abdominal wall soft, liver and spleen\nnot enlarged, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged in the axillary or inguinal region palpable.\n\nPET-CT from 01/02/2021:\n\nIntense metabolically active lymph node metastases, otherwise no\nevidence of vital tumor tissue in the study area.\n\n**PET CT report from 01/02/2021: **\n\nProcedure: PET/CT with 246 MBq (F-18)-fluorodeoxyglucose and a 60-minute\nuptake period.\n\nFindings: CT Findings: Neck: Right Level II: Three lymph nodes, largest\nmeasuring 2.1 x 1.8 cm with central necrosis. Right Level III: Two lymph\nnodes, largest measuring 1.5 x 1.2 cm. Left Level II: One lymph node\nmeasuring 1.3 x 1.1 cm. Left Level IV: Two lymph nodes, largest\nmeasuring 1.7 x 1.4 cm. Retropharyngeal space: One lymph node measuring\n1.0 x 0.9 cm.\n\nPET Findings: Neck: Right Level II: Increased FDG uptake with SUVmax of\n7.8, consistent with metastatic disease. Right Level III: Increased FDG\nuptake with SUVmax of 6.5. Left Level II: Increased FDG uptake with\nSUVmax of 6.0. Left Level IV: Increased FDG uptake with SUVmax of 7.2.\nRetropharyngeal space: Increased FDG uptake with SUVmax of 6.1.\nImpression: Cervical Lymph Nodes: Multiple pathologically enlarged\ncervical lymph nodes in bilateral level II, right level III, left level\nIV, and retropharyngeal space with increased FDG uptake, highly\nsuggestive of metastatic involvement from the known primary melanoma.\n\n**Surgery report 01/05/2021: **\n\nThe surgery commenced with a collaborative discussion with the\nanesthesia team and a standard team time-out was executed. The patient\nwas properly positioned, and the surgical site was aseptically draped.\nThe facial neuromonitoring system was set up and verified. Local\nanesthesia was then administered at the site of the skin incision, which\nwas located near the previous scar. This incision followed the anterior\nborder of the sternocleidomastoid muscle in a curved pattern. Upon\nincising the subcutaneous tissue, the external jugular vein became\nvisible and was selectively ligated. The encountered tissue appeared\nnotably fibrotic and scarred. A skin incision extended from the mastoid\nregion down nearly to the clavicle. The platysma muscle was subsequently\ncut. Due to the presence of a lymph node mass, the auricularis magnus\nnerve had to be severed. The sternocleidomastoid muscle and the\nposterior belly of the digastric muscle were then exposed. Multiple\ndarkened lymph node metastases were identified, both beneath the skin\nand within the sternocleidomastoid muscle. In subsequent steps, efforts\nwere made to distinguish the internal jugular vein from the surrounding\nscarred tissue. A lymph node mass, which exhibited characteristics\nhighly suggestive of metastasis (given its darkened color), was removed.\nThe accessory nerve was identified and preserved. Further dissection was\ndone posteriorly to the sternocleidomastoid muscle, in the direction of\nlevel V. An expansive mass of lymph nodes was excised in this region.\nThe trapezoid branch of the accessory nerve was visualized, and its\nfunction was monitored and preserved with the aid of neuromonitoring.\nThe removed lymph node mass, some excised tissue, and portions of the\nsternocleidomastoid muscle with embedded lymph nodes were sent for\nhistological analysis. During the procedure, care was taken to avoid\ndamaging major neck vessels and nerves. Concluding the procedure, 8 and\n10 French Redon drains were placed, the wound was closed in layers, and\nthen covered with a spray-on bandage, steristrips, and a pressure\ndressing. The surgical site appeared bloodless at the conclusion of the\nsurgery.\n\n**Macroscopy:**\n\n**Macroscopic Description:**\n\nDimensions: 6.8 x 0.7 x 0.4 cm spindle-shaped, non-oriented skin and\nsubcutaneous tissue resection. Central area shows an irritation-free,\nfine scar measuring up to 6.3 x 4.8 cm. The cut surface appears\nconsistently off-white.\n\nInk markings: soft tissue margin of specimen = green. A: central\nlamellae B: spindle tips perpendicular\n\nAnterior Margin of Upper Third of Sternocleidomastoid Muscle:\nDimensions: Four combined tissue samples totaling 4.7 x 3.8 x 1.1 cm.\n\nAppearance: Tan, fibrous soft tissues with multiple uniformly dark\nnodules on the cut surface, each measuring up to 1.1 cm.\n\nA, B: one nodule each halved C, D: other nodular sections E: remaining\ntan fibrous sections Anterior Margin of Lower Third of\nSternocleidomastoid Muscle: Largest measurement: 3.4 cm.\n\nAppearance: Grayish-brown with some fibrous regions and homogeneously\ndark-brown nodes up to 1.5 cm in size on the cut surface. A, B: one node\neach halved C: other nodes D: brown-fibrous sections Region V Occipital:\nLargest measurement: Two samples, each up to 3.8 cm.\n\nAppearance: Mixture of grayish-tan and light brown fibrous soft tissue\nwith nodes up to 2.2 cm, uniformly dark brown.\n\nA, B: one node halved C, D: another node halved each Processing: 16\nparaffin blocks, HE stained.\n\nMicroscopic Description: Dermis and subcutaneous resection shows\nscarring with fibrosis. Epidermis is regular, without any atypical\ncells. No evidence of melanoma or carcinoma. 2./3.\n\nMultiple nodular tumor clusters present in the soft tissue and skeletal\nmuscles, lacking lymph node structure. Tumor cells are polygonal, with\nsome spindle-shaped cells having moderately large, irregular nuclei and\nnoticeable nucleoli. Cytoplasm appears slightly granular with a light\nbrownish pigment.\n\nSeven lymph nodes (measuring up to 3.6 cm) indicate metastasis from the\npreviously mentioned tumor, with extracapsular spread. Four other lymph\nnodes are free from the tumor.\n\n**Critical Findings:** Multiple nodular soft tissue metastases, with the\nlargest measuring 1.3 cm, indicative of melanoma present in both soft\ntissue and muscle. Resection margins are mostly free of tumor, with the\nclosest approach being less than 0.15 cm (points 2 and 3). Seven lymph\nnodes (up to 3.6 cm in size) show metastasis from the melanoma, with\nextracapsular spread. Four lymph nodes are tumor-free (7 out of 11\nnodes, ECE positive) (point 4). Dermis and subcutaneous excision shows\nscarring fibrosis (point 1).\n\nFor the optimal management of Mrs. Done, close monitoring and a\nmultidisciplinary approach will be essential. Thank you for your\ncontinued collaboration in ensuring the best care for our mutual\npatient.\n\n**Lab values upon discharge: **\n\n **Parameter** **Result** **Reference Range** **Interpretation**\n -------------------------------- -------------- ---------------------------------------- ---------------------\n **Complete Blood Count (CBC)** \n Hemoglobin (Hb) 12.4 g/dL 12.0 - 16.0 g/dL Within normal range\n White Blood Cell (WBC) 9.2 x10\\^9/L 4.0 - 10.0 x10\\^9/L Within normal range\n Platelets 250 x10\\^9/L 150 - 400 x10\\^9/L Within normal range\n **Liver Function Tests (LFT)** \n AST 28 U/L 10 - 35 U/L Within normal range\n ALT 32 U/L 10 - 40 U/L Within normal range\n Total Bilirubin 0.8 mg/dL 0.2 - 1.2 mg/dL Within normal range\n **Kidney Function Test** \n Serum Creatinine 0.9 mg/dL 0.5 - 1.2 mg/dL Within normal range\n Blood Urea Nitrogen (BUN) 15 mg/dL 7 - 20 mg/dL Within normal range\n **Electrolytes** \n Sodium 138 mEq/L 135 - 145 mEq/L Within normal range\n Potassium 4.2 mEq/L 3.5 - 5.0 mEq/L Within normal range\n Chloride 101 mEq/L 95 - 105 mEq/L Within normal range\n **Thyroid Function Tests** \n TSH 3.1 mU/L 0.5 - 5.0 mU/L Within normal range\n Free T4 1.4 ng/dL 0.9 - 2.4 ng/dL Within normal range\n **Lipid Profile** \n Total Cholesterol 190 mg/dL \\< 200 mg/dL Desirable\n LDL Cholesterol 100 mg/dL \\< 100 mg/dL Optimal\n HDL Cholesterol 55 mg/dL \\> 40 mg/dL (Men), \\> 50 mg/dL (Women) Normal\n Triglycerides 110 mg/dL \\< 150 mg/dL Normal\n\n**Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ---------------- ------------ ----------- -----------------------------\n Pembrolizumab 200mg IV Every 3 weeks\n Nivolumab 60mg IV As per oncologist\\'s advice\n Ipilimumab 200mg IV As per oncologist\\'s advice\n Paracetamol 500mg Oral Every 4-6 hours as needed\n Omeprazole 20mg Oral Once daily\n\n\n\n### text_4\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/14/2022 to\n03/01/2022.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done showed multiple metastases in her CT examination. On physical\nexamination, Mrs. Done appears well-nourished and in no acute distress.\nHer vital signs are stable. Cardiovascular examination reveals regular\nheart sounds with no murmurs. Respiratory examination shows clear breath\nsounds bilaterally. Abdominal examination reveals no palpable masses or\norganomegaly. Neurological examination is within normal limits.\n\n**Radiology/Nuclear Medicine**\n\n**CT thorax/abdomen/pelvis + Contrast from 02/10/2022**\n\n**Technique:** Multi-phase, multi-slice computed tomography of the\nthorax, abdomen, and pelvis was performed following the intravenous\nadministration of contrast material. Coronal and sagittal\nreconstructions were obtained.\n\n**Thorax:** In the thoracic region, the lungs are notable for multiple\nnodular opacities across both lung fields, consistent with metastatic\ndeposits. The most sizable lesion is seen in the right upper lobe,\napproximately 1.5 cm in diameter. No associated cavitation or pleural\neffusion is detected. A concerning 2 cm mass abutting the lateral wall\nof the left ventricle is noted, raising the suspicion for cardiac\nmetastasis. The mediastinum also exhibits lymphadenopathy with a\ndominant node in the prevascular space, measuring 2.2 cm. Further, there\nare lytic lesions involving the sternum and right 4th rib, consistent\nwith osseous metastatic disease.\n\n**Abdomen/pelvis**: Liver shows multiple hypodense lesions throughout\nboth lobes, indicative of metastatic spread. The dominant lesion in the\nright lobe measures 3 cm. The kidneys, however, are unremarkable without\ndiscernible metastatic deposits. Retroperitoneal lymphadenopathy is also\npresent, highlighted by a node anterior to the aorta of 1.8 cm. In\naddition, there is a 2.5 cm mass identified within the left psoas\nmuscle, consistent with muscular metastasis. Both the left acetabulum\nand the right iliac wing manifest with lytic lesions, suggestive of\nmetastatic involvement. There is also enlargement of the bilateral\ninternal iliac lymph nodes, with the left side\\'s node measuring up to\n1.6 cm. Bladder, prostate, and rectum with no discernible pathology.\n\n**Impression**: Multiple pulmonary nodules consistent with pulmonary\nmetastases. Cardiac lesion suggestive of metastatic involvement.\nEvidence of skeletal metastases in the thorax and pelvis. Hepatic and\nmuscular metastases, indicative of disseminated disease. Lymphadenopathy\nin the mediastinal, retroperitoneal, and pelvic regions.\n\n**PET-CT scan from 02/11/2022**\n\n**Clinical Indication:** Follow-up evaluation of a known case of\nMetastatic Melanoma, Stage IV, M1c with notable findings from a CT scan\ndated 12/01/2014.\n\n**Technique:** Whole-body PET-CT scan was conducted after intravenous\nadministration of 18F-FDG. The patient fasted for 6 hours prior to the\nscan, and blood glucose levels were confirmed to be within the\nacceptable range. Both CT and PET images were acquired, and images were\nco-registered for optimal evaluation. Standard uptake values (SUVs) were\ncalculated for areas of interest.\n\n**Findings: **\n\n**Thorax:** Both lungs depict several hypermetabolic foci, corroborating\nthe CT findings of multiple nodules. The largest lesion in the right\nupper lobe demonstrates an SUVmax of 8.2, indicative of active metabolic\ndisease. The cardiac mass adjacent to the left ventricle, measuring\napproximately 2 cm, also reveals increased 18F-FDG uptake with an SUVmax\nof 9.5, strengthening the suspicion of cardiac metastasis. Enlarged\nmediastinal lymph nodes, particularly the node in the prevascular space,\nshows marked hypermetabolism with an SUVmax of 7.4. Notably, the lytic\nskeletal lesions identified on the CT in the sternum and right 4th rib\nalso display increased metabolic activity, consistent with metastatic\nbone disease.\n\n**Abdomen/Pelvis:** Hepatic lesions are congruent with the findings of\nthe preceding CT, showing heightened metabolic activity. The most\nprominent lesion in the right lobe exhibits an SUVmax of 8.8.\nRetroperitoneal lymph nodes are metabolically active, with the anterior\naortic node demonstrating an SUVmax of 6.9. The 2.5 cm left psoas muscle\nmass also reveals increased uptake with an SUVmax of 7.3, suggesting\nactive muscular metastasis. In the pelvic region, the lytic lesions\nidentified in the left acetabulum and right iliac wing on the CT confirm\ntheir malignant nature with notable metabolic activity. Bilateral\ninternal iliac lymph nodes show hypermetabolism with the left node\\'s\nSUVmax reaching 7.1. Other pelvic organs, including the bladder,\nprostate, and rectum, did not show any significant 18F-FDG uptake, in\nline with the unremarkable CT findings.\n\n**Impression:** The PET-CT findings are consistent with active\nmetastatic disease. There is evidence of hypermetabolic pulmonary\nnodules, a likely cardiac metastasis, hepatic and muscular metastases,\nand metabolically active skeletal lesions in both the thorax and pelvis.\nAdditionally, there is hypermetabolism in the lymph nodes across\nmultiple regions. These findings align closely with the previously\ndiagnosed metastatic melanoma, Stage IV, M1c**. **\n\n**Discussion**\n\nMrs. Done has been diagnosed with recurrent metastatic melanoma with\nlymph node involvement. This poses significant implications for her\nprognosis, emphasizing the need for urgent and comprehensive\nintervention.\n\nHer molecular profile has revealed the presence of the BRAF V600E\nmutation.\n\nOur recommended therapeutic combination includes Vemurafenib and\nCobimetinib, both of which are aimed at disrupting the aberrant BRAF-MEK\nsignaling cascade. Complementing this, we suggest the administration of\nPembrolizumab.\n\nMrs. Done is scheduled for six cycles of this treatment regimen. We will\nmonitor her laboratory parameters, such as blood counts, electrolytes,\nand hepatic and renal profiles, bi-weekly. It is imperative to note that\nany fevers surpassing 38.3°C warrant immediate medical attention.\n\nComprehensive patient education module has been designed to enable Mrs.\nDone to identify and manage any potential side effects efficiently.\n\nWe will ensure rigorous monitoring of her blood pressure and lipid\nmetrics, with the possibility of introducing alternative medications if\nclinical scenarios demand.\n\nWe deeply value your collaboration in Mrs. Done\\'s healthcare journey.\nOur team remains at your disposal for any queries or clarifications.\n\n\n\n\n\nHere is the query:\nBased on the discharge letter, which of the following statements best represents Mrs. Jane Done's SARS-CoV-2 status and its trend during her hospitalization?\n\nChoose the correct answer from the following options:\nA. Her viral load increased while Ct values decreased from admission to discharge.\nB. Both her viral load and Ct values remained unchanged during her hospital stay.\nC. Her viral load decreased, but Ct values remained the same from admission to discharge.\nD. Both her viral load and Ct values decreased from admission to discharge.\nE. Her viral load and Ct values both increased from admission to discharge.\n\n\nYour response:\n", "role": "user" }, { "content": "Her viral load decreased, but Ct values remained the same from admission to discharge.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/18/2018 to\n03/01/2018.\n\n**Diagnoses: **\n\n- Malignant melanoma of the left scapula, TD 16 mm, exophytic\n ulcerating, invasion stage - III, R0\n\n- **Mutation analysis:** BRAF status: mutated. PD-L1 status: PD-L1\n tumor proportion score (TPS): \\<1%. Immune cell infiltrate (IC): 2%\n of tumor area. PD-L1 combined-positive score (CPS): 2.\n\n- **History:** Ms. Done was admitted to the hospital with high grade\n suspicion of malignant melanoma of the back. The patient reported a\n skin lesion that had been present for approximately 4 weeks. The\n lesion had grown rapidly during this time and appeared to be oozing\n and bleeding. She presented to our outpatient clinic, where she was\n advised to undergo surgical excision in case of suspected\n malignancy.\n\n- Questions about B-symptoms, AP complaints, stool or urine\n abnormalities were negated.\n\n- System Therapy (Adjuvant Treatment for Stage III Melanoma): 1\n\n02/22/18: 1st dose pembrolizumab 200mg\n\n03/15/18: 2nd dose Pembrolizumab 200mg\n\n04/05/18: 3rd dose Pembrolizumab 200mg\n\n04/26/18: 4th dose Pembrolizumab 200mg\n\n05/17/18: 5th dose Pembrolizumab 200mg\n\n06/07/18: 6th dose Pembrolizumab 200mg\n\n06/28/18: 7th dose Pembrolizumab 200mg\n\n07/19/18: 8th dose Pembrolizumab 200mg\n\n08/09/18: 9th dose Pembrolizumab 200mg i.v.\n\n**Physical examination findings:** 52-year-old female patient in normal\ngeneral condition, nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement normal. Pupils are equal and\nreactive to light and accommodation. Regular, normocardial heart rate\nduring recording. Cor and pulmo auscultatory and percutaneously\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall, liver\nand spleen not enlarged, no pain to palpation, no resistance to\npalpation, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged cervical, submandibular, supra- and infraclavicular, axillary\nand inguinal lymph nodes palpable. inguinal lymph nodes palpable.\nFurther internal and orienting neurological examination neurological\nexamination remained without pathological findings.\n\n**Skin findings:** In the area of the left scapula, a table tennis-ball\nsized area with a slightly fissured, oozing, pink-black pigmented\nsurface. On the cranial side an irregularly black-brown pigmented macula\nof about 3.2x1.2 cm is visible.\n\n**PET/CT with 203 MBq (F-18)-Fluorodeoxyglucose from 02/18/2018: **\n\nWeight: 66 kg, blood glucose: 118 mg/dL. 20 mg furosemide; acquisition\nstart 91 min after tracer injection; 821 mm scan length á () mm/s in\nflow technique (neck to proximal thigh); oral and i.v. contrast (1.5\nmL/kg, i.v., max. 120 mL). Quantitative analysis of\nattenuation-corrected image data using SUV calculation.\n\n**Findings:**\n\nCT: In case of known contrast agent allergy, premedication was performed\nwith one ampoule each of H1 and H2 antihistamine. The contrast-enhanced\nexamination proceeded without complications during the course.\n\nNeck: Symmetrical visualization of the soft tissues of the neck. No\nevidence of pathologically enlarged cervical lymph nodes. Struma nodosa\nwith several hypodense nodes on the right side up to max. approx. 1 cm.\n\nThorax: Cutaneous/subcutaneous irregular-shaped lesion caudal to the\nright scapula. Limited assessability in the lung window with motion\nartifacts and shallow inspiration depth. As far as assessable, no\nevidence of larger suspicious intrapulmonary pulmonary round foci. No\ninfiltrate. No pleural effusion. No evidence of pathologically enlarged\nlymph nodes mediastinal, hilar and axillary bilaterally.\n\nAbdomen/pelvis: Normal contrast of liver parenchyma without evidence of\nsuspicious focal liver lesions. Portal vein and hepatic veins perfused\nregularly. Gallbladder without irritation. Spleen with accessory spleen,\npancreas and adrenal glands bds. regular. Kidneys perfused at the same\nside. No urinary retention. Nephrolithiasis on the right side.\nVisualization of the parenchymatous upper abdominal organs. No evidence\nof pathologically enlarged coeliacal, mesenteric, retroperitoneal,\niliac, and inguinal lymph nodes. Inhomogeneously contrasted enlarged\nprostate. Urinary bladder wall, as far as assessable with low filling\ncircumferentially wall thickened.\n\nSkeleton: no evidence of suspicious osteodestructive lesions. Osteopenia\nwith degenerative skeletal changes.\n\nPET:\n\nIncreased tracer enhancement of the suspicious lesion caudal to left\nscapula, indicative of a melanoma (SUVmax 67). Focal intense tracer\nenhancement in the right thyroid lobe (SUVmax approximately 7.9).\nElongated intense tracer enhancement in the lower abdomen ventrally\nmedian without clear correlate, most consistent with contamination.\nOtherwise, unremarkable activity distribution in the study area.\n\nAssessment:\n\nNo evidence of metabolically active metastases in the study area.\n\n**Operation report from** **02/22/2018**:\n\nProcedure: Excision of malignant melanoma on the left upper back.\n\nPreoperative Diagnosis: Malignant melanoma, left upper back.\n\nPostoperative Diagnosis: Malignant melanoma, left upper back.\n\nAnesthesia: Local anesthesia using 70 mL tumescent solution comprising\n0.21% Lidocaine/Ropivacaine with epinephrine.\n\nProcedure Details: The surgical area was prepped using Betadine. The\narea was draped in a sterile fashion. Excision of the exophytic tumor\nwas performed, measuring 51 x 20 x 15 mm. A safety margin of 10 mm was\nmaintained in depth, with the excision extending slightly into the\nsubcutaneous tissue but not beyond the fascia. This resulted in a total\ndefect size of 75 x 45 mm. The defect could not be closed with a simple\nprimary suture. Perforator vessels were coagulated, and the defect was\nbridged using skin flaps. Additional resection of Burow triangles was\ndone according to aesthetic units. The wound was closed using an\nintracutaneous suture technique. A continuous overhand blocked suture\nwas used with 3-0 Vicryl. The patient was advised that the visible\nsuture material could be removed between postoperative days 14 and 16. A\ndressing was applied, followed by a pressure dressing to minimize\nswelling and promote healing. Comments: The patient tolerated the\nprocedure well and was provided postoperative care instructions.\n\nPlan: Follow up in clinic for suture removal and wound assessment\nbetween postoperative days 14 and 16.\n\n**Histology Dermatohistology:** **02/23/2018.**\n\n**Gross Examination:** A roughly oval excision specimen measuring 48 x\n36 x 14 mm. The specimen is serially sectioned into lamellar stages A\nthrough H (8 cassettes).\n\n**Microscopic Examination:**\n\nStage A: Displays a benign epidermis and dermis without evidence of\nmelanocytic tumor cells.\n\nStage B: Features an irregularly thickened epidermis. At the center of\nthe section, melanocytic tumor cells are observed at the dermoepidermal\njunction (positive for MelanA stain). Additionally, abundant\nmelanophages and pigment deposits are noted. The lateral safety margin\nmeasures at least 8 mm.\n\nStage C: Resembles stage B. Atypical melanocytic tumor cells are present\nat the dermoepidermal junction. Upper dermis displays fibrosis,\ninflammation, and numerous melanophages (confirmed by positive MelanA\nstaining). The lateral safety margin is at least 6 mm.\n\nStage D: Central region shows melanocytic tumor cells in both the\nepidermis and upper dermis. There is significant inflammation,\nmelanophages, and pigment deposition (confirmed by MelanA staining).\n\nThe maximum lateral safety margin here is approximately 8 mm. A small\nlymph node in the subcutaneous fat tissue is also seen, infiltrated by\nmelanocytic tumor cells.\n\nThe tumor shows stages E, F, G and H: Exophytic, bovist-like growing\nulcerated hemorrhagic tumor consisting of completely pleomorphic tumor\ncells. These cells vary in morphology, appearing both nested and\nspindle-shaped, with clear cytoplasm and conspicuous nucleoli. Notable\npigment production is observed, as are numerous atypical mitoses.\nControl staining in stage F with MelanA is completely positive. The\nsections are entirely excised.\n\n**Diagnosis:** Exophytic, ulcerated malignant melanoma with a tumor\nthickness of at least 15 mm. The tumor invasion is categorized as stage\nIII.\n\n**Medication upon discharge: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ----------------------------------------- --------------- -------------- ------------------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Oral Once daily in the morning\n Enoxaparin (Lovenox) 0.2 mL Subcutaneous In the evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Oral Morning and evening\n Leuprorelin (Lupron Depot) 3.75 mg Depot Subcutaneous Every 4 weeks\n Fentanyl Transdermal System (Duragesic) 12 μg/hr Transdermal Changed every 3 days\n Pantoprazole (Protonix) 40 mg Oral Once daily in the morning\n Sevelamer (Renagel) 800 mg Oral Once daily in the morning\n Multivitamin One tablet Oral Once daily in the morning\n Torsemide (Demadex) 200 mg Oral Once daily in the morning\n Cholecalciferol (Dekristol) 20,000 IU Oral Once weekly\n Sodium Bicarbonate (Bicanorm) One tablet Oral Once daily in the morning\n Calcitriol (Rocaltrol) 0.25 μg Oral Once daily in the morning\n Valacyclovir (Valtrex) 500 mg Oral Half-tablet daily in the morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Oral Mornings on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Oral In the morning on day 1 and day 2 following daratumumab administration\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 10/23/2020 to\n11/01/2020.\n\n- Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\n according to UICC.\n\n- Therapies to date:\n\n- Resection of primary tumor (malignant melanoma) on the left upper\n back (02/2018)\n\n- 01/20 Microsurgical resection right frontal tumor\n\n- 02/20 Excision of empyema\n\n- 02-03/20: Radiation therapy\n\n- 05/02/20: Start of immunotherapy with Nivolumab & 05/26/20: Start of\n combination immunotherapy 60 mg nivolumab, 200 mg ipilimumab (-\\>\n drug exanthema)\n\n**Physical examination findings: **\n\nOn admission, the patient was awake and adequately oriented. Height:\n166cm, weight: 56kg. Nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement regular. Pupils equal, pupillary\nreflex responsive to accommodation and light. Regular, normocardial\nheart rate on admission. Heart and lung: auscultatory and percutaneous\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall Liver\nand spleen are not enlarged, no tenderness, no rebound palpable.\nResistences palpable, loud bowel sounds. No enlarged No enlarged\ncervical, submandibular, supra- and infraclavicular lymph nodes\npalpable. **Skin findings:** Pronounced xerosis cutis, raised skin\nfolds, some with erythema and fine lamellar scale and fine lamellar\nscale, especially on the arms and face. **Microbiology:** Nasal swab:\nnormal flora, no MRSA. Throat swab: Normal flora, no MRSA Virology:\n10/23/2020: No detection of SARS-CoV-2 by PCR in the submitted material.\n\n**Therapy and Progression:**\n\n**Summary:** The patient presented with exsiccation eczema on the arms,\nlegs, and face.\n\n**Treatment Details:** Topical Treatment for Eczema: Applied Desonide\nCream once daily to the affected areas. For maintenance, applied Eucerin\nCream daily to the body and a moisturizing ointment like Cetaphil to the\nface.\n\n**Antipruritic Treatment:** Prescribed Benadryl tablets, to be taken as\nneeded.\n\n**Oncology Consultation:** The patient was educated by our oncologist,\nDr. Ex, regarding adjuvant therapy options. The potential benefits and\nrisks of a combination immunotherapy with Nivolumab and Ipilimumab were\ndiscussed. The patient had already started Nivolumab 200 mg therapy on\n05/26/2020.\n\n**Incident on 10/28/2020**: The patient had an unattended fall,\nresulting in a hematoma on the left forehead. An emergency CT scan\nshowed no new fractures or acute hemorrhage but confirmed the presence\nof previously known cystic metastasis.\n\n**Operation report (01/02/2020): **\n\n**Diagnosis:** Hemorrhaged right frontal metastasis from previously\ndiagnosed malignant melanoma (ID 2018)\n\n**Procedure:** Microsurgical resection of right frontal mass with\nintraoperative neuromonitoring (MEPs stable) and neuronavigation via a\nleft frontolateral craniotomy.\n\nTime: 10:34 am Closure Time: 1:04 pm. Total Duration: 2 hours 30 minutes\n\n**Preoperative Evaluation:** Imaging identified a hemorrhage in the\nright frontal lobe. Given the patient\\'s history of malignant melanoma,\na hemorrhagic melanoma metastasis was suspected. No other intracranial\nmetastases were detected. The patient and their family were informed of\nthe surgical benefits and risks. After ample time for consideration and\nquestions, written informed consent was obtained.\n\n**Procedure Details:** The patient was positioned supine and intubated.\nThe head was secured in a Mayfield clamp and rotated 60° to the right.\nThe navigation dataset was reviewed. Using the navigation system, a left\nfrontotemporal craniotomy was planned. An arcuate incision line was\ndrawn. The surgical area was shaved, cleaned, and sterilized.\nProphylactic antibiotics and mannitol were administered. A time-out was\nconducted preoperatively. The skin was incised, and Raney clips were\ninserted. The left temporal muscle was split. Using the navigation\nsystem for guidance, a left frontolateral craniotomy was performed. The\nbone flap was carefully removed and preserved in an antibiotic solution\nfor later reimplantation. The dura mater was opened, and the operating\nmicroscope was introduced. Upon inspection, the tumor was evident.\n\n**MRI brain report (01/04/2020): **\n\n**Clinical Information:** Postoperative assessment following\nmicrosurgical resection of a left frontal hemorrhaged metastasis from\npreviously diagnosed malignant melanoma.\n\n**Technique:** Multiplanar, multisequence MRI of the brain, including\nT1-weighted, T2-weighted, FLAIR, diffusion-weighted imaging (DWI), and\npost-contrast T1-weighted sequences.\n\n**Findings:** There is evidence of a right frontotemporal craniotomy\nwith associated post-surgical changes in the right frontal region.\nTitanium plates and screws are noted securing the bone flap, causing\nminimal artifact. The previous tumor site in the right frontal lobe\nshows post-surgical changes with a well-circumscribed cavity. There is\nno evidence of residual enhancing tumor within this cavity on\npost-contrast sequences, suggesting complete resection. Surrounding this\ncavity, there\\'s mild edema, consistent with expected post-operative\nchanges. No other intracranial metastases. The ventricles are of normal\nsize and symmetric. There is no evidence of hydrocephalus. No midline\nshift or mass effect is observed. There are scattered foci of\nsusceptibility artifact in the surgical bed on gradient echo sequences,\nconsistent with expected postoperative blood products. Major\nintracranial vessels appear patent with no evidence of vascular\nocclusion or significant stenosis. The remaining brain parenchyma\nappears normal in signal intensity and morphology on all sequences. No\nother significant abnormalities are identified.\n\n**Impression:** Post-surgical changes in the left frontal lobe\nconsistent with recent tumor resection. There is no evidence of residual\ntumor in the surgical bed. Expected postoperative edema and blood\nproducts adjacent to the resection site. No new metastatic foci\nidentified. No evidence of complications such as hydrocephalus, midline\nshift, or vascular abnormalities.\n\n**Operation report (02/04/2020): **\n\n**Diagnosis:** Subfascial, epidural, and subdural empyema following\nresection of right frontal metastasis for malignant melanoma.\n\n**Procedure:** Empyema removal (subfascial, epidural, subdural) S\nIncision Time: 15:23 Closure Time: 04:01 PM Total Duration: 2 hours 31\nminutes\n\n**Preoperative Evaluation:** The patient had a prior surgical resection\nof a right frontal metastasis due to known malignant melanoma. On a\nrecent outpatient visit, a cerebrospinal fluid (CSF) cushion was\nidentified and punctured, revealing the presence of pathogens. Imaging\nindicated deep and subcutaneous abscesses, necessitating revision\nsurgery. The patient was adequately informed about the procedure,\nunderstood the associated risks, and provided written consent.\n\n**Procedure Details:** The patient was positioned supine with the head\nrotated approximately 60° in a Mayfield clamp. The surgical area was\nwashed and sterilized, focusing on the pre-existing access point. A team\ntime-out was conducted. Perioperative antibiotics were withheld until\nall samples for microbiology were obtained. The skin was incised,\nrevealing multiple layers of muscle. These were carefully dissected,\nleading to the identification and evacuation of the subcutaneous\nepifascial abscess. Infected muscle tissue and abscess walls were\nresected. The skull flap appeared loosened. A miniplate was removed, and\nupon further inspection, the dura mater appeared strained. It was\nincised and revealed turbid fluid, indicating a deep abscess. The dura\nmater was mobilized, though adherence to the cortex was observed around\nthe resection cavity, suggesting possible tumor regrowth. Affected areas\nwere carefully resected. After thorough irrigation, a drainage system\nwas inserted into the resection cavity. A duraplasty was performed,\nfollowed by the reimplantation of the bone flap using a miniplate. The\npatient was also included in a bone flap study and was randomized for\nflap reimplantation. After further irrigation, the wound was\nmeticulously closed, and a subfascial drain was inserted. The final\nclosure was completed with single button sutures. Under the guidance of\nthe operating microscope, the tumor was meticulously dissected from the\nsurrounding healthy tissue. Special care was taken to minimize damage to\nthe surrounding brain structures. The intraoperative neuromonitoring\nindicated stable MEPs throughout, suggesting that motor pathways\nremained undisturbed during the procedure. Throughout the resection,\nperiodic hemostasis was achieved using bipolar electrocautery to control\nbleeding. Following the complete resection of the tumor, the surgical\ncavity was irrigated with sterile saline to remove any residual debris.\nThe integrity of the surrounding brain tissue was assessed, and no\nimmediate complications were observed. The dura mater was sutured,\nensuring a watertight closure. A synthetic dural graft was used to\nreinforce the suture line. The preserved bone flap was reimplanted and\nsecured in place using titanium plates and screws. The temporal muscle\nand soft tissues were reapproximated and sutured in layers. The skin was\nclosed using a combination of absorbable sutures for the subcutaneous\nlayer and non-absorbable sutures for the skin. Sterile dressings were\napplied to the incision site. Postoperative Assessment: The procedure\nwas completed without complications. Immediate postoperative\nneurological examination revealed no new deficits. The patient was\ntransferred to the recovery room in stable condition, awaiting\nextubation by the anesthesiology team.\n\n**Recommendations:** Close monitoring in the neurological intensive care\nunit (NICU) is advised for the first 24 hours. Postoperative imaging,\ntypically an MRI, should be scheduled within the next 48 hours to assess\nthe extent of tumor resection and to rule out any postoperative\ncomplications.\n\n**Summary:** Mrs. Done\\'s recent hospital course was complicated by the\ndetection and subsequent excision of a hemorrhagic metastasis from a\nknown history of malignant melanoma. She continues to be on targeted\ntherapy with close monitoring. No new metastasis or recurrence has been\ndetected as of the last evaluation. The interdisciplinary approach\ninvolving the neurosurgery and oncology teams has been pivotal in her\nmanagement. Given the aggressive nature of melanoma, regular\nsurveillance and immediate action upon detection of new\nlesions/metastasis are paramount for her prognosis.\n\n**02-03/20: Radiation therapy **\n\nDiagnosis: Metastatic malignant melanoma with a focus on the right\nfrontal metastasis. Technique: Stereotactic radiosurgery (SRS) using a\nlinear accelerator (LINAC). Fractionation: Given the aggressive nature\nof malignant melanoma, a hypofractionated regimen was adopted. The\npatient underwent five sessions, each delivering a dose of 6 Gy for a\ncumulative total dose of 30 Gy.\n\nTreatment Planning: A simulation CT scan with a 1mm slice thickness was\nperformed in the treatment position, with a thermoplastic mask for\nimmobilization. The treatment planning system utilized the simulation\nCT, along with MRI for better tumor delineation. The target volume and\ncritical structures like the eyes, optic nerves, chiasm, and brainstem\nwere contoured. The radiation plan was optimized to ensure maximal dose\nto the target while sparing the critical structures.\n\nProcedure: At each session, patient positioning was verified using\ncone-beam CT (CBCT) to ensure precise targeting. Real-time monitoring\nwas employed to account for any intrafraction motion.\n\nSide Effects: The patient tolerated the treatment well. She reported\ntransient fatigue and mild scalp irritation, which resolved with\nconservative measures. No acute radiation-induced neurotoxicity was\nobserved.\n\n**Patient History Update: Mrs. Jane Done (DOB: 01/01/1966)**\n\n**General Status (10/03/2020):**\n\nMrs. Done presented in stable condition with stable vital signs.\nNeurologically, she\\'s intact with no new focal deficits. The surgical\nscars in the frontal region from previous operations are not fully\nhealed and there is some dehiscence and swelling, indicative of\ninfection. This wound complication can be traced back to her previous\nhistory of an empyema which required surgical intervention.\n\n**Dermatological Assessment:**\n\nThe previous exsiccation eczema, prominent on her arms, legs, and face,\nhas improved markedly. The treatment regimen involving consistent\nmoisturization and targeted topical therapies seems effective.\nImportantly, there were no new suspicious skin lesions or nodules noted\nduring her most recent full-body skin check.\n\n**Oncology Status:**\n\nMrs. Done remains on her immunotherapy regimen, specifically the\ncombination of Nivolumab and Ipilimumab. Her response has been positive,\nwith no new metastatic sites identified in the latest assessments. She\nhas displayed commendable compliance with this regimen and regular\nfollow-up evaluations.\n\n**Recent MRI Brain (09/30/2020):**\n\nHer latest multiplanar, multisequence MRI revealed post-surgical\nalterations in the right frontal lobe, consistent with previous\nobservations. Encouragingly, there was no sign of any residual or\nrecurrent tumor activity. Moreover, the MRI did not show any new\nintracranial metastatic sites or other significant abnormalities.\n\n**Thoracic CT Scan (10/01/2020): **\n\nTechnique: Post complication-free bolus i.v. administration of Imeron\n400, a multiline spiral CT was performed through the thorax during the\nvenous contrast phase, supplemented with thin-section, coronary, and\nsagittal secondary reconstructions.\n\nFindings: Multiple roundish subsolid nodules found bipulmonary, notably\na 4mm nodule in the right upper lobe. Blurred subpleural condensations\nin the left upper lobe. Another blurred bronchus-associated\nconsolidation was observed in the left upper lobe and pleurally in the\nleft dorsal lower lobe. No evidence of pathologically enlarged lymph\nnodes in the hilar, mediastinal, or axillary regions. Unchanged\npresentation of the left adrenal gland from the preliminary examination.\nThickened imprinting of the gastric wall noted. Ventrally emphasized\nspondylophytic attachments observed in the thoracic spine. No\nosteodestructive processes detected.\n\n**Impression:** Presence of multiple subsolid pulmonary nodules;\nrecommended follow-up in 4-6 weeks for potential (post-) inflammatory or\nmalignant genesis. No evidence of pathologically enlarged lymph nodes.\n\n**Abdomen/Pelvis CT Scan (10/01/2023): **\n\nTechnique: A low dose CT scan was taken of the abdomen and pelvis.\n\n**Findings:** Regular visualization of the acquired basal lung sections.\nOrthotopic kidneys without urinary stasis. No evidence of urinary\ncalculi. Suspected uterine fibroids attached to the uterus wall.\nEnlarged right ovary with minor calcifications. Assessment: Absence of\nurinary calculi. Possible uterine fibroids and an enlarged right ovary,\nsuggesting a specialized gynecological examination.\n\n**PICC Line Installation (10/02/2020)**\n\n**Diagnosis:**\n\nHome antibiotics required for wound healing disorder following discharge\ndue to an empyema.\n\n**Type of Surgery:**\n\nInstallation of a PICC line in the left basilic vein.\n\n**Anesthesia:**\n\nLocal anesthesia\n\n**Procedure Details:**\n\nThe patient was presented for long-term antibiotic treatment due to a\nwound healing disturbance post the discharge of an epidural abscess. The\nprimary aim was to apply a PICC-line catheter for the antibiotic\nregimen. A written informed consent was duly obtained prior to the\nprocedure.\n\nThe standard procedure began with the washing off and draping of the\npatient. A preoperative sonography of the arm veins was conducted. Based\non the sonographic results, it was decided to insert the catheter via\nthe left basilica vein.\n\nUnder venous congestion and following local anesthesia with 2mL Mecain,\na 2mm skin incision was made. The sonographically guided puncture was\nperformed successfully. Post this, the peel-away sheath was inserted.\nWith the wire in place, the catheter was advanced with its tip\npositioned approximately 2cm below the carina. The wire was subsequently\nremoved. Following this, the catheter was aspirated and flushed with\nNaCl to ensure its patency. A sterile fixation was then applied, and the\nwound was dressed.\n\n**Notes:**\n\nNo complications were observed during the procedure. The patient was\nadvised on the care and maintenance of the PICC line. Regular follow-ups\nare recommended to monitor the wound healing and the effectiveness of\nthe antibiotic treatment.\n\nThe patient was discharged with instructions and is scheduled for a\nfollow-up in two weeks.\n\n**Additional Therapeutic Engagements:**\n\nFor her overall well-being and to counter the side effects of her\ntreatment journey, Mrs. Done has been actively involved in physical\ntherapy sessions. These sessions focus on enhancing her strength and\nbalance, especially given the previous incident of an unattended fall.\nTo address the inevitable psychological strains of her diagnosis, she\nhas also been attending counseling sessions.\n\n**Current Recommendations:**\n\n-Continue the ongoing immunotherapy without changes.\n\n-Dermatological check-ups every month are advised for early detection of\nany potential skin abnormalities.\n\n-Regular neurological evaluations are crucial to ensure no emergence of\nnew deficits.\n\n-Imaging should be scheduled every six months for proactive monitoring.\n\n-Her physical therapy regimen should be ongoing to maintain and improve\nmobility.\n\n-Continue counseling to support her emotional and psychological\nwell-being.\n\n**Summary and Notes:**\n\nMrs. Done\\'s resilience and adherence to her treatments are commendable.\nHer progress is a testament to the integrated care approach she has been\nreceiving. Maintaining a proactive surveillance stance will be essential\nfor her long-term prognosis and quality of life.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding our mutual patient, Mrs. Jane\nDone, born on 01.01.1966. She was admitted to our clinic from 11/23/2020\nto 12/01/2020.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done presented for a follow-up visit on 11/23/2020. Over the past\nfew months, she reported fatigue and intermittent bouts of nausea. Of\nsignificant concern were newly identified skin changes located on her\nright arm.\n\n**Clinical Findings:**\n\nSkin: Multiple macules and patches on the right arm, the largest\nmeasuring about 1.5cm in diameter, hyperpigmented with irregular\nborders.\n\n**US: **\n\nUltrasound imaging of the right arm revealed no deep extension or\ninvasion of underlying structures. This preliminary assessment was\ncrucial, suggesting that if malignancy is present, it might be in early\nstages.\n\n**Histology: **\n\nHistological examination: Gross Description: The sample consists of\nmultiple tan-pink soft tissue fragments, aggregating to 1.8 cm in the\ngreatest dimension.\n\nMicroscopic description: Sections show a proliferation of atypical\nmelanocytes arranged in nests and as single units at the dermoepidermal\njunction. Some of these cells infiltrate the papillary dermis.\n\nImmunohistochemistry: The atypical cells are positive for HMB-45 and\nS-100. Melan A is focally positive. Ki-67 proliferation index is about\n10%.\n\nFinal Diagnosis: Dysplastic nevus with severe atypia; margins appear\nclear. Further excision is recommended to ensure complete removal and to\nrule out invasive melanoma.\n\n**Lab results: **\n\nComplete Blood Count (CBC):\n\nHemoglobin: 12.3 g/dL (Normal range: 12-16 g/dL)\n\nWhite Blood Cell Count: 6,200 cells/µL (Normal range: 4,000-11,000\ncells/µL)\n\nPlatelet Count: 290,000 cells/µL (Normal range: 150,000-450,000\ncells/µL)\n\nDifferential:\n\nNeutrophils 65%, Lymphocytes 25%, Monocytes 8%, Eosinophils 2%. B.\n\nLiver Function Tests (LFTs):\n\nALT (Alanine Aminotransferase): 40 U/L (Normal range: 7-56 U/L)\n\nAST (Aspartate Aminotransferase): 38 U/L (Normal range: 10-40 U/L)\n\nALP (Alkaline Phosphatase): 90 U/L (Normal range: 44-147 U/L)\n\nTotal Bilirubin: 1.0 mg/dL (Normal range: 0.1-1.2 mg/dL)\n\nAlbumin: 4.2 g/dL (Normal range: 3.4-5.4 g/dL)\n\nAssessment/Recommendations:\n\nGiven her history and the suspicious nature of the new skin changes, we\nhave decided to send the biopsy for urgent histological assessment.\n\nFurthermore, considering her reported symptoms, we have conducted a\nthorough internal check-up, including blood tests and liver function\ntests, to rule out any systemic side effects of the immunotherapy.\n\nWe recommend continuous monitoring of Mrs. Done's condition and kindly\nrequest your valuable input in managing her case optimally. A\nmultidisciplinary approach, given her complicated medical history, will\nbe most beneficial for the patient.\n\nPlease find attached the detailed examination and investigative reports\nfor your reference.\n\nWith kind regards,\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe wish to provide a comprehensive update regarding our mutual patient,\nMrs. Jane Done, born on 01.01.1966. She has had a history of various\nmedical conditions and treatments, which we believe is essential to\ndiscuss for her optimal management and was admitted to our clinical from\n01/01/2021 to 01/28/2021.\n\n**Previous Diagnoses and Therapies:**\n\nMetastatic malignant melanoma (presumed ID 2018); M1, stage IV according\nto UICC. Resection of primary tumor (malignant melanoma) on the left\nupper back (02/2018)\n\n01/20 Microsurgical resection right frontal tumor\n\n02/20 Excision of empyema\n\n02-03/20: Radiation therapy\n\n05/02/20: Start of immunotherapy with Nivolumab\n\n05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\nImaging 01/02/2021: PET/CT: Cervical lymph node metastasis;\n\ncMRI: no evidence of metastases. Contrast-enhancing meninges.\n\n**Virology: **\n\nUpon Admission: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load\nof 7,000 Geq/mL and a Ct value of 32.\n\nAt Discharge: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load of\n2,350 Geq/mL and a Ct value of 32.\n\n**Microbiology: **\n\nMRSA Screening Upon Admission: Nasal Swab: Normal flora detected; MRSA\nnot present. Throat Swab: Normal flora detected; MRSA not present.\n\nProcedures:\n\n\\- Presentation to neurology for CSF puncture (e.g., exclude\nmeningeosis)\n\n\\- Panel sequencing complement\n\n\\- Surgery/therapy: Neck dissection followed by adjuvant therapy with\npembrolizumab.\n\nClinical examination:\n\nExamination findings: Patient in normal general and nutritional\ncondition, consciousness unremarkable. Cranial mobility free, ocular\nmobility normal. Pupils are isocor, pupillary reflex prompt to\naccommodation and light. Regular, normocardial heart rate on admission.\nNo typical heart murmurs. Abdomen: abdominal wall soft, liver and spleen\nnot enlarged, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged in the axillary or inguinal region palpable.\n\nPET-CT from 01/02/2021:\n\nIntense metabolically active lymph node metastases, otherwise no\nevidence of vital tumor tissue in the study area.\n\n**PET CT report from 01/02/2021: **\n\nProcedure: PET/CT with 246 MBq (F-18)-fluorodeoxyglucose and a 60-minute\nuptake period.\n\nFindings: CT Findings: Neck: Right Level II: Three lymph nodes, largest\nmeasuring 2.1 x 1.8 cm with central necrosis. Right Level III: Two lymph\nnodes, largest measuring 1.5 x 1.2 cm. Left Level II: One lymph node\nmeasuring 1.3 x 1.1 cm. Left Level IV: Two lymph nodes, largest\nmeasuring 1.7 x 1.4 cm. Retropharyngeal space: One lymph node measuring\n1.0 x 0.9 cm.\n\nPET Findings: Neck: Right Level II: Increased FDG uptake with SUVmax of\n7.8, consistent with metastatic disease. Right Level III: Increased FDG\nuptake with SUVmax of 6.5. Left Level II: Increased FDG uptake with\nSUVmax of 6.0. Left Level IV: Increased FDG uptake with SUVmax of 7.2.\nRetropharyngeal space: Increased FDG uptake with SUVmax of 6.1.\nImpression: Cervical Lymph Nodes: Multiple pathologically enlarged\ncervical lymph nodes in bilateral level II, right level III, left level\nIV, and retropharyngeal space with increased FDG uptake, highly\nsuggestive of metastatic involvement from the known primary melanoma.\n\n**Surgery report 01/05/2021: **\n\nThe surgery commenced with a collaborative discussion with the\nanesthesia team and a standard team time-out was executed. The patient\nwas properly positioned, and the surgical site was aseptically draped.\nThe facial neuromonitoring system was set up and verified. Local\nanesthesia was then administered at the site of the skin incision, which\nwas located near the previous scar. This incision followed the anterior\nborder of the sternocleidomastoid muscle in a curved pattern. Upon\nincising the subcutaneous tissue, the external jugular vein became\nvisible and was selectively ligated. The encountered tissue appeared\nnotably fibrotic and scarred. A skin incision extended from the mastoid\nregion down nearly to the clavicle. The platysma muscle was subsequently\ncut. Due to the presence of a lymph node mass, the auricularis magnus\nnerve had to be severed. The sternocleidomastoid muscle and the\nposterior belly of the digastric muscle were then exposed. Multiple\ndarkened lymph node metastases were identified, both beneath the skin\nand within the sternocleidomastoid muscle. In subsequent steps, efforts\nwere made to distinguish the internal jugular vein from the surrounding\nscarred tissue. A lymph node mass, which exhibited characteristics\nhighly suggestive of metastasis (given its darkened color), was removed.\nThe accessory nerve was identified and preserved. Further dissection was\ndone posteriorly to the sternocleidomastoid muscle, in the direction of\nlevel V. An expansive mass of lymph nodes was excised in this region.\nThe trapezoid branch of the accessory nerve was visualized, and its\nfunction was monitored and preserved with the aid of neuromonitoring.\nThe removed lymph node mass, some excised tissue, and portions of the\nsternocleidomastoid muscle with embedded lymph nodes were sent for\nhistological analysis. During the procedure, care was taken to avoid\ndamaging major neck vessels and nerves. Concluding the procedure, 8 and\n10 French Redon drains were placed, the wound was closed in layers, and\nthen covered with a spray-on bandage, steristrips, and a pressure\ndressing. The surgical site appeared bloodless at the conclusion of the\nsurgery.\n\n**Macroscopy:**\n\n**Macroscopic Description:**\n\nDimensions: 6.8 x 0.7 x 0.4 cm spindle-shaped, non-oriented skin and\nsubcutaneous tissue resection. Central area shows an irritation-free,\nfine scar measuring up to 6.3 x 4.8 cm. The cut surface appears\nconsistently off-white.\n\nInk markings: soft tissue margin of specimen = green. A: central\nlamellae B: spindle tips perpendicular\n\nAnterior Margin of Upper Third of Sternocleidomastoid Muscle:\nDimensions: Four combined tissue samples totaling 4.7 x 3.8 x 1.1 cm.\n\nAppearance: Tan, fibrous soft tissues with multiple uniformly dark\nnodules on the cut surface, each measuring up to 1.1 cm.\n\nA, B: one nodule each halved C, D: other nodular sections E: remaining\ntan fibrous sections Anterior Margin of Lower Third of\nSternocleidomastoid Muscle: Largest measurement: 3.4 cm.\n\nAppearance: Grayish-brown with some fibrous regions and homogeneously\ndark-brown nodes up to 1.5 cm in size on the cut surface. A, B: one node\neach halved C: other nodes D: brown-fibrous sections Region V Occipital:\nLargest measurement: Two samples, each up to 3.8 cm.\n\nAppearance: Mixture of grayish-tan and light brown fibrous soft tissue\nwith nodes up to 2.2 cm, uniformly dark brown.\n\nA, B: one node halved C, D: another node halved each Processing: 16\nparaffin blocks, HE stained.\n\nMicroscopic Description: Dermis and subcutaneous resection shows\nscarring with fibrosis. Epidermis is regular, without any atypical\ncells. No evidence of melanoma or carcinoma. 2./3.\n\nMultiple nodular tumor clusters present in the soft tissue and skeletal\nmuscles, lacking lymph node structure. Tumor cells are polygonal, with\nsome spindle-shaped cells having moderately large, irregular nuclei and\nnoticeable nucleoli. Cytoplasm appears slightly granular with a light\nbrownish pigment.\n\nSeven lymph nodes (measuring up to 3.6 cm) indicate metastasis from the\npreviously mentioned tumor, with extracapsular spread. Four other lymph\nnodes are free from the tumor.\n\n**Critical Findings:** Multiple nodular soft tissue metastases, with the\nlargest measuring 1.3 cm, indicative of melanoma present in both soft\ntissue and muscle. Resection margins are mostly free of tumor, with the\nclosest approach being less than 0.15 cm (points 2 and 3). Seven lymph\nnodes (up to 3.6 cm in size) show metastasis from the melanoma, with\nextracapsular spread. Four lymph nodes are tumor-free (7 out of 11\nnodes, ECE positive) (point 4). Dermis and subcutaneous excision shows\nscarring fibrosis (point 1).\n\nFor the optimal management of Mrs. Done, close monitoring and a\nmultidisciplinary approach will be essential. Thank you for your\ncontinued collaboration in ensuring the best care for our mutual\npatient.\n\n**Lab values upon discharge: **\n\n **Parameter** **Result** **Reference Range** **Interpretation**\n -------------------------------- -------------- ---------------------------------------- ---------------------\n **Complete Blood Count (CBC)** \n Hemoglobin (Hb) 12.4 g/dL 12.0 - 16.0 g/dL Within normal range\n White Blood Cell (WBC) 9.2 x10\\^9/L 4.0 - 10.0 x10\\^9/L Within normal range\n Platelets 250 x10\\^9/L 150 - 400 x10\\^9/L Within normal range\n **Liver Function Tests (LFT)** \n AST 28 U/L 10 - 35 U/L Within normal range\n ALT 32 U/L 10 - 40 U/L Within normal range\n Total Bilirubin 0.8 mg/dL 0.2 - 1.2 mg/dL Within normal range\n **Kidney Function Test** \n Serum Creatinine 0.9 mg/dL 0.5 - 1.2 mg/dL Within normal range\n Blood Urea Nitrogen (BUN) 15 mg/dL 7 - 20 mg/dL Within normal range\n **Electrolytes** \n Sodium 138 mEq/L 135 - 145 mEq/L Within normal range\n Potassium 4.2 mEq/L 3.5 - 5.0 mEq/L Within normal range\n Chloride 101 mEq/L 95 - 105 mEq/L Within normal range\n **Thyroid Function Tests** \n TSH 3.1 mU/L 0.5 - 5.0 mU/L Within normal range\n Free T4 1.4 ng/dL 0.9 - 2.4 ng/dL Within normal range\n **Lipid Profile** \n Total Cholesterol 190 mg/dL \\< 200 mg/dL Desirable\n LDL Cholesterol 100 mg/dL \\< 100 mg/dL Optimal\n HDL Cholesterol 55 mg/dL \\> 40 mg/dL (Men), \\> 50 mg/dL (Women) Normal\n Triglycerides 110 mg/dL \\< 150 mg/dL Normal\n\n**Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ---------------- ------------ ----------- -----------------------------\n Pembrolizumab 200mg IV Every 3 weeks\n Nivolumab 60mg IV As per oncologist\\'s advice\n Ipilimumab 200mg IV As per oncologist\\'s advice\n Paracetamol 500mg Oral Every 4-6 hours as needed\n Omeprazole 20mg Oral Once daily\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/14/2022 to\n03/01/2022.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done showed multiple metastases in her CT examination. On physical\nexamination, Mrs. Done appears well-nourished and in no acute distress.\nHer vital signs are stable. Cardiovascular examination reveals regular\nheart sounds with no murmurs. Respiratory examination shows clear breath\nsounds bilaterally. Abdominal examination reveals no palpable masses or\norganomegaly. Neurological examination is within normal limits.\n\n**Radiology/Nuclear Medicine**\n\n**CT thorax/abdomen/pelvis + Contrast from 02/10/2022**\n\n**Technique:** Multi-phase, multi-slice computed tomography of the\nthorax, abdomen, and pelvis was performed following the intravenous\nadministration of contrast material. Coronal and sagittal\nreconstructions were obtained.\n\n**Thorax:** In the thoracic region, the lungs are notable for multiple\nnodular opacities across both lung fields, consistent with metastatic\ndeposits. The most sizable lesion is seen in the right upper lobe,\napproximately 1.5 cm in diameter. No associated cavitation or pleural\neffusion is detected. A concerning 2 cm mass abutting the lateral wall\nof the left ventricle is noted, raising the suspicion for cardiac\nmetastasis. The mediastinum also exhibits lymphadenopathy with a\ndominant node in the prevascular space, measuring 2.2 cm. Further, there\nare lytic lesions involving the sternum and right 4th rib, consistent\nwith osseous metastatic disease.\n\n**Abdomen/pelvis**: Liver shows multiple hypodense lesions throughout\nboth lobes, indicative of metastatic spread. The dominant lesion in the\nright lobe measures 3 cm. The kidneys, however, are unremarkable without\ndiscernible metastatic deposits. Retroperitoneal lymphadenopathy is also\npresent, highlighted by a node anterior to the aorta of 1.8 cm. In\naddition, there is a 2.5 cm mass identified within the left psoas\nmuscle, consistent with muscular metastasis. Both the left acetabulum\nand the right iliac wing manifest with lytic lesions, suggestive of\nmetastatic involvement. There is also enlargement of the bilateral\ninternal iliac lymph nodes, with the left side\\'s node measuring up to\n1.6 cm. Bladder, prostate, and rectum with no discernible pathology.\n\n**Impression**: Multiple pulmonary nodules consistent with pulmonary\nmetastases. Cardiac lesion suggestive of metastatic involvement.\nEvidence of skeletal metastases in the thorax and pelvis. Hepatic and\nmuscular metastases, indicative of disseminated disease. Lymphadenopathy\nin the mediastinal, retroperitoneal, and pelvic regions.\n\n**PET-CT scan from 02/11/2022**\n\n**Clinical Indication:** Follow-up evaluation of a known case of\nMetastatic Melanoma, Stage IV, M1c with notable findings from a CT scan\ndated 12/01/2014.\n\n**Technique:** Whole-body PET-CT scan was conducted after intravenous\nadministration of 18F-FDG. The patient fasted for 6 hours prior to the\nscan, and blood glucose levels were confirmed to be within the\nacceptable range. Both CT and PET images were acquired, and images were\nco-registered for optimal evaluation. Standard uptake values (SUVs) were\ncalculated for areas of interest.\n\n**Findings: **\n\n**Thorax:** Both lungs depict several hypermetabolic foci, corroborating\nthe CT findings of multiple nodules. The largest lesion in the right\nupper lobe demonstrates an SUVmax of 8.2, indicative of active metabolic\ndisease. The cardiac mass adjacent to the left ventricle, measuring\napproximately 2 cm, also reveals increased 18F-FDG uptake with an SUVmax\nof 9.5, strengthening the suspicion of cardiac metastasis. Enlarged\nmediastinal lymph nodes, particularly the node in the prevascular space,\nshows marked hypermetabolism with an SUVmax of 7.4. Notably, the lytic\nskeletal lesions identified on the CT in the sternum and right 4th rib\nalso display increased metabolic activity, consistent with metastatic\nbone disease.\n\n**Abdomen/Pelvis:** Hepatic lesions are congruent with the findings of\nthe preceding CT, showing heightened metabolic activity. The most\nprominent lesion in the right lobe exhibits an SUVmax of 8.8.\nRetroperitoneal lymph nodes are metabolically active, with the anterior\naortic node demonstrating an SUVmax of 6.9. The 2.5 cm left psoas muscle\nmass also reveals increased uptake with an SUVmax of 7.3, suggesting\nactive muscular metastasis. In the pelvic region, the lytic lesions\nidentified in the left acetabulum and right iliac wing on the CT confirm\ntheir malignant nature with notable metabolic activity. Bilateral\ninternal iliac lymph nodes show hypermetabolism with the left node\\'s\nSUVmax reaching 7.1. Other pelvic organs, including the bladder,\nprostate, and rectum, did not show any significant 18F-FDG uptake, in\nline with the unremarkable CT findings.\n\n**Impression:** The PET-CT findings are consistent with active\nmetastatic disease. There is evidence of hypermetabolic pulmonary\nnodules, a likely cardiac metastasis, hepatic and muscular metastases,\nand metabolically active skeletal lesions in both the thorax and pelvis.\nAdditionally, there is hypermetabolism in the lymph nodes across\nmultiple regions. These findings align closely with the previously\ndiagnosed metastatic melanoma, Stage IV, M1c**. **\n\n**Discussion**\n\nMrs. Done has been diagnosed with recurrent metastatic melanoma with\nlymph node involvement. This poses significant implications for her\nprognosis, emphasizing the need for urgent and comprehensive\nintervention.\n\nHer molecular profile has revealed the presence of the BRAF V600E\nmutation.\n\nOur recommended therapeutic combination includes Vemurafenib and\nCobimetinib, both of which are aimed at disrupting the aberrant BRAF-MEK\nsignaling cascade. Complementing this, we suggest the administration of\nPembrolizumab.\n\nMrs. Done is scheduled for six cycles of this treatment regimen. We will\nmonitor her laboratory parameters, such as blood counts, electrolytes,\nand hepatic and renal profiles, bi-weekly. It is imperative to note that\nany fevers surpassing 38.3°C warrant immediate medical attention.\n\nComprehensive patient education module has been designed to enable Mrs.\nDone to identify and manage any potential side effects efficiently.\n\nWe will ensure rigorous monitoring of her blood pressure and lipid\nmetrics, with the possibility of introducing alternative medications if\nclinical scenarios demand.\n\nWe deeply value your collaboration in Mrs. Done\\'s healthcare journey.\nOur team remains at your disposal for any queries or clarifications.\n\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n\n\n\n\nHere is the query:\nHow did Mr. Rudolph's medication plan change between 06/29/2021 and 02/22/2022?\n\nChoose the correct answer from the following options:\nA. Pantoprazole and Prednisolone were removed from the medication plan.\nB. Pantoprazole and Aspirin were removed from the medication plan.\nC. Pantoprazole was added to the medication plan.\nD. Bisoprolol was added to the medication plan.\nE. Pantoprazole and Bisoprolol were removed from the medication plan.\n\n\nYour response:\n", "role": "user" }, { "content": "Pantoprazole and Prednisolone were removed from the medication plan.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n\n\n### text_3\n**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n\n\n### text_7\n**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n\n\n### text_8\n**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n\n\n### text_9\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n\n\n### text_10\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n\n\n### text_11\n**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n\n\n### text_12\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n\n\n\n\nHere is the query:\nRegarding her pancreatic condition, which procedure was Mrs. Anderson subjected to on 09/29/21?\n\nChoose the correct answer from the following options:\nA. Surgical port placement\nB. Endoscopic ultrasound-guided FNA\nC. Radiation therapy\nD. Neoadjuvant chemotherapy with FOLFIRINOX\nE. Thyroidectomy\n\n\nYour response:\n", "role": "user" }, { "content": "Endoscopic ultrasound-guided FNA", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n", "title": "text_9" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n", "title": "text_10" }, { "content": "**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n", "title": "text_11" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n", "title": "text_12" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n\n\n### text_5\n**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n\n\n\n\nHere is the query:\nCould you please specify the chronological sequence of the radiology imaging examinations that Mr. Wells underwent?\n\nChoose the correct answer from the following options:\nA. Ultrasound < Liver MRI < CT Chest/Abdomen/Pelvis Gastroscopy < Colonoscopy < DSA Coeliac-Mesenteric < Perfusion Scintigraphy of the Liver and Lungs with SPECT/CT < MRI liver < CT Chest/Abdomen/Pelvis < Gastroscopy < Colonoscopy\nB. Ultrasound < Liver MRI < CT Chest/Abdomen/Pelvis Gastroscopy < Colonoscopy < DSA Coeliac-Mesenteric < Perfusion Scintigraphy of the Liver and Lungs with SPECT/CT < MRI liver < CT Chest/Abdomen/Pelvis < Pulmonary function testing < Gastroscopy < Colonoscopy\nC. Ultrasound < Liver MRI < CT Chest/Abdomen/Pelvis < DSA Coeliac-Mesenteric < MRI liver < CT Chest/Abdomen/Pelvis\nD. Ultrasound < Liver MRI < DSA Coeliac-Mesenteric < CT Chest/Abdomen/Pelvis < MRI liver < CT Chest/Abdomen/Pelvis\nE. Ultrasound < Liver MRI < CT Chest/Abdomen/Pelvis < DSA Coeliac-Mesenteric < MRI liver < CT Chest/Abdomen/Pelvis\n\n\nYour response:\n", "role": "user" }, { "content": "Ultrasound < Liver MRI < CT Chest/Abdomen/Pelvis < DSA Coeliac-Mesenteric < MRI liver < CT Chest/Abdomen/Pelvis", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report to you about Mrs. Linda Mayer, born on 01/12/1948, who\npresented to our outpatient clinic on 07/13/19.\n\n**Diagnoses:**\n\n- BIRADS IV, recommended biopsy during breast diagnostics.\n\n- Left breast carcinoma: iT1b; iN0; MX; ER: 12/12; PR: 2/12; Her-2:\n neg; Ki67: 15%.\n\n**Other Diagnoses: **\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Pemphigus vulgaris under azathioprine therapy\n\n- Osteoporosis\n\n- Obesity with a BMI of 35\n\n- Undergoing immunosuppressive therapy with prednisolone\n\n**Family History:**\n\n- Sister deceased at age 39 from breast cancer.\n\n- Mother and grandmother (maternal and paternal) were diagnosed with\n breast cancer.\n\n**Medical History:** The CT thorax report indicates the presence of\ninflammatory foci, warranting further follow-up. The relevant data was\ndocumented and presented during the tumor conference. Subsequently, a\ntelephone conversation was conducted with the patient to discuss the\nnext steps.\n\n**Tumor board decision from 07/13/2019:**\n\n**Imaging: **\n\n1) MRI examination detected a unifocal lesion on the left external\n aspect, measuring approximately 2.4 cm in size.\n\n2) CT scan (thorax/abdomen 07/12/2019) revealed a previously known\n liver lesion, likely a hemangioma. No evidence of metastases was\n identified. Nonspecific, small foci were observed in the lungs,\n likely indicative of post-inflammatory changes.\n\n**Recommendations:**\n\n1. If no metastasis (M0): Fast-track BRCA testing is recommended.\n\n2. If BRCA testing returns negative: Proceed with a selective excision\n of the left breast after ultrasound-guided fine needle marking and\n sentinel lymph node biopsy on the left side. Additionally, perform\n Endopredict analysis on the surgical specimen.\n\n**Current Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ------------------------------- ------------ ----------- ---------------\n Aspirin 100mg Oral 1-0-0\n Simvastatin (Zocor) 40mg Oral 0-1-0\n Haloperidol (Haldol) 100mg Oral ½-0-½\n Zopiclone (Imovane) 7.5mg Oral 0-0-1\n Trazodone (Desyrel) 100mg Oral 0-0-½-\n Calcium Supplement (Caltrate) 500mg Oral 1-0-1\n Nystatin (Bio-Statin) As advised Oral 1-1-1-1\n Pantoprazole (Protonix) 40mg Oral 1-0-0\n Prednisolone (Prelone) 40mg Oral As advised\n Tramadol/Naloxone (Ultram) 50/4mg Oral 1-0-1\n Acyclovir (Zovirax) 800mg Oral 1-1-1\n\n**Mammography and Tomosynthesis from 07/8/2019:**\n\n[Findings]{.underline}**: **During the inspection and palpation, no\nsignificant findings were noted on either side. Some areas with higher\nmammographic density were observed, which slightly limited the\nassessment. However, during the initial examination, a small\narchitectural irregularity was identified on the outer left side. This\nirregularity appeared as a small, roundish compression measuring\napproximately 6mm and was visible only in the medio-lateral oblique\nimage, with a nipple distance of 8cm. Apart from this discovery, there\nwere no other suspicious focal findings on either side. No clustered or\nirregular microcalcifications were detected. Additionally, a long-term,\nunchanged observation noted some asymmetry with denser breast tissue\npresent on both sides, particularly on the outer aspects. Sonographic\nevaluation posed challenges due to the mixed echogenic glandular tissue.\nAs a possible corresponding feature to the questionable architectural\nirregularity on the outer left side, a blurred, echo-poor area with a\nvertical alignment measuring about 7x5mm was identified. Importantly, no\nother suspicious focal findings were observed, and there was no evidence\nof enlarged lymph nodes in the axilla on both sides.\n\n[Assessment]{.underline}**:** The observed finding on the left side\npresents an uncertain nature, categorized as BIRADS IVb. In contrast,\nthe finding on the right side appears benign, categorized as BIRADS II.\nTo gain a more conclusive understanding of the left-sided finding, we\nrecommend a histological assessment through a sonographically guided\nhigh-speed punch biopsy. An appointment has been scheduled with the\npatient to proceed with this biopsy and obtain a definitive\ndiagnosis.Formularbeginn\n\nFormularende**Current Recommendations:**\\\nA fast-track decision will be made regarding tumor genetics, and the\npatient will be notified of the appointment via telephone. The patient\nshould bring the pathology blocks from Fairview Clinic on the day of\nblood collection for genetic testing, along with a referral for an\nEndopredict test. A multidisciplinary team meeting will be convened\nafter the Endopredict test and genetic testing results are available. If\nthere is persistence or worsening of symptoms, we strongly advise the\npatient to seek immediate re-evaluation. Additionally, outside of\nregular office hours, the patient can seek assistance at the emergency\ncare unit in case of emergency.\n\n**MRI from 07/11/2019:**\n\n[Technique:]{.underline} Breast MRI (3T scanner) with dedicated mammary\nsurface coil: \n\n[Findings:]{.underline} The overall contrast enhancement was observed\nbilaterally to evaluate the Grade II findings. There was low to moderate\nsmall-spotted contrast enhancement with slightly limited assessability.\nThe contrast dynamics revealed a patchy, confluent, blurred, and\nelongated contrast enhancement, corresponding to the primary lesion,\nwhich measured approximately 2.4 cm on the lower left exterior. Single\nspicules were noted, and the lesion appeared hypointense in T1w imaging.\nNo suspicious focal findings with contrast enhancement were detected on\nthe right side. Small axillary lymph nodes were observed on the left\nside, but they did not appear suspicious based on MR morphology.\nAdditionally, there were no suspicious lymph nodes on the right side.\n\n[Assessment:]{.underline} An unifocal primary lesion measuring\napproximately 2.4 cm in diameter was identified on the lower left\nexterior. It exhibited patchy confluent enhancement and architectural\ndisturbance, with single spicules. No evidence of suspicious lymph nodes\nwas found. The left side is categorized as BIRADS 6, indicating a high\nsuspicion of malignancy, while the right side is categorized as BIRADS\n2, indicating a benign finding.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide you with an update on the medical condition of\nMrs. Linda Mayer, born on 01/12/1948, who attended our outpatient clinic\non 08/02/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast (17mm)\n\n- Histological grade G3, estrogen receptor (ER) and progesterone\n receptor (PR) negative.\n\n- Postmenopausal for the past eight years.\n\n- Previous surgical history includes an appendectomy.\n\n- Allergies: Hay fever\n\n \n\n**Current Presentation**: The patient sought consultation following a\nconfirmed diagnosis of DCIS (Ductal Carcinoma In Situ) in the right\nbreast, which was determined through a vacuum-assisted biopsy.\n\n**Physical Examination**: Upon physical examination, there is evidence\nof a post-intervention hematoma located in the upper right quadrant of\nthe right breast. However, the clip from the biopsy is not clearly\nvisible. A sonographic examination of the right axilla reveals no\nabnormalities.\n\n**Current Recommendations:**\n\n- Imaging studies have been conducted.\n\n- A case presentation is scheduled for our mammary conference\n tomorrow.\n\n- Subsequently, planning for surgery will commence, including the\n evaluation of sentinel lymph nodes following a right mastectomy and\n axillary lymph node dissection.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient care at our facility on 08/29/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast, measuring 17mm in size, classified as Grade 3, and\n testing negative for estrogen receptors (ER) and progesterone\n receptors (PR).\n\n- Mrs. Mayer has been postmenopausal for eight years.\n\n- Notable allergy: Hay fever\n\n**Tumor Board Decision:** Mammography imaging revealed a clip associated\nwith a focal finding in the right breast adjacent to calcifications.\n\n[Recommendation]{.underline}: Proceed with sentinel lymph node\nevaluation after right mastectomy, including clip localization on the\nright side.\n\n**Current Presentation**: During the patient\\'s recent outpatient visit,\nan extensive pre-operative consultation was conducted. This discussion\ncovered the indications for the surgery, details of the surgical\nprocess, potential alternative options, as well as general and specific\nrisks associated with the procedure. These risks included the\npossibility of an aesthetically suboptimal outcome and the chance of\nencountering an R1 situation. The patient did not have any further\nquestions and provided written consent for the procedure.\n\n**Physical Examination:** Both breasts appear normal upon inspection and\npalpation. The right axilla shows no abnormalities.\n\n**Medical History:** Mrs. Linda Mayer presented to our clinic with a\nvacuum biopsy-confirmed DCIS of the right breast for therapeutic\nintervention. The decision for surgery was reached following a\ncomprehensive review by our interdisciplinary breast board. After an\nextensive discussion of the procedure\\'s scope, associated risks, and\nalternative options, the patient provided informed consent for the\nproposed surgery.\n\n**Preoperative Procedure:** Sonographic and mammographic fine needle\nmarking of the remaining findings and the clip in the right breast.\n\n**Surgical Report:** Team time-out conducted with colleagues of\nanesthesia. Patient positioned in the supine position. Surgical site\ndisinfection and sterile draping. Marking of the incision site.\n\nA semicircular incision was made laterally on the right breast.\nVisualization and dissection along the marking wire towards the marked\nfinding. Excision of the marked findings, with a safety margin of\napproximately 1-2 cm. The excised specimen measured approximately 4 x 5\nx 3 cm. Markings using standard protocol (green thread cranially, blue\nthread ventrally). The excised specimen was sent for preparation\nradiography. Hemostasis was meticulously ensured. Insertion of a 10Ch\nBlake drain into the segmental cavity, followed by suturing.\nVerification of a blood-dry wound cavity. Preparation radiography\nincluded the marked area and the marking wires. The excised material was\ntransferred to our pathology colleagues for histological examination.\nSubdermal and intracutaneous sutures with Monocryl 3/0 in a continuous\nmanner. Application of Steristrips and dressing. Instruments, swabs, and\ncloths were accounted for per the nurse\\'s checklist. The patient was\ncorrectly positioned throughout the operation. The anesthesiologic\ncourse was without significant problems. A thorax compression bandage\nwas applied in the operating room as a preventive measure against\nbleeding.\n\n**Postoperative Procedure:** Pain management, thrombosis prophylaxis,\napplication of a pressure dressing, drainage under suction.\n\n**Examinations:** **Digital Mammography performed on 08/29/2019**\n\n[Clinical indication]{.underline}: DCIS right\n\n[Question]{.underline}: Please send specimen + Mx-FNM\n\n**Findings**: Sonographically guided wire marking of the maximum\nmicrocalcification group measuring about 12 mm. Local hematoma cavity\nand inset clip marking directly cranial to the finding. Stitch direction\nfrom lateral to medial. The wire is positioned with the tip caudal to\nthe clip in close proximity to the microcalcification. Additional\nmarking of the focal localization on the skin. Documentation of the wire\ncourse in two planes.\n\n- Telephone discussion of findings with the surgeon.\n\n- Preparation radiography and preparation sonography are recommended.\n\n- Marking wire and suspicious focal findings centrally included in the\n preparation.\n\n- Intraoperative report of findings has been conveyed to the surgeon.\n\n**Current Recommendations:**\n\n- Scheduled for inpatient admission on ward 22 tomorrow.\n\n- Right breast mastectomy with sentinel lymph node evaluation.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to update you on the clinical course of Mrs. Linda Mayer,\nborn on 01/12/1948, who was under our inpatient care from 08/30/2019 to\n09/12/2019.\n\n**Diagnosis:** Vacuum-assisted biopsy confirmed Ductal Carcinoma In Situ\n(DCIS) in the right breast, measuring 17mm, Grade 3, ER/PR negative.\n\n**Tumor Board Decision (07/13/2019):**\n\n[Imaging:]{.underline} Clip identified in focal lesion in the right\nbreast, adjacent to calcifications.\n\n[Recommendation]{.underline}**:** Spin Echo following fine-needle\nlocalization with mammography-guided control of the clip in the right\nbreast.\n\n[Subsequent Recommendation (08/27/2019):]{.underline} Radiation therapy\nto the right breast. Regular follow-up is advised.\n\n**Medical History:** Ms. Linda Mayer presented to our facility on\n08/30/2019 for the aforementioned surgical procedure. After a\ncomprehensive discussion regarding the surgical plan, potential risks,\nand possible complications, the patient consented to proceed. The\nsurgery was executed without complications on 09/01/2019. The\npostoperative course was unremarkable, allowing for Ms. Mayer\\'s\ndischarge on 09/12/2019 in stable condition and with no signs of wound\nirritation.\n\n**Histopathological Findings (09/01/2019):**\n\nThe resected segment from the right breast showed a maximum necrotic\nzone of 1.6 cm with foreign body reaction, chronic resorptive\ninflammation, fibrosis, and residual hemorrhage. These findings\nprimarily correspond to the pre-biopsy site. Surrounding this were areas\nof DCIS with solid and cribriform growth patterns and comedonecrosis,\nWHO Grade 3, Nuclear Grade 3, with a reconstructed extent of 3.5 cm.\nResection margins were as follows: ventral 0.15 cm, caudal 0.2 cm,\ndorsal 0.4 cm, with remaining margins exceeding 0.5 cm. TNM\nClassification (8th Edition, 2017): pTis (DCIS), R0, G3. Additional\nimmunohistochemical studies are underway to determine hormone receptor\nstatus; a supplementary report will follow.\n\n**Postoperative Plan:**\n\nThe patient was educated on standard postoperative care and the\nimportance of immediate re-evaluation for any persistent or worsening\nsymptoms. Radiation therapy to the right breast is planned, along with\nregular follow-up appointments.\n\nShould you have any questions or require further clarification, we are\nreadily available. For urgent concerns outside of regular office hours,\nemergency care is available at the Emergency Department.\n\n**Internal Histopathological Findings Report**\n\n**Clinical Data:** DCIS in the right breast (17 mm), Grade 3, ER/PR\nnegative.\n\n**Macroscopic Examination:**\n\nThe resected mammary segment from the right breast, marked with dual\nthreads and containing a fine-needle marker inserted ventro-laterally,\nmeasures 4.5 x 5.5 x 3 cm (HxWxD) and weighs 35 grams. The specimen was\nsectioned from medial to lateral into 14 lamellae. The cut surface\npredominantly shows yellowish, lobulated mammary parenchyma with sparse\nstriated whitish glandular components. A DCIS-suspected area, up to 2.1\ncm in size, is evident caudally and centro-ventrally (from lamellae\n4-10), displaying both reddish-hemorrhagic and whitish-nodular\nindurations. Minimal distances from the suspicious area to the resection\nmargins are as follows: cranial 2 cm, caudal 0.2 cm, dorsal 0.2 cm,\nventral 0.1 cm, medial 1.6 cm, lateral 2.5 cm. The suspect area was\ncompletely embedded. Ink markings: green/cranial, yellow/caudal,\nblue/ventral, black/dorsal.\n\n**Microscopic Examination:**\n\nHistological sections of the mammary parenchyma reveal fibro-lipomatous\nstroma and glandular lobules with a two-layered epithelial lining. In\nlamellae 3-6 and 11, solid and cribriform epithelial proliferations are\nevident. Cells are cuboidal with variably enlarged, predominantly\nmoderately pleomorphic, round to oval nuclei. Comedo-like necroses are\noccasionally observed in secondary lumina. Microscopic distances to the\ndeposition margins are consistent with the macroscopic findings. The\nsurrounding stroma in lamellae 6-9 shows extensive geographic adipose\ntissue necrosis, multinucleated foreign body-type giant cells, foamy\ncell macrophages, collagen fiber proliferation, and fresh hemorrhages.\n\n**Supplemental Immunohistochemical Findings\n(09/04/2019):** **Microscopy:** In the meantime, the material was\nfurther processed as announced.\n\nHere, the previously described intraductal epithelial growths, each with\nnegative staining reaction for the estrogen and progesterone receptor\n(with regular external and internal control reaction).\n\n \n\n**Critical Findings:**\n\nResected mammary segment with paracentral, max. 1.6 cm necrotic zone\nwith foreign body reaction, chronic resorptive. Chronic resorptive\ninflammation, fibrosis, and hemorrhage remnants (primarily corresponding\nto the pre-biopsy site), and surrounding portions of ductal carcinoma in\nsitu. Ductal carcinoma in situ, solid and rib-shaped growth type with\ncomedonecrosis, WHO grade 3, nuclear grade 3. The resection was locally\ncomplete with the following Safety margins: ventral 0.15 cm, caudal 0.2\ncm, dorsal 0.4 cm, and the remaining sedimentation margins more than 0.5\ncm.\n\nTNM classification (8th edition 2017): pTis (DCIS), R0, G3.\n\n[Hormone receptor status:]{.underline}\n\n- Estrogen receptor: negative (0%).\n\n- Progesterone receptor: negative (0%).\n\n \n\n \n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient treatment on 27/09/2019.\n\n**Diagnoses**: Left breast carcinoma; iT1c; iN0; MX; ER:12/12; PR:2/12;\nHer-2: neg; Ki67:15%, BRCA 2 mutation.\n\n**Other Diagnoses**:\n\n- Hailey-Hailey disease - currently regressing under prednisolone.\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 due to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage (Abrasio) in 2004\n\n- Hysterectomy in 2005\n\n**Allergies**: Hay fever\n\n**Imaging**:\n\n- CT revealed a cystic lesion in the liver, not suspicious for\n metastasis. Granulomatous, post-inflammatory changes in the lung.\n\n- An MRI of the left breast showed a unifocal lesion on the outer left\n side with a 2.4 cm extension.\n\n**Histology: **Gene score of 6.5, indicating a high-risk profile (pT2 or\npN1) if BRCA negative.\n\n**Recommendation**: If BRCA negative, SE left mamma after ultrasound-FNM\nwith correlation in Mx and SLNB on the left.\n\n**Current Presentation**: Mrs. Linda Mayer presented for pre-operative\nevaluation for left mastectomy. BRCA testing confirmed a BRCA2 mutation,\nwarranting bilateral subcutaneous mastectomy and SLNB on the left.\nReconstruction with implants and mesh is planned, along with a breast\nlift as requested by the patient.\n\n**Macroscopy:**\n\n**Left Subcutaneous Mastectomy (Blue/Ventral, Green/Cranial):**\n\n- Specimen Size: 17 x 15 x 6 cm (Height x Width x Depth), Weight: 410\n g\n\n- Description: Dual filament-labeled subcutaneous mastectomy specimen\n\n- Specimen Workup: 27 lamellae from lateral to medial\n\n- Tumor-Suspect Area (Lamellae 17-21): Max. 1.6 cm, white dermal,\n partly blurred\n\n- Margins from Tumor Area: Ventral 0.1 cm, Caudal 1 cm, Dorsal 1.2 cm,\n Cranial \\> 5 cm, Lateral \\> 5 cm, Medial \\> 2 cm\n\n- Remaining Mammary Parenchyma: Predominantly yellowish lipomatous\n with focal nodular appearance\n\n- Ink Markings: Cranial/Green, Caudal/Yellow, Ventral/Blue,\n Dorsal/Black\n\n - A: Lamella 17 - Covers dorsal and caudal\n\n - B: Lamella 18 - Covers ventral\n\n - C: Lamella 19 - Covers ventral\n\n - D: Blade 21 - Covers ventral\n\n - E: Lamella 20 - Reference cranial\n\n - F: Lamella 16 - Immediately laterally following mammary\n parenchyma\n\n - G: Blade 22 - Reference immediately medial following mammary\n tissue\n\n - H: Lamella 12 - Central section\n\n - I: Lamella 8 - Documented section top/outside\n\n - J: Lamella 3 - Vestigial section below/outside\n\n - K: Lamella 21 - White-nodular imposing area\n\n - L: Lamella 8 - Further section below/outside with nodular area\n\n - M: Lateral border lamella perpendicularly\n\n - N: Medial border lamella perpendicular (Exemplary)\n\n**Second Sentinel Lymph Node on the Left:**\n\n- Specimen: Maximum of 6 cm of fat tissue resectate with 1 to 2 cm of\n lymph nodes and smaller nodular indurations.\n\n- A, B: One lymph node each divided\n\n- C: Further nodular indurations\n\n**Palpable Lymph Nodes Level I:**\n\n- Specimen: One max. 4.5 cm large fat resectate with nodular\n indurations up to 1.5 cm in size\n\n- A: One nodular induration divided\n\n- B: Further nodular indurated portions\n\n**Right Subcutaneous Mastectomy:**\n\n- Specimen: Double thread-labeled 450 g subcutaneous mastectomy\n specimen\n\n- Assumed Suture Markings: Blue (Ventral) and Green (Cranial)\n\n- Dorsal Fascia Intact\n\n- [Specimen Preparation:]{.underline} 16 lamellae from medial to\n lateral\n\n- Predominantly yellowish lobulated with streaky, beige, impinging\n strands of tissue\n\n- Isolated hemorrhages in the parenchyma\n\n- Ink Markings: Green = Cranial, Yellow = Caudal, Blue = Ventral,\n Black = Dorsal\n\n<!-- -->\n\n- A: Medial border lamella perpendicular (Exemplary)\n\n- B: Lamella 5 with reference ventrally (below inside)\n\n- C: Lamella 8 with reference ventrally (below inside)\n\n- D: Lamella 6 with ventral and dorsal reference (upper inside)\n\n- E: Blade 8 with ventral and dorsal cover (top inside)\n\n- F: Blade 11 with cover dorsal and caudal (bottom outside)\n\n- G: Blade 13 with dorsal cover (bottom outside)\n\n- H: Blade 10 with ventral and dorsal cover (top outside)\n\n- I: Lamella 14 with reference cranial and dorsal and bleeding in\n (upper outer)\n\n- J: Lateral border lamella perpendicular (Exemplary)\n\n**Microscopy:**\n\n1\\) In the tumor-suspicious area, a blurred large fibrosis zone with\nstar-shaped extensions is visible. Intercalated are single-cell and\nstranded epithelial cells with a high nuclear-cytoplasmic ratio. The\nnuclei are monomorphic with finely dispersed chromatin, at most, very\nisolated mitoses. Adjacent distended glandular ducts with a discohesive\ncell proliferate with the same cytomorphology. Sporadically, preexistent\nglandular ducts are sheared disc-like by the infiltrative tumor cells.\nSamples from the nodular area of lamella 21 show areas of cell-poor\nhyaline sclerosis with partly ectatically dilated glandular ducts.\n\n2\\) Second lymph node with partial infiltrates of the neoplasia described\nabove. The cells here are relatively densely packed. Somewhat increased\nmitoses. In the lymph nodes, iron deposition is also in the sinus\nhistiocytes.\n\n3\\) Lymph nodes with partly sparse iron deposition. No epithelial foreign\ninfiltrates.\n\n4\\) Regular mammary gland parenchyma. No tumor infiltrates. Part of the\nglandular ducts are slightly cystically dilated.\n\n**Preliminary Critical Findings Report: **\n\nLeft breast carcinoma measuring max 1.6 cm diagnosed as moderately\ndifferentiated invasive lobular carcinoma, B.R.E. score 6 (3+2+1, G2).\nPresence of tumor-associated and peritumoral lobular carcinoma in situ.\nResection status indicates locally complete excision of both invasive\nand non-invasive carcinoma; minimal margins as follows: ventral \\<0.1\ncm, caudal 0.2 cm, dorsal 0.8 cm, remaining margins ≥0.5 cm. Nodal\nstatus reveals max 0.25 cm metastasis in 1/5 nodes, 0/2 additional\nnodes, without extracapsular spread. Right mammary gland from\nsubcutaneous mastectomy shows tumor-free parenchyma.\n\n**TNM classification (8th ed. 2017):** pT1c, pTis (LCIS), pN1a, G2, L0,\nV0, Pn0, R0. Investigations to determine tumor biology were initiated.\nAddendum follows.\n\n**Supplementary findings on 10/07/2019**\n\nEditing: immunohistochemistry:** **\n\nEstrogen receptor, Progesterone receptor, Her2neu, MIB-1 (block 1D).\n\n**Critical Findings Report:** Breast carcinoma on the left with a 1.6 cm\ninvasive lobular carcinoma, moderately differentiated, with a B.R.E.\nscore of 6 (3+2+1, G2). Additionally, tumor-associated and peritumoral\nlobular carcinoma in situ are noted. Resection status confirms locally\ncomplete excision of both invasive and non-invasive carcinomas; minimal\nresection margins are ventral \\<0.1 cm, caudal (LCIS) 0.2 cm, dorsal 0.8\ncm, and all other margins ≥0.5 cm. Nodal assessment reveals a single\nmetastasis with a maximum dimension of 0.25 cm among 7 lymph nodes,\nspecifically found in 1/5 nodes, with no additional metastasis in 0/2\nnodes and no extracapsular extension. Contralateral right mammary gland\nfrom subcutaneous mastectomy is tumor-free.\n\nTumor biology of the invasive carcinoma demonstrates strong positive\nestrogen receptor expression in 100% of tumor cells, strong positive\nprogesterone receptor expression in 1% of tumor cells, negative HER2/neu\nstatus (Score 1+), and a Ki67 (MIB-1) proliferation index of 25%.\n\n**TNM classification (8th Edition 2017):** pT1c, pTis (LCIS), pN1a (1/7\nECE-, sn), G2, L0, V0, Pn0, R0.\n\n**Surgery Report (Vac Change + Irrigation)**: Indication for VAC change.\nAfter a detailed explanation of the procedure, its risks, and\nalternatives, the patient agrees to the proposed procedure.\n\nThe course of surgery: Proper positioning in a supine position. Removal\nof the VAC sponge. A foul odor appears from the wound cavity. Careful\ndisinfection of the surgical area. Sterile draping. Detailed inspection\nof the wound conditions. Wound debridement with removal of fibrin\ncoatings and freshening of the wound. Resection of necrotic material in\nplaces with sharp spoon. Followed by extensive Irrigation of the entire\nwound bed and wound edges using 1 l Polyhexanide solution. Renewed VAC\nsponge application according to standard.\n\n**Postoperative procedure**: Pain medication, thrombosis prophylaxis,\ncontinuation of antibiotic therapy. In the case of abundant\nStaphylococcus aureus and isolated Pseudomosas in the smear and still\nclinical suspected infection, extension of antibiotic treatment to\nMeropenem.\n\n**Surgery Report: Implant Placement**\n\n**Type of Surgery:** Implant placement and wound closure.\n\n**Report:** After infection and VAC therapy, clean smears and planning\nof reinsertion. Informed consent. Intraoperative consults: Anesthesia.\n\n**Course of Surgery:** Team time out. Removal VAC sponge. Disinfection\nand covering. Irrigation of the wound cavity with Serasept. Blust\nirrigation. Fixation cranially and laterally with 4 fixation sutures\nwith Vircryl 2-0. Choice of trial implant. Temporary insertion. Control\nin sitting and lying positions. Choice of the implant. Repeated\ndisinfection. Change of gloves. Insertion of the implant into the\npocket. Careful hemostasis. Insertion of a Blake drain into the wound\ncavity. Suturing of the drainage. Subcutaneous sutures with Monocryl\n3-0.\n\n**Type of Surgery:** Prophylactic open Laparoscopy, extensive\nadhesiolysis\n\n**Type of Anesthesia:** ITN\n\n**Report:** Patient presented for prophylactic right adnexectomy in the\ncourse of hysterectomy and left adnexectomy due to genetic burden.\nIntraoperatively, secondary wound closure was to be performed in the\ncase of a right mammary wound weeping more than one year\npostoperatively. The patient agreed to the planned procedure in writing\nafter receiving detailed information about the extent, the risks, and\nthe alternatives.\n\n**Course of the Operation:** Team time out with anesthesia colleagues.\nFlat lithotomy positioning, disinfection, and sterile draping. Placement\nof permanent transurethral catheter. Subumbilical incision and\ndissection onto the fascia. Opening of the fascia and suturing of the\nsame. Exposure of the peritoneum and opening of the same. Insertion of\nthe 10-mm optic trocar. Insertion of three additional trocars into the\nlower abdomen (left and center right, each 5mm; right 10mm). The\nfollowing situation is seen: when the camera is inserted from the\numbilical region, an extensive adhesion is seen. Only by changing the\ncamera to the right lower bay is extensive adhesiolysis possible. The\nomentum is fused with the peritoneum and the serosa of the uterus. Upper\nabdomen as far as visible inconspicuous.\n\nAfter hysterectomy and adnexectomy on the left side, adnexa on the right\nside atrophic and inconspicuous. The peritoneum is smooth as far as can\nbe seen.\n\nVisualization of the right adnexa and the suspensory ligament of ovary.\n\nCoagulation of the suspensory ligament of ovary ligament after\nvisualization of the ureter on the same side. Stepwise dissection of the\nadnexa from the pelvic wall.\n\nRecovery via endobag. Hemostasis. Inspection of the situs.\n\nRemoval of instrumentation under vision and draining of\npneumoperitoneum.\n\nClosure of the abdominal fascia at the umbilicus and right lower\nabdomen. Suturing of the skin with Monocryl 3/0. Compression bandage at\neach trocar insertion site. Inspection of the right mamma. In the area\nof the surgical scar laterally/externally, 2-3 small epithelium-lined\npore-like openings are visible; here, on pressure, discharge of rather\nviscous/sebaceous, non-odorous, or purulent fluid. No dehiscence is\nvisible, suspected. fistula ducts to the implant cavity. After\nconsultation with the mamma surgeon, a two-stage procedure was planned\nfor the treatment of the fistula tracts. Correct positioning and\ninconspicuous anesthesiological course. Instrumentation, swabs, and\ncloths complete according to the operating room nurse. Postoperative\nprocedures include analgesia, mobilization, thrombosis prophylaxis, and\nwaiting for histology.\n\n**Internal Histopathological Report** \n\n[Clinical information/question]{.underline}: Fistula formation mammary\nright. Dignity?\n\n[Macroscopy]{.underline}**:** Skin spindle from scar mammary right: fix.\na 2.4 cm long, stranded skin-subcutaneous excidate. Lamellation and\ncomplete embedding.\n\n[Processing]{.underline}**:** 1 block, HE\n\n[Microscopy]{.underline}**:** Histologic skin/subcutaneous\ncross-sections with overlay by a multilayered keratinizing squamous\nepithelium. The dermis with few inset regular skin adnexal structures,\nsparse to moderately dense mononuclear-dominated inflammatory\ninfiltrates, and proliferation of cell-poor, fiber-rich collagenous\nconnective tissue.\n\n**Critical Findings Report:** \n\nSkin spindle on scar mamma right: skin/subcutaneous resectate with\nfibrosis and chronic inflammation. To ensure that all findings are\nrecorded, the material will be further processed. A follow-up report\nwill follow.\n\n[Microscopy]{.underline}**:** In the meantime, the material was further\nprocessed as announced. The van Gieson stain showed extensive\nproliferation of collagenous and, in some places elastic fibers. Also in\nthe additional immunohistochemical staining against no evidence of\natypical epithelial infiltrates.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n CRP 7.8 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 11.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 3.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to provide an update on Mrs. Linda Mayer, born on\n01/12/1948, who received inpatient care at our facility from 01/01/2021\nto 01/14/2021.\n\n**Diagnosis:** Hailey-Hailey disease.\n\n- Upon admission, the patient was under treatment with Acitretin 25mg.\n\n**Other Diagnoses**:\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 die to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage in 2004\n\n- Hysterectomy in 2005\n\n**Medical History:** Mrs. Linda Mayer was referred to our hospital for\nthe management of Hailey-Hailey disease after assessment in our\noutpatient clinic. She reported a worsening of painful skin erosions on\nher neck and inner thighs over a span of approximately 3 weeks.\nItchiness was not reported. Prior attempts at treatment, including the\ntopical use of Fucicort, Prednisolone with Octenidine, and Polidocanol\ngel, had provided limited relief. She denied any other physical\ncomplaints, dyspnea, B symptoms, infections, or irregularities in stool\nand micturition.\n\nHer history revealed the initial onset of Hailey-Hailey disease,\ninitially presenting as itching followed by skin erosions, which\nsubsequently healed with scarring. The diagnosis was established at the\nFairview Clinic. Previous therapeutic interventions included systemic\ncortisone shock therapy, as-needed application of Fucicort ointment, and\naxillary laser therapy.\n\n**Family History:**\n\n- Father: Hailey-Hailey Disease (M. Hailey-Hailey)\n\n- Mother and Sister: Breast carcinoma\n\n**Psychosocial History:** Socially, Ms. Linda Mayer is described as a\nretiree, having previously worked as a nurse.\n\n**Physical Examination on Admission:**\n\nHeight: 16 cm, Body Weight: 80.0 kg, BMI: 29.7\n\n**Physical Examination Findings:**\n\nGenerally stable condition with increased nutritional status. Her\nconsciousness was unremarkable, and cranial mobility was free. Ocular\nmobility was regular, with prompt pupillary reflexes to accommodation\nand light. She exhibited a normal heart rate, and cardiac and pulmonary\nexaminations were unremarkable. No heart murmurs were detected. Renal\nbed and spine were not palpable. Further internal and orienting\nneurological examinations revealed no pathological findings.\n\n**Skin Findings on Admission:** Sharp erosions, approximately 10x10 cm\nin size, with a livid-erythematous base, partly crusty, were observed on\nthe neck and proximal inner thighs.\n\nIn the axillary regions on both sides, there were marginal,\nlivid-erythematous, well-demarcated plaques interspersed with scarring\nstrands, more pronounced on the right side.\n\nSkin type II.\n\nMucous membranes appeared normal. Dermographism was noted to be ruber.\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------ ------------ -------------------------------\n Prednisolone (Deltasone) 5 mg 1.5-0-0-0-0-0\n Aspirin (Bayer) 100 mg 0-1-0-0-0-0\n Simvastatin (Zocor) 40 mg 0-0-0-0-1\n Pantoprazole (Protonix) 45.1 mg 1-0-0-0-0\n Acitretin (Soriatane) 25 mg 1-0-0-0-0\n Tetrabenazine (Xenazine) 111 mg 0.25-0.25-0.25-0.25-0.25-0.25\n Letrozole (Femara) 2.5 mg 0-0-1-0\n Risedronate Sodium (Actonel) 35 mg 1-0-0-0-0\n Acetaminophen (Tylenol) 500 mg 0-1-0-1\n Naloxone (Narcan) 8.8 mg 1-0-1-0\n Eszopiclone (Lunesta) 7.5 mg 0-0-1-0\n\n**Other Findings:** MRSA Smears:\n\n- Nasal Smear: Normal flora, no MRSA.\n\n- Throat Swab: Normal flora, no MRSA.\n\n- Non-lesional Skin Smear: Normal flora.\n\n- Lesional Skin Swab: Abundant Pseudomonas aeruginosa, abundant\n Klebsiella oxytoca, and abundant Serratia sp., sensitive to\n piperacillin-tazobactam.\n\n**Therapy and Progression:** Mrs. Linda Mayer was admitted on 01/01/2021\nas an inpatient for a refractory exacerbation of previously diagnosed\nHailey-Hailey disease. On admission, both bacteriological and\nmycological smears were conducted, which indicated abundant levels of\nPseudomonas aeruginosa, Klebsiella oxytoca, and Serratia sp. Lab tests\nshowed a CRP level of 2.83 mg/dL and a leukocyte count of 8.8 G/L.\n\nInitial topical therapy consisted of Zinc oxide ointment, Clotrimazole\npaste, and Triamcinolone Acetonide shake lotion. Treatment was modified\non 01/04/2021 to include Clotrimazole (Lotrimin) paste in the mornings\nand methylprednisolone emulsion in the evenings. Starting on 01/08,\neosin aqueous solution was introduced for application on the thighs,\nserving antiseptic and drying purposes. A hydrophilic prednicarbate\ncream at 0.25% concentration, combined with octenidine at 0.1%, was\napplied to the neck and thighs twice daily, also starting on 01/08. For\nshowering, octenidine-based wash lotion was utilized. Additionally, Mrs.\nLinda Mayer received an emulsifying ointment as part of her treatment.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are providing an update on our patient Mrs. Linda Mayer, born on\n01/12/1948, who presented to our outpatient clinic on 09/22/2021.\n\n**Diagnoses:** M. Hailey-Hailey\n\n**Medical History:**\n\n- Diagnosis of M. Hailey-Hailey at the Fairview Clinic\n\n<!-- -->\n\n- Treatment involved systemic steroid shock therapy, laser therapy,\n and the initiation of Acitretin in October 2021, with no observed\n improvement.\n\n<!-- -->\n\n- A dermabrasion procedure was scheduled on 03/18/2021, during a\n previous inpatient admission.\n\n- Acitretin 25mg has been administered daily, with favorable outcomes\n noted when using Triamcinolone/Triclosan or Prednisolone +\n Octenidine.\n\n- A history of mastectomy with Vacuum-Assisted Closure (VAC) has\n resulted in breast erosion.\n\n**Skin Findings:**\n\n- Erythematous and partially mottled lesions have been identified in\n the axillary and inguinal regions, with some scarring observed in\n the axillary area.\n\n- On 04/28/2021, somewhat erosive plaques were noted in the inguinal\n regions.\n\n- As of 05/05/2021 discrete erosions are currently present on both\n forearms.\n\n**Current Recommendations:**\n\n- Inpatient admission is scheduled for September 2021.\n\n- The prescribed treatment plan includes topical prednicarbate\n (Dermatop) 0.25% with Octenidine 0.1%, per NRF 11.145, in a 50g\n container, to be applied once daily for 1-2 weeks.\n\n- Hydrocortisone 5% in a suitable base, 200g, is to be applied daily.\n\n- The regimen also includes prednicarbate (Dermatop) combined with\n Octenidine.\n\n- Acitretin will be continued temporarily.\n\n- A follow-up appointment in the outpatient clinic is scheduled for\n three months from now.\n\n- Discontinuation of Acitretin.\n\n- It is recommended to avoid the use of compresses on the erosions to\n prevent constant trauma.\n\n- Topical therapy with petrolatum-based wound ointment and sterile\n compresses.\n\n\n\n\nHere is the query:\nWhat is the notable allergy Mrs. Mayer has?\n\nChoose the correct answer from the following options:\nA. Penicillin\nB. Latex\nC. Hay fever\nD. Peanuts\nE. Aspirin\n\n\nYour response:\n", "role": "user" }, { "content": "Hay fever", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report to you about Mrs. Linda Mayer, born on 01/12/1948, who\npresented to our outpatient clinic on 07/13/19.\n\n**Diagnoses:**\n\n- BIRADS IV, recommended biopsy during breast diagnostics.\n\n- Left breast carcinoma: iT1b; iN0; MX; ER: 12/12; PR: 2/12; Her-2:\n neg; Ki67: 15%.\n\n**Other Diagnoses: **\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Pemphigus vulgaris under azathioprine therapy\n\n- Osteoporosis\n\n- Obesity with a BMI of 35\n\n- Undergoing immunosuppressive therapy with prednisolone\n\n**Family History:**\n\n- Sister deceased at age 39 from breast cancer.\n\n- Mother and grandmother (maternal and paternal) were diagnosed with\n breast cancer.\n\n**Medical History:** The CT thorax report indicates the presence of\ninflammatory foci, warranting further follow-up. The relevant data was\ndocumented and presented during the tumor conference. Subsequently, a\ntelephone conversation was conducted with the patient to discuss the\nnext steps.\n\n**Tumor board decision from 07/13/2019:**\n\n**Imaging: **\n\n1) MRI examination detected a unifocal lesion on the left external\n aspect, measuring approximately 2.4 cm in size.\n\n2) CT scan (thorax/abdomen 07/12/2019) revealed a previously known\n liver lesion, likely a hemangioma. No evidence of metastases was\n identified. Nonspecific, small foci were observed in the lungs,\n likely indicative of post-inflammatory changes.\n\n**Recommendations:**\n\n1. If no metastasis (M0): Fast-track BRCA testing is recommended.\n\n2. If BRCA testing returns negative: Proceed with a selective excision\n of the left breast after ultrasound-guided fine needle marking and\n sentinel lymph node biopsy on the left side. Additionally, perform\n Endopredict analysis on the surgical specimen.\n\n**Current Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ------------------------------- ------------ ----------- ---------------\n Aspirin 100mg Oral 1-0-0\n Simvastatin (Zocor) 40mg Oral 0-1-0\n Haloperidol (Haldol) 100mg Oral ½-0-½\n Zopiclone (Imovane) 7.5mg Oral 0-0-1\n Trazodone (Desyrel) 100mg Oral 0-0-½-\n Calcium Supplement (Caltrate) 500mg Oral 1-0-1\n Nystatin (Bio-Statin) As advised Oral 1-1-1-1\n Pantoprazole (Protonix) 40mg Oral 1-0-0\n Prednisolone (Prelone) 40mg Oral As advised\n Tramadol/Naloxone (Ultram) 50/4mg Oral 1-0-1\n Acyclovir (Zovirax) 800mg Oral 1-1-1\n\n**Mammography and Tomosynthesis from 07/8/2019:**\n\n[Findings]{.underline}**: **During the inspection and palpation, no\nsignificant findings were noted on either side. Some areas with higher\nmammographic density were observed, which slightly limited the\nassessment. However, during the initial examination, a small\narchitectural irregularity was identified on the outer left side. This\nirregularity appeared as a small, roundish compression measuring\napproximately 6mm and was visible only in the medio-lateral oblique\nimage, with a nipple distance of 8cm. Apart from this discovery, there\nwere no other suspicious focal findings on either side. No clustered or\nirregular microcalcifications were detected. Additionally, a long-term,\nunchanged observation noted some asymmetry with denser breast tissue\npresent on both sides, particularly on the outer aspects. Sonographic\nevaluation posed challenges due to the mixed echogenic glandular tissue.\nAs a possible corresponding feature to the questionable architectural\nirregularity on the outer left side, a blurred, echo-poor area with a\nvertical alignment measuring about 7x5mm was identified. Importantly, no\nother suspicious focal findings were observed, and there was no evidence\nof enlarged lymph nodes in the axilla on both sides.\n\n[Assessment]{.underline}**:** The observed finding on the left side\npresents an uncertain nature, categorized as BIRADS IVb. In contrast,\nthe finding on the right side appears benign, categorized as BIRADS II.\nTo gain a more conclusive understanding of the left-sided finding, we\nrecommend a histological assessment through a sonographically guided\nhigh-speed punch biopsy. An appointment has been scheduled with the\npatient to proceed with this biopsy and obtain a definitive\ndiagnosis.Formularbeginn\n\nFormularende**Current Recommendations:**\\\nA fast-track decision will be made regarding tumor genetics, and the\npatient will be notified of the appointment via telephone. The patient\nshould bring the pathology blocks from Fairview Clinic on the day of\nblood collection for genetic testing, along with a referral for an\nEndopredict test. A multidisciplinary team meeting will be convened\nafter the Endopredict test and genetic testing results are available. If\nthere is persistence or worsening of symptoms, we strongly advise the\npatient to seek immediate re-evaluation. Additionally, outside of\nregular office hours, the patient can seek assistance at the emergency\ncare unit in case of emergency.\n\n**MRI from 07/11/2019:**\n\n[Technique:]{.underline} Breast MRI (3T scanner) with dedicated mammary\nsurface coil: \n\n[Findings:]{.underline} The overall contrast enhancement was observed\nbilaterally to evaluate the Grade II findings. There was low to moderate\nsmall-spotted contrast enhancement with slightly limited assessability.\nThe contrast dynamics revealed a patchy, confluent, blurred, and\nelongated contrast enhancement, corresponding to the primary lesion,\nwhich measured approximately 2.4 cm on the lower left exterior. Single\nspicules were noted, and the lesion appeared hypointense in T1w imaging.\nNo suspicious focal findings with contrast enhancement were detected on\nthe right side. Small axillary lymph nodes were observed on the left\nside, but they did not appear suspicious based on MR morphology.\nAdditionally, there were no suspicious lymph nodes on the right side.\n\n[Assessment:]{.underline} An unifocal primary lesion measuring\napproximately 2.4 cm in diameter was identified on the lower left\nexterior. It exhibited patchy confluent enhancement and architectural\ndisturbance, with single spicules. No evidence of suspicious lymph nodes\nwas found. The left side is categorized as BIRADS 6, indicating a high\nsuspicion of malignancy, while the right side is categorized as BIRADS\n2, indicating a benign finding.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide you with an update on the medical condition of\nMrs. Linda Mayer, born on 01/12/1948, who attended our outpatient clinic\non 08/02/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast (17mm)\n\n- Histological grade G3, estrogen receptor (ER) and progesterone\n receptor (PR) negative.\n\n- Postmenopausal for the past eight years.\n\n- Previous surgical history includes an appendectomy.\n\n- Allergies: Hay fever\n\n \n\n**Current Presentation**: The patient sought consultation following a\nconfirmed diagnosis of DCIS (Ductal Carcinoma In Situ) in the right\nbreast, which was determined through a vacuum-assisted biopsy.\n\n**Physical Examination**: Upon physical examination, there is evidence\nof a post-intervention hematoma located in the upper right quadrant of\nthe right breast. However, the clip from the biopsy is not clearly\nvisible. A sonographic examination of the right axilla reveals no\nabnormalities.\n\n**Current Recommendations:**\n\n- Imaging studies have been conducted.\n\n- A case presentation is scheduled for our mammary conference\n tomorrow.\n\n- Subsequently, planning for surgery will commence, including the\n evaluation of sentinel lymph nodes following a right mastectomy and\n axillary lymph node dissection.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient care at our facility on 08/29/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast, measuring 17mm in size, classified as Grade 3, and\n testing negative for estrogen receptors (ER) and progesterone\n receptors (PR).\n\n- Mrs. Mayer has been postmenopausal for eight years.\n\n- Notable allergy: Hay fever\n\n**Tumor Board Decision:** Mammography imaging revealed a clip associated\nwith a focal finding in the right breast adjacent to calcifications.\n\n[Recommendation]{.underline}: Proceed with sentinel lymph node\nevaluation after right mastectomy, including clip localization on the\nright side.\n\n**Current Presentation**: During the patient\\'s recent outpatient visit,\nan extensive pre-operative consultation was conducted. This discussion\ncovered the indications for the surgery, details of the surgical\nprocess, potential alternative options, as well as general and specific\nrisks associated with the procedure. These risks included the\npossibility of an aesthetically suboptimal outcome and the chance of\nencountering an R1 situation. The patient did not have any further\nquestions and provided written consent for the procedure.\n\n**Physical Examination:** Both breasts appear normal upon inspection and\npalpation. The right axilla shows no abnormalities.\n\n**Medical History:** Mrs. Linda Mayer presented to our clinic with a\nvacuum biopsy-confirmed DCIS of the right breast for therapeutic\nintervention. The decision for surgery was reached following a\ncomprehensive review by our interdisciplinary breast board. After an\nextensive discussion of the procedure\\'s scope, associated risks, and\nalternative options, the patient provided informed consent for the\nproposed surgery.\n\n**Preoperative Procedure:** Sonographic and mammographic fine needle\nmarking of the remaining findings and the clip in the right breast.\n\n**Surgical Report:** Team time-out conducted with colleagues of\nanesthesia. Patient positioned in the supine position. Surgical site\ndisinfection and sterile draping. Marking of the incision site.\n\nA semicircular incision was made laterally on the right breast.\nVisualization and dissection along the marking wire towards the marked\nfinding. Excision of the marked findings, with a safety margin of\napproximately 1-2 cm. The excised specimen measured approximately 4 x 5\nx 3 cm. Markings using standard protocol (green thread cranially, blue\nthread ventrally). The excised specimen was sent for preparation\nradiography. Hemostasis was meticulously ensured. Insertion of a 10Ch\nBlake drain into the segmental cavity, followed by suturing.\nVerification of a blood-dry wound cavity. Preparation radiography\nincluded the marked area and the marking wires. The excised material was\ntransferred to our pathology colleagues for histological examination.\nSubdermal and intracutaneous sutures with Monocryl 3/0 in a continuous\nmanner. Application of Steristrips and dressing. Instruments, swabs, and\ncloths were accounted for per the nurse\\'s checklist. The patient was\ncorrectly positioned throughout the operation. The anesthesiologic\ncourse was without significant problems. A thorax compression bandage\nwas applied in the operating room as a preventive measure against\nbleeding.\n\n**Postoperative Procedure:** Pain management, thrombosis prophylaxis,\napplication of a pressure dressing, drainage under suction.\n\n**Examinations:** **Digital Mammography performed on 08/29/2019**\n\n[Clinical indication]{.underline}: DCIS right\n\n[Question]{.underline}: Please send specimen + Mx-FNM\n\n**Findings**: Sonographically guided wire marking of the maximum\nmicrocalcification group measuring about 12 mm. Local hematoma cavity\nand inset clip marking directly cranial to the finding. Stitch direction\nfrom lateral to medial. The wire is positioned with the tip caudal to\nthe clip in close proximity to the microcalcification. Additional\nmarking of the focal localization on the skin. Documentation of the wire\ncourse in two planes.\n\n- Telephone discussion of findings with the surgeon.\n\n- Preparation radiography and preparation sonography are recommended.\n\n- Marking wire and suspicious focal findings centrally included in the\n preparation.\n\n- Intraoperative report of findings has been conveyed to the surgeon.\n\n**Current Recommendations:**\n\n- Scheduled for inpatient admission on ward 22 tomorrow.\n\n- Right breast mastectomy with sentinel lymph node evaluation.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to update you on the clinical course of Mrs. Linda Mayer,\nborn on 01/12/1948, who was under our inpatient care from 08/30/2019 to\n09/12/2019.\n\n**Diagnosis:** Vacuum-assisted biopsy confirmed Ductal Carcinoma In Situ\n(DCIS) in the right breast, measuring 17mm, Grade 3, ER/PR negative.\n\n**Tumor Board Decision (07/13/2019):**\n\n[Imaging:]{.underline} Clip identified in focal lesion in the right\nbreast, adjacent to calcifications.\n\n[Recommendation]{.underline}**:** Spin Echo following fine-needle\nlocalization with mammography-guided control of the clip in the right\nbreast.\n\n[Subsequent Recommendation (08/27/2019):]{.underline} Radiation therapy\nto the right breast. Regular follow-up is advised.\n\n**Medical History:** Ms. Linda Mayer presented to our facility on\n08/30/2019 for the aforementioned surgical procedure. After a\ncomprehensive discussion regarding the surgical plan, potential risks,\nand possible complications, the patient consented to proceed. The\nsurgery was executed without complications on 09/01/2019. The\npostoperative course was unremarkable, allowing for Ms. Mayer\\'s\ndischarge on 09/12/2019 in stable condition and with no signs of wound\nirritation.\n\n**Histopathological Findings (09/01/2019):**\n\nThe resected segment from the right breast showed a maximum necrotic\nzone of 1.6 cm with foreign body reaction, chronic resorptive\ninflammation, fibrosis, and residual hemorrhage. These findings\nprimarily correspond to the pre-biopsy site. Surrounding this were areas\nof DCIS with solid and cribriform growth patterns and comedonecrosis,\nWHO Grade 3, Nuclear Grade 3, with a reconstructed extent of 3.5 cm.\nResection margins were as follows: ventral 0.15 cm, caudal 0.2 cm,\ndorsal 0.4 cm, with remaining margins exceeding 0.5 cm. TNM\nClassification (8th Edition, 2017): pTis (DCIS), R0, G3. Additional\nimmunohistochemical studies are underway to determine hormone receptor\nstatus; a supplementary report will follow.\n\n**Postoperative Plan:**\n\nThe patient was educated on standard postoperative care and the\nimportance of immediate re-evaluation for any persistent or worsening\nsymptoms. Radiation therapy to the right breast is planned, along with\nregular follow-up appointments.\n\nShould you have any questions or require further clarification, we are\nreadily available. For urgent concerns outside of regular office hours,\nemergency care is available at the Emergency Department.\n\n**Internal Histopathological Findings Report**\n\n**Clinical Data:** DCIS in the right breast (17 mm), Grade 3, ER/PR\nnegative.\n\n**Macroscopic Examination:**\n\nThe resected mammary segment from the right breast, marked with dual\nthreads and containing a fine-needle marker inserted ventro-laterally,\nmeasures 4.5 x 5.5 x 3 cm (HxWxD) and weighs 35 grams. The specimen was\nsectioned from medial to lateral into 14 lamellae. The cut surface\npredominantly shows yellowish, lobulated mammary parenchyma with sparse\nstriated whitish glandular components. A DCIS-suspected area, up to 2.1\ncm in size, is evident caudally and centro-ventrally (from lamellae\n4-10), displaying both reddish-hemorrhagic and whitish-nodular\nindurations. Minimal distances from the suspicious area to the resection\nmargins are as follows: cranial 2 cm, caudal 0.2 cm, dorsal 0.2 cm,\nventral 0.1 cm, medial 1.6 cm, lateral 2.5 cm. The suspect area was\ncompletely embedded. Ink markings: green/cranial, yellow/caudal,\nblue/ventral, black/dorsal.\n\n**Microscopic Examination:**\n\nHistological sections of the mammary parenchyma reveal fibro-lipomatous\nstroma and glandular lobules with a two-layered epithelial lining. In\nlamellae 3-6 and 11, solid and cribriform epithelial proliferations are\nevident. Cells are cuboidal with variably enlarged, predominantly\nmoderately pleomorphic, round to oval nuclei. Comedo-like necroses are\noccasionally observed in secondary lumina. Microscopic distances to the\ndeposition margins are consistent with the macroscopic findings. The\nsurrounding stroma in lamellae 6-9 shows extensive geographic adipose\ntissue necrosis, multinucleated foreign body-type giant cells, foamy\ncell macrophages, collagen fiber proliferation, and fresh hemorrhages.\n\n**Supplemental Immunohistochemical Findings\n(09/04/2019):** **Microscopy:** In the meantime, the material was\nfurther processed as announced.\n\nHere, the previously described intraductal epithelial growths, each with\nnegative staining reaction for the estrogen and progesterone receptor\n(with regular external and internal control reaction).\n\n \n\n**Critical Findings:**\n\nResected mammary segment with paracentral, max. 1.6 cm necrotic zone\nwith foreign body reaction, chronic resorptive. Chronic resorptive\ninflammation, fibrosis, and hemorrhage remnants (primarily corresponding\nto the pre-biopsy site), and surrounding portions of ductal carcinoma in\nsitu. Ductal carcinoma in situ, solid and rib-shaped growth type with\ncomedonecrosis, WHO grade 3, nuclear grade 3. The resection was locally\ncomplete with the following Safety margins: ventral 0.15 cm, caudal 0.2\ncm, dorsal 0.4 cm, and the remaining sedimentation margins more than 0.5\ncm.\n\nTNM classification (8th edition 2017): pTis (DCIS), R0, G3.\n\n[Hormone receptor status:]{.underline}\n\n- Estrogen receptor: negative (0%).\n\n- Progesterone receptor: negative (0%).\n\n \n\n \n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient treatment on 27/09/2019.\n\n**Diagnoses**: Left breast carcinoma; iT1c; iN0; MX; ER:12/12; PR:2/12;\nHer-2: neg; Ki67:15%, BRCA 2 mutation.\n\n**Other Diagnoses**:\n\n- Hailey-Hailey disease - currently regressing under prednisolone.\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 due to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage (Abrasio) in 2004\n\n- Hysterectomy in 2005\n\n**Allergies**: Hay fever\n\n**Imaging**:\n\n- CT revealed a cystic lesion in the liver, not suspicious for\n metastasis. Granulomatous, post-inflammatory changes in the lung.\n\n- An MRI of the left breast showed a unifocal lesion on the outer left\n side with a 2.4 cm extension.\n\n**Histology: **Gene score of 6.5, indicating a high-risk profile (pT2 or\npN1) if BRCA negative.\n\n**Recommendation**: If BRCA negative, SE left mamma after ultrasound-FNM\nwith correlation in Mx and SLNB on the left.\n\n**Current Presentation**: Mrs. Linda Mayer presented for pre-operative\nevaluation for left mastectomy. BRCA testing confirmed a BRCA2 mutation,\nwarranting bilateral subcutaneous mastectomy and SLNB on the left.\nReconstruction with implants and mesh is planned, along with a breast\nlift as requested by the patient.\n\n**Macroscopy:**\n\n**Left Subcutaneous Mastectomy (Blue/Ventral, Green/Cranial):**\n\n- Specimen Size: 17 x 15 x 6 cm (Height x Width x Depth), Weight: 410\n g\n\n- Description: Dual filament-labeled subcutaneous mastectomy specimen\n\n- Specimen Workup: 27 lamellae from lateral to medial\n\n- Tumor-Suspect Area (Lamellae 17-21): Max. 1.6 cm, white dermal,\n partly blurred\n\n- Margins from Tumor Area: Ventral 0.1 cm, Caudal 1 cm, Dorsal 1.2 cm,\n Cranial \\> 5 cm, Lateral \\> 5 cm, Medial \\> 2 cm\n\n- Remaining Mammary Parenchyma: Predominantly yellowish lipomatous\n with focal nodular appearance\n\n- Ink Markings: Cranial/Green, Caudal/Yellow, Ventral/Blue,\n Dorsal/Black\n\n - A: Lamella 17 - Covers dorsal and caudal\n\n - B: Lamella 18 - Covers ventral\n\n - C: Lamella 19 - Covers ventral\n\n - D: Blade 21 - Covers ventral\n\n - E: Lamella 20 - Reference cranial\n\n - F: Lamella 16 - Immediately laterally following mammary\n parenchyma\n\n - G: Blade 22 - Reference immediately medial following mammary\n tissue\n\n - H: Lamella 12 - Central section\n\n - I: Lamella 8 - Documented section top/outside\n\n - J: Lamella 3 - Vestigial section below/outside\n\n - K: Lamella 21 - White-nodular imposing area\n\n - L: Lamella 8 - Further section below/outside with nodular area\n\n - M: Lateral border lamella perpendicularly\n\n - N: Medial border lamella perpendicular (Exemplary)\n\n**Second Sentinel Lymph Node on the Left:**\n\n- Specimen: Maximum of 6 cm of fat tissue resectate with 1 to 2 cm of\n lymph nodes and smaller nodular indurations.\n\n- A, B: One lymph node each divided\n\n- C: Further nodular indurations\n\n**Palpable Lymph Nodes Level I:**\n\n- Specimen: One max. 4.5 cm large fat resectate with nodular\n indurations up to 1.5 cm in size\n\n- A: One nodular induration divided\n\n- B: Further nodular indurated portions\n\n**Right Subcutaneous Mastectomy:**\n\n- Specimen: Double thread-labeled 450 g subcutaneous mastectomy\n specimen\n\n- Assumed Suture Markings: Blue (Ventral) and Green (Cranial)\n\n- Dorsal Fascia Intact\n\n- [Specimen Preparation:]{.underline} 16 lamellae from medial to\n lateral\n\n- Predominantly yellowish lobulated with streaky, beige, impinging\n strands of tissue\n\n- Isolated hemorrhages in the parenchyma\n\n- Ink Markings: Green = Cranial, Yellow = Caudal, Blue = Ventral,\n Black = Dorsal\n\n<!-- -->\n\n- A: Medial border lamella perpendicular (Exemplary)\n\n- B: Lamella 5 with reference ventrally (below inside)\n\n- C: Lamella 8 with reference ventrally (below inside)\n\n- D: Lamella 6 with ventral and dorsal reference (upper inside)\n\n- E: Blade 8 with ventral and dorsal cover (top inside)\n\n- F: Blade 11 with cover dorsal and caudal (bottom outside)\n\n- G: Blade 13 with dorsal cover (bottom outside)\n\n- H: Blade 10 with ventral and dorsal cover (top outside)\n\n- I: Lamella 14 with reference cranial and dorsal and bleeding in\n (upper outer)\n\n- J: Lateral border lamella perpendicular (Exemplary)\n\n**Microscopy:**\n\n1\\) In the tumor-suspicious area, a blurred large fibrosis zone with\nstar-shaped extensions is visible. Intercalated are single-cell and\nstranded epithelial cells with a high nuclear-cytoplasmic ratio. The\nnuclei are monomorphic with finely dispersed chromatin, at most, very\nisolated mitoses. Adjacent distended glandular ducts with a discohesive\ncell proliferate with the same cytomorphology. Sporadically, preexistent\nglandular ducts are sheared disc-like by the infiltrative tumor cells.\nSamples from the nodular area of lamella 21 show areas of cell-poor\nhyaline sclerosis with partly ectatically dilated glandular ducts.\n\n2\\) Second lymph node with partial infiltrates of the neoplasia described\nabove. The cells here are relatively densely packed. Somewhat increased\nmitoses. In the lymph nodes, iron deposition is also in the sinus\nhistiocytes.\n\n3\\) Lymph nodes with partly sparse iron deposition. No epithelial foreign\ninfiltrates.\n\n4\\) Regular mammary gland parenchyma. No tumor infiltrates. Part of the\nglandular ducts are slightly cystically dilated.\n\n**Preliminary Critical Findings Report: **\n\nLeft breast carcinoma measuring max 1.6 cm diagnosed as moderately\ndifferentiated invasive lobular carcinoma, B.R.E. score 6 (3+2+1, G2).\nPresence of tumor-associated and peritumoral lobular carcinoma in situ.\nResection status indicates locally complete excision of both invasive\nand non-invasive carcinoma; minimal margins as follows: ventral \\<0.1\ncm, caudal 0.2 cm, dorsal 0.8 cm, remaining margins ≥0.5 cm. Nodal\nstatus reveals max 0.25 cm metastasis in 1/5 nodes, 0/2 additional\nnodes, without extracapsular spread. Right mammary gland from\nsubcutaneous mastectomy shows tumor-free parenchyma.\n\n**TNM classification (8th ed. 2017):** pT1c, pTis (LCIS), pN1a, G2, L0,\nV0, Pn0, R0. Investigations to determine tumor biology were initiated.\nAddendum follows.\n\n**Supplementary findings on 10/07/2019**\n\nEditing: immunohistochemistry:** **\n\nEstrogen receptor, Progesterone receptor, Her2neu, MIB-1 (block 1D).\n\n**Critical Findings Report:** Breast carcinoma on the left with a 1.6 cm\ninvasive lobular carcinoma, moderately differentiated, with a B.R.E.\nscore of 6 (3+2+1, G2). Additionally, tumor-associated and peritumoral\nlobular carcinoma in situ are noted. Resection status confirms locally\ncomplete excision of both invasive and non-invasive carcinomas; minimal\nresection margins are ventral \\<0.1 cm, caudal (LCIS) 0.2 cm, dorsal 0.8\ncm, and all other margins ≥0.5 cm. Nodal assessment reveals a single\nmetastasis with a maximum dimension of 0.25 cm among 7 lymph nodes,\nspecifically found in 1/5 nodes, with no additional metastasis in 0/2\nnodes and no extracapsular extension. Contralateral right mammary gland\nfrom subcutaneous mastectomy is tumor-free.\n\nTumor biology of the invasive carcinoma demonstrates strong positive\nestrogen receptor expression in 100% of tumor cells, strong positive\nprogesterone receptor expression in 1% of tumor cells, negative HER2/neu\nstatus (Score 1+), and a Ki67 (MIB-1) proliferation index of 25%.\n\n**TNM classification (8th Edition 2017):** pT1c, pTis (LCIS), pN1a (1/7\nECE-, sn), G2, L0, V0, Pn0, R0.\n\n**Surgery Report (Vac Change + Irrigation)**: Indication for VAC change.\nAfter a detailed explanation of the procedure, its risks, and\nalternatives, the patient agrees to the proposed procedure.\n\nThe course of surgery: Proper positioning in a supine position. Removal\nof the VAC sponge. A foul odor appears from the wound cavity. Careful\ndisinfection of the surgical area. Sterile draping. Detailed inspection\nof the wound conditions. Wound debridement with removal of fibrin\ncoatings and freshening of the wound. Resection of necrotic material in\nplaces with sharp spoon. Followed by extensive Irrigation of the entire\nwound bed and wound edges using 1 l Polyhexanide solution. Renewed VAC\nsponge application according to standard.\n\n**Postoperative procedure**: Pain medication, thrombosis prophylaxis,\ncontinuation of antibiotic therapy. In the case of abundant\nStaphylococcus aureus and isolated Pseudomosas in the smear and still\nclinical suspected infection, extension of antibiotic treatment to\nMeropenem.\n\n**Surgery Report: Implant Placement**\n\n**Type of Surgery:** Implant placement and wound closure.\n\n**Report:** After infection and VAC therapy, clean smears and planning\nof reinsertion. Informed consent. Intraoperative consults: Anesthesia.\n\n**Course of Surgery:** Team time out. Removal VAC sponge. Disinfection\nand covering. Irrigation of the wound cavity with Serasept. Blust\nirrigation. Fixation cranially and laterally with 4 fixation sutures\nwith Vircryl 2-0. Choice of trial implant. Temporary insertion. Control\nin sitting and lying positions. Choice of the implant. Repeated\ndisinfection. Change of gloves. Insertion of the implant into the\npocket. Careful hemostasis. Insertion of a Blake drain into the wound\ncavity. Suturing of the drainage. Subcutaneous sutures with Monocryl\n3-0.\n\n**Type of Surgery:** Prophylactic open Laparoscopy, extensive\nadhesiolysis\n\n**Type of Anesthesia:** ITN\n\n**Report:** Patient presented for prophylactic right adnexectomy in the\ncourse of hysterectomy and left adnexectomy due to genetic burden.\nIntraoperatively, secondary wound closure was to be performed in the\ncase of a right mammary wound weeping more than one year\npostoperatively. The patient agreed to the planned procedure in writing\nafter receiving detailed information about the extent, the risks, and\nthe alternatives.\n\n**Course of the Operation:** Team time out with anesthesia colleagues.\nFlat lithotomy positioning, disinfection, and sterile draping. Placement\nof permanent transurethral catheter. Subumbilical incision and\ndissection onto the fascia. Opening of the fascia and suturing of the\nsame. Exposure of the peritoneum and opening of the same. Insertion of\nthe 10-mm optic trocar. Insertion of three additional trocars into the\nlower abdomen (left and center right, each 5mm; right 10mm). The\nfollowing situation is seen: when the camera is inserted from the\numbilical region, an extensive adhesion is seen. Only by changing the\ncamera to the right lower bay is extensive adhesiolysis possible. The\nomentum is fused with the peritoneum and the serosa of the uterus. Upper\nabdomen as far as visible inconspicuous.\n\nAfter hysterectomy and adnexectomy on the left side, adnexa on the right\nside atrophic and inconspicuous. The peritoneum is smooth as far as can\nbe seen.\n\nVisualization of the right adnexa and the suspensory ligament of ovary.\n\nCoagulation of the suspensory ligament of ovary ligament after\nvisualization of the ureter on the same side. Stepwise dissection of the\nadnexa from the pelvic wall.\n\nRecovery via endobag. Hemostasis. Inspection of the situs.\n\nRemoval of instrumentation under vision and draining of\npneumoperitoneum.\n\nClosure of the abdominal fascia at the umbilicus and right lower\nabdomen. Suturing of the skin with Monocryl 3/0. Compression bandage at\neach trocar insertion site. Inspection of the right mamma. In the area\nof the surgical scar laterally/externally, 2-3 small epithelium-lined\npore-like openings are visible; here, on pressure, discharge of rather\nviscous/sebaceous, non-odorous, or purulent fluid. No dehiscence is\nvisible, suspected. fistula ducts to the implant cavity. After\nconsultation with the mamma surgeon, a two-stage procedure was planned\nfor the treatment of the fistula tracts. Correct positioning and\ninconspicuous anesthesiological course. Instrumentation, swabs, and\ncloths complete according to the operating room nurse. Postoperative\nprocedures include analgesia, mobilization, thrombosis prophylaxis, and\nwaiting for histology.\n\n**Internal Histopathological Report** \n\n[Clinical information/question]{.underline}: Fistula formation mammary\nright. Dignity?\n\n[Macroscopy]{.underline}**:** Skin spindle from scar mammary right: fix.\na 2.4 cm long, stranded skin-subcutaneous excidate. Lamellation and\ncomplete embedding.\n\n[Processing]{.underline}**:** 1 block, HE\n\n[Microscopy]{.underline}**:** Histologic skin/subcutaneous\ncross-sections with overlay by a multilayered keratinizing squamous\nepithelium. The dermis with few inset regular skin adnexal structures,\nsparse to moderately dense mononuclear-dominated inflammatory\ninfiltrates, and proliferation of cell-poor, fiber-rich collagenous\nconnective tissue.\n\n**Critical Findings Report:** \n\nSkin spindle on scar mamma right: skin/subcutaneous resectate with\nfibrosis and chronic inflammation. To ensure that all findings are\nrecorded, the material will be further processed. A follow-up report\nwill follow.\n\n[Microscopy]{.underline}**:** In the meantime, the material was further\nprocessed as announced. The van Gieson stain showed extensive\nproliferation of collagenous and, in some places elastic fibers. Also in\nthe additional immunohistochemical staining against no evidence of\natypical epithelial infiltrates.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n CRP 7.8 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 11.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 3.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to provide an update on Mrs. Linda Mayer, born on\n01/12/1948, who received inpatient care at our facility from 01/01/2021\nto 01/14/2021.\n\n**Diagnosis:** Hailey-Hailey disease.\n\n- Upon admission, the patient was under treatment with Acitretin 25mg.\n\n**Other Diagnoses**:\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 die to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage in 2004\n\n- Hysterectomy in 2005\n\n**Medical History:** Mrs. Linda Mayer was referred to our hospital for\nthe management of Hailey-Hailey disease after assessment in our\noutpatient clinic. She reported a worsening of painful skin erosions on\nher neck and inner thighs over a span of approximately 3 weeks.\nItchiness was not reported. Prior attempts at treatment, including the\ntopical use of Fucicort, Prednisolone with Octenidine, and Polidocanol\ngel, had provided limited relief. She denied any other physical\ncomplaints, dyspnea, B symptoms, infections, or irregularities in stool\nand micturition.\n\nHer history revealed the initial onset of Hailey-Hailey disease,\ninitially presenting as itching followed by skin erosions, which\nsubsequently healed with scarring. The diagnosis was established at the\nFairview Clinic. Previous therapeutic interventions included systemic\ncortisone shock therapy, as-needed application of Fucicort ointment, and\naxillary laser therapy.\n\n**Family History:**\n\n- Father: Hailey-Hailey Disease (M. Hailey-Hailey)\n\n- Mother and Sister: Breast carcinoma\n\n**Psychosocial History:** Socially, Ms. Linda Mayer is described as a\nretiree, having previously worked as a nurse.\n\n**Physical Examination on Admission:**\n\nHeight: 16 cm, Body Weight: 80.0 kg, BMI: 29.7\n\n**Physical Examination Findings:**\n\nGenerally stable condition with increased nutritional status. Her\nconsciousness was unremarkable, and cranial mobility was free. Ocular\nmobility was regular, with prompt pupillary reflexes to accommodation\nand light. She exhibited a normal heart rate, and cardiac and pulmonary\nexaminations were unremarkable. No heart murmurs were detected. Renal\nbed and spine were not palpable. Further internal and orienting\nneurological examinations revealed no pathological findings.\n\n**Skin Findings on Admission:** Sharp erosions, approximately 10x10 cm\nin size, with a livid-erythematous base, partly crusty, were observed on\nthe neck and proximal inner thighs.\n\nIn the axillary regions on both sides, there were marginal,\nlivid-erythematous, well-demarcated plaques interspersed with scarring\nstrands, more pronounced on the right side.\n\nSkin type II.\n\nMucous membranes appeared normal. Dermographism was noted to be ruber.\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------ ------------ -------------------------------\n Prednisolone (Deltasone) 5 mg 1.5-0-0-0-0-0\n Aspirin (Bayer) 100 mg 0-1-0-0-0-0\n Simvastatin (Zocor) 40 mg 0-0-0-0-1\n Pantoprazole (Protonix) 45.1 mg 1-0-0-0-0\n Acitretin (Soriatane) 25 mg 1-0-0-0-0\n Tetrabenazine (Xenazine) 111 mg 0.25-0.25-0.25-0.25-0.25-0.25\n Letrozole (Femara) 2.5 mg 0-0-1-0\n Risedronate Sodium (Actonel) 35 mg 1-0-0-0-0\n Acetaminophen (Tylenol) 500 mg 0-1-0-1\n Naloxone (Narcan) 8.8 mg 1-0-1-0\n Eszopiclone (Lunesta) 7.5 mg 0-0-1-0\n\n**Other Findings:** MRSA Smears:\n\n- Nasal Smear: Normal flora, no MRSA.\n\n- Throat Swab: Normal flora, no MRSA.\n\n- Non-lesional Skin Smear: Normal flora.\n\n- Lesional Skin Swab: Abundant Pseudomonas aeruginosa, abundant\n Klebsiella oxytoca, and abundant Serratia sp., sensitive to\n piperacillin-tazobactam.\n\n**Therapy and Progression:** Mrs. Linda Mayer was admitted on 01/01/2021\nas an inpatient for a refractory exacerbation of previously diagnosed\nHailey-Hailey disease. On admission, both bacteriological and\nmycological smears were conducted, which indicated abundant levels of\nPseudomonas aeruginosa, Klebsiella oxytoca, and Serratia sp. Lab tests\nshowed a CRP level of 2.83 mg/dL and a leukocyte count of 8.8 G/L.\n\nInitial topical therapy consisted of Zinc oxide ointment, Clotrimazole\npaste, and Triamcinolone Acetonide shake lotion. Treatment was modified\non 01/04/2021 to include Clotrimazole (Lotrimin) paste in the mornings\nand methylprednisolone emulsion in the evenings. Starting on 01/08,\neosin aqueous solution was introduced for application on the thighs,\nserving antiseptic and drying purposes. A hydrophilic prednicarbate\ncream at 0.25% concentration, combined with octenidine at 0.1%, was\napplied to the neck and thighs twice daily, also starting on 01/08. For\nshowering, octenidine-based wash lotion was utilized. Additionally, Mrs.\nLinda Mayer received an emulsifying ointment as part of her treatment.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are providing an update on our patient Mrs. Linda Mayer, born on\n01/12/1948, who presented to our outpatient clinic on 09/22/2021.\n\n**Diagnoses:** M. Hailey-Hailey\n\n**Medical History:**\n\n- Diagnosis of M. Hailey-Hailey at the Fairview Clinic\n\n<!-- -->\n\n- Treatment involved systemic steroid shock therapy, laser therapy,\n and the initiation of Acitretin in October 2021, with no observed\n improvement.\n\n<!-- -->\n\n- A dermabrasion procedure was scheduled on 03/18/2021, during a\n previous inpatient admission.\n\n- Acitretin 25mg has been administered daily, with favorable outcomes\n noted when using Triamcinolone/Triclosan or Prednisolone +\n Octenidine.\n\n- A history of mastectomy with Vacuum-Assisted Closure (VAC) has\n resulted in breast erosion.\n\n**Skin Findings:**\n\n- Erythematous and partially mottled lesions have been identified in\n the axillary and inguinal regions, with some scarring observed in\n the axillary area.\n\n- On 04/28/2021, somewhat erosive plaques were noted in the inguinal\n regions.\n\n- As of 05/05/2021 discrete erosions are currently present on both\n forearms.\n\n**Current Recommendations:**\n\n- Inpatient admission is scheduled for September 2021.\n\n- The prescribed treatment plan includes topical prednicarbate\n (Dermatop) 0.25% with Octenidine 0.1%, per NRF 11.145, in a 50g\n container, to be applied once daily for 1-2 weeks.\n\n- Hydrocortisone 5% in a suitable base, 200g, is to be applied daily.\n\n- The regimen also includes prednicarbate (Dermatop) combined with\n Octenidine.\n\n- Acitretin will be continued temporarily.\n\n- A follow-up appointment in the outpatient clinic is scheduled for\n three months from now.\n\n- Discontinuation of Acitretin.\n\n- It is recommended to avoid the use of compresses on the erosions to\n prevent constant trauma.\n\n- Topical therapy with petrolatum-based wound ointment and sterile\n compresses.\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n\n\n\n\nHere is the query:\nRegarding Mr. Rudolph, what was the size of the left renal pelvis mass according to the histopathological report?\n\nChoose the correct answer from the following options:\nA. 2.5 cm\nB. 3.4 cm\nC. 4.3 cm\nD. 5.1 cm\nE. 6.0 cm\n\n\nYour response:\n", "role": "user" }, { "content": "4.3 cm", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nHerewith we report on Mr. John Williams, born 08/08/1956, inpatient from\n10/03/2015 to 10/06/2015.\n\n**Diagnosis:**\n\nMultiple Myeloma IgG kappa.\n\n**Staging and Initial Diagnosis:**\n\nDate: 03/2015\n\nStage: IIA based on the Salmon and Durie scale, ISS II.\n\n- CT whole body 03/11/2015: Osteolysis detected in the seventh\n thoracic vertebra (T7); pathologic fracture observed in the first\n lumbar vertebra (L1).\n\n- Bone marrow infiltration: Initial histological evaluation showed\n 22%; cytomorphological assessment revealed 28%.\n\n**Histological Findings:**\n\nDate: 03/2015\n\n**FISH (Fluorescence In Situ Hybridization) Results:** Detected an\nadditional signal for both CCND1 and CCND3. Presence of one trisomy or\ntetrasomy 9. Additional signals observed for 5p15- and 5q31- as well as\n19p13- and 19q13-. 46, XY with a detected ASxL1 mutation.\n\n**Treatment Timeline:**\n\n**01-02/15:** Administered 2 cycles of\nCyclophosphamide-Bortezomib-Dexamethasone (CyBorD). Resulted in stable\ndisease but caused prolonged pancytopenia.\n\n**03/15 - 06/15:** Administered 3 cycles of a combination treatment\nincluding Carfilzomib, Lenalidomide, and Dexamethasone.\n\n**07/15:** Underwent stem cell mobilization using cyclophosphamide.\n\n**07-08/15:** Experienced extended pancytopenia and regeneration. Bone\nmarrow puncture showed progressive disease with a significant increase\nin plasma cell infiltration, reaching 92%.\n\n**09/02/15:** Received the first dosage of daratumumab at 16mg/kg.\nSubsequently developed thrombocytopenia. Treatment did not include\nRevlimid.\n\n**Histopathological report: **\n\nMultiple myeloma, IgG kappa. The evaluation is for myelodysplastic\nsyndrome in the presence of tricytopenia and an ASXL1 mutation.\n\n**Methods:** Hematoxylin and eosin (HE), periodic acid-Schiff (PAS),\niron, Giemsa, Gomori, chloroacetate esterase, step sections,\ndecalcification, and 1 block.\n\n**Microscopic Examination:**\n\nThe sample is a 2 cm long bone marrow biopsy core that contains more\nthan ten medullary canals. The cellularity is around 20-30%, which is\nconsidered normocellular for the patient\\'s age. There is evidence of\nbone marrow edema and heightened hemosiderosis. Recent stromal\nhemorrhages are also observed. There is a relative increase in\nerythropoiesis with a ratio of erythropoiesis to granulopoiesis being\napproximately 2:1. Erythropoiesis is present in well-defined zones with\nregular maturation. Only minimal nuclear rounding is observed.\nGranulopoiesis matures into segmented granulocytes. PAS staining reveals\nsome morphologically normal megakaryocytes. Occasionally there are bare\nnuclei and possible microforms. Scattered mature plasma cells are\nobserved with no signs of atypical proliferation. The argyrophilic\nfibrous network is fine, and no fibrosis is detected.\n\n**Preliminary Findings:**\n\nThe bone marrow biopsy is normocellular for the age with a relative\nincrease in erythropoiesis that shows only minimal cytological atypia.\nGranulopoiesis is slightly reduced, while megakaryopoiesis is\nnormocellular with a few cells that are hypolobulated.There is bone\nmarrow edema and enhanced hemosiderosis. Scattered mature plasma cells\nare also noted.\n\nBased solely on histomorphologic observations, it is not enough to\nconfirm a diagnosis of myelodysplastic syndrome (MDS), which is the\nsuspected clinical diagnosis. For a more thorough evaluation of\npotential atypicalities in the megakaryopoiesis (like\nmicromegakaryocytes), further immunohistochemical examination is\nrecommended. Assessing the blast content is also advised. There is no\nevidence currently of manifest infiltrates from the previously diagnosed\nmultiple myeloma.\n\n**Immunohistochemical Additional Findings (Dated 10/04/2015):**\n\n**Immunohistochemistry Stains Used:** CD3, CD79a, CD34, CD117, MUM-1,\nKappa, lambda, CyclinD1, CD61.\n\nBlast cells positive for CD34 and CD117 are below 5% of the total. CD3\nstains scattered T lymphocytes, and CD79a identifies sporadic B\nlymphocytes and some plasma cells. Plasma cells are also positive for\nMUM-1 and exhibit polytypic expression of kappa and lambda light chains.\nThere is no co-expression with CyclinD1. CD61 highlights the previously\ndescribed megakaryocytes, and no micromegakaryocytes are observed.\n\n**Final Report:**\n\nThe bone marrow biopsy is representative and normocellular for the\npatient\\'s age. There is a relative increase in erythropoiesis that\nshows only minor cytological atypia. Granulopoiesis appears slightly\nreduced, while megakaryopoiesis presents with a few hypolobulated cell\nforms. Evidence of bone marrow edema and increased hemosiderosis is\nnoted, along with scattered mature plasma cells.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe hereby report on Mr. Williams, John, born 08/08/1956, inpatient from\n11/30/2015 to 12/28/2015.\n\n**Oncological Diagnosis**:\n\nMultiple myeloma IgG kappa.\n\nInitial diagnosis 03/15: Stage IIA (Salmon and Durie), ISS II.\n\n**Sites**:\n\nOsteolysis in T7 vertebra, fracture in T1 vertebra.\n\nBone marrow: 22% histological, 28% cytomorphologic infiltration.\n\n**Histology**:\n\nBone marrow biopsy 11/16: FISH: Additional signals for CCND1, CCND3;\nTrisomy 3, 9; Additional signals on chromosomes 5 and 19. Chromosomal\nanalysis: 46, XY with ASxL1 mutation.\n\n**Treatment**:\n\n01-02/15: 2 cycles Cyclophosphamide-Bortezomib-Dexamethasone -\\>\nStable disease, prolonged low blood counts.\n\n03/15 - 06/15: 3 cycles Carfilzomib/Lenolidomide/Dexamethasone.\n\n07/15: Stem cell mobilization with Cyclophosphamide.\n\n07-08/15: Extended low blood count. Bone marrow biopsy: 92% plasma cell\ninfiltration.\n\n09/02/15: Darzalex 16mg/kg initial dose, with platelet count drop. No\nLenalidomide.\n\n09/04/15: 10 cycles of Darzalex, 1 cycle with Lenalidomide due to\nrenewed low platelet and white blood cell counts.\n\n11-12/15: Conditioning chemo with Fludarabine/Treosulfan, then\nallogeneic stem cell transplant from HLA-matched unrelated donor.\nImmunosuppression with ATG, cyclosporine, Mycophenolate Mofetil.\n\n**Complications**:\n\nMucositis, central line infection, gastrointestinal symptoms, urinary\ninfections with E. faecium and E.coli, JC virus bladder infection.\n\n**Secondary Diagnoses**:\n\nDry eye syndrome, Type 2 diabetes managed with oral meds, Hypertension.\n\n**Treatment Plan**:\n\nGradual reduction of immunosuppression based on graft vs. host disease\nsigns.\n\n**Radiology**:\n\nCT Whole Body: 12/01/15: Various areas of bone osteolysis. Degeneration\nof spine.\n\nCT Chest 12/02/15 and 12/03/15: Changes in lungs and some fluid\naccumulation.\n\n**Medication**:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------- ---------------\n Mycophenolic Acid (Myfortic) 360 mg Twice Daily\n Cyclosporine (Sandimmune) 200 mg Daily\n Artificial Tears As directed 3x Daily\n Candesartan (Atacand) 8 mg Daily\n Tamsulosin (Flomax) 0.4 mg Daily\n Pantoprazole (Protonix) 40 mg Daily\n Amlodipine (Norvasc) 5 mg Twice Daily\n Cotrimoxazole (Bactrim) 960 mg Mon/Wed/Fri\n Valacyclovir (Valtrex) 500 mg Twice Daily\n\n**Summary**:\n\nMr. Williams was admitted on 11/30/2015 for treatment related to his\nMultiple Myeloma. He underwent conditioning chemotherapy,\nimmunosuppressive therapy, and stem cell transplantation. He experienced\ncomplications, including infections and symptoms affecting multiple\nsystems. Close monitoring of blood pressure and glucose is recommended.\nHe was discharged on 12/28/2015 in good condition and will be followed\nup in the outpatient clinic. If there are worsening symptoms, he should\nvisit the emergency department immediately.\n\n**Dear Mr. Williams,**\n\nWe report on your outpatient treatment on 02/15/2016.\n\n**Diagnoses:**\n\n1. **Multiple Myeloma** IgG kappa, diagnosed 03/2015.\n\n Stage IIA as per Salmon and Durie, stage II as per ISS.\n\n Osteolysis at T7 vertebra, fracture at T1 vertebra.\n\n Bone marrow infiltration: 22% histologically, 28% cytologically.\n\n FISH: Indications of additional CCND1 and CCND3 signals; Trisomy 3,\n additional signals at various chromosomes.\n\n Chromosome analysis: 46, XY \\[20\\].\n\n**Secondary diagnoses:**\n\nType 2 diabetes mellitus\n\nHypertension\n\nCataract (surgery 06/2018)\n\nNodular goiter\n\nRSV pneumonia (03/2018)\n\n**Summary:**\n\nMr. Williams presents in good general health to our bone marrow\ntransplant (BMT) outpatient clinic. There are no signs of infection or\nchronic graft rejection. He has shown significant improvement in\nresilience and does not have any complaints. Vital signs are stable.\nBlood tests showed ongoing regeneration with normal light chains and\npersistent positive immunofixation. There is no need for\nmyeloma-specific therapy at present, but close monitoring of the\nparaprotein is required.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ---------------------- -------------------------------------------------------\n Tamsulosin (Flomax) 0.4 mg Daily in the morning\n Candesartan (Atacand) 8 mg Twice Daily\n Metformin (Glucophage) 1000 mg 0.5 tablet in the morning, 1.5 tablets in the evening\n Pantoprazole (Protonix) 20 mg Daily in the morning\n Vitamin D3 (various brands) 20,000 IU Once a week\n Allopurinol (Zyloprim) 100 mg Daily in the morning\n Insulin (various types) As per sliding scale As per sliding scale\n\nWith kind regards\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are providing an update on our shared patient, Mr. John Williams, who\nconsulted with us on June 15, 2018.\n\n**Consultation Summary:**\n\n8. **Multiple Myeloma**\n\n **Kidney biopsy scheduled for tomorrow.**\n\n **Prostate cancer**\n\n**Current Status:**\n\nAcute renal failure accompanied by proteinuria due to the recent\ndiagnosis of multiple myeloma.\n\nMultiple osteolytic lesions, including at the T4, T7, L1 vertebra and\nthe ribs.\n\n**Diagnosis:**\n\nMultiple myeloma.\n\nProstate cancer\n\n**Clinical Presentation:**\n\nOsteolytic lesion presenting as thoracic pain.\n\n**Imaging Findings:**\n\nOsteolytic lesion at T4 vertebra with involvement of the posterior edge.\n\n**Planned Procedures:**\n\nRestricted bed rest.\n\nWhole spine MRI with STIR sequences, to be presented in the upcoming\ntumor board meeting for deciding further course of action.\n\n**Previous Diagnoses:**\n\nMay, 2018, Nephrology: Enlarged kidneys noted bilaterally.\n\nJanuary, 2018, Urology: Prostate cancer\n\nDecember, 2015, Internal Medicine: Multiple myeloma without evidence of\ncomplete remission.\n\n**Previous Procedures:**\n\nTransrectal biopsy of the prostate.\n\n**Histology Report, Date: June 13, 2018:**\n\nSuspected plasmacytoma with paraproteinemia.\n\nWBC 6.47; Hb 10.8; Platelets 251,000.\n\nBone marrow biopsy: Cellularity approximated at 48%, indicating slightly\nincreased cellularity. Amidst reduced hematopoiesis, there is\nproliferation of plasmacytoid cells with certain features.\n\n**Preliminary Report:**\n\nThe bone marrow sample indicates possible infiltration due to plasma\ncell myeloma. Additional tests will be conducted to confirm and further\nelucidate this finding.\n\n**Supplementary Findings:**\n\nImmunohistochemical staining: CD138, Kappa, Lambda, CD20.\n\nMicroscopic findings confirm the presence of nodular infiltrates with\ncertain features.\n\n**Final Report:**\n\nBone marrow sample indicates infiltration by a plasma cell myeloma with\nkappa light chain restriction. Additionally, regular trilinear\nhematopoiesis is significantly reduced.\n\n\n\n### text_3\n**Dear colleague, **\n\nI wish to provide an update on our mutual patient, Mr. John Williams,\nborn 08/08/1956, who presented at our clinic at 08/20/2018.\n\n**Diagnosis:**\n\nPresent condition: Multiple Myeloma IgG type, coded under ICD-10.\n\nStage: II B based on Durie and Salmon criteria; determined from Hb 9.1,\nCreatinine 4.5 mg/dL.\n\n**Histology:**\n\nBone marrow biopsy presents a strong indication of interstitial and\nfocal nodular invasion of the marrow space by plasma cell myeloma,\npredominantly of high to intermediate maturity.\n\n**Immunohistochemistry:**\n\nThe nodular infiltrates were found positive for CD138 with a kappa-light\nchain restriction (infiltration rate at 62%).\n\nCytological findings align with high-grade bone marrow infiltration by\nmultiple myeloma.\n\n**Tumor Localization:**\n\nMRI of the entire spine conducted on 06/20/2018 reveals disseminated\nbone lesions throughout the spine without any soft tissue involvement.\nThere is noted anterior vertebral body involvement at T4.\n\n**Secondary Diagnoses:**\n\nCysts in the right kidney.\n\nAs of 01/2018, a diagnosis of Prostate cancer with a Gleason score of 8\nand a PSA reading of 10.02.\n\nPrevious rib fracture, which may be associated with the multiple\nmyeloma.\n\nChronic renal failure, with ongoing dialysis treatment.\n\nDocumented mitral valve surgery in 2015.\n\nHistory of Deep Vein Thrombosis in 1999.\n\n**Prior Treatments:**\n\nInitial diagnosis of multiple myeloma IgG kappa in 2015.\n\nProstate cancer was diagnosed in 01/2018 following spontaneous rib\nfractures, Gleason score of 8.\n\nA PSMA-PET-CT scan in 05/18 showed multiple bone lesions, notably\npronounced at Th4.\n\nTumor board review in 06/2018 concluded treatment strategies for\nurological tumors, encompassing radiation therapy targeting Th4 and\nantiandrogen therapy for the identified prostate cancer, using a GnRH\nanalog.\n\nThe progression of multiple myeloma required the commencement of\nsystemic treatment with Velcade and Dexamethasone.\n\n**Study**: PSMA-PET-CT Scan\n\n**Date of Study**: 05/2018\n\n**Clinical Information**: Prostate cancer diagnosed in 01/2018 following\nspontaneous rib fractures. Gleason score of 8.\n\n**Technique**:\n\nWhole body positron emission tomography/computed tomography (PET/CT) was\nperformed following the intravenous administration of PSMA-radiotracer.\nCoronal, sagittal, and axial images were acquired and reviewed.\n\n**Findings**:\n\nBone: Notably increased PSMA uptake is seen at the level of T4 vertebral\nbody consistent with metastatic involvement. The lesion has caused\ncortical erosion and expansion with potential involvement of the\nanterior spinal canal. Multiple rib lesions are identified,\ncorresponding with the clinical history of spontaneous rib fractures.\nThese lesions exhibit no increased PSMA uptake. No other foci of\nincreased PSMA uptake throughout the axial and appendicular skeleton.\n\n**Prostate**:\n\n12. The prostate gland demonstrates diffusely increased uptake, which is\n consistent with primary prostate malignancy, especially given the\n known clinical history.\n\n**Thorax/Abdomen: **\n\n13. No abnormal PSMA avid soft tissue masses or lymphadenopathies were\n noted in the visualized fields. No pulmonary nodules or masses\n suggestive of metastatic disease were identified. Liver, spleen,\n kidneys, and adrenal glands appear unremarkable with no evidence of\n metastatic lesions.\n\n**Impression**:\n\nOsseous metastasis from prostate cancer with involvement of the T4\nvertebral body. No evidence of soft tissue, lymph node, or pulmonary\nmetastases in the visualized fields. Prostate gland showing evidence\nconsistent with primary malignancy.\n\n**Current Radiation Therapy:**\n\n**Indication:** Radiotherapy became a consideration due to a sizable\nosteolytic lesion at T4, both for pain alleviation and stabilization.\nConcurrent treatment of the aching ribs on the right side (7th-9th) was\nalso performed.\n\n**Technique:** 6 MeV photons from a linear accelerator, administering a\ncumulative dose of 30 Gy to thoracic vertebra 4 and 20 Gy to the ribs\nwith respective daily doses.\n\n1. **Treatment Duration:**\n\n Th4: 08/21/2018 to 08/27/2018\n\n Rib area: 08/21/2018 to 08/27/2018\n\n**Clinical Update:**\n\nThroughout the therapy period, Mr. Williams remained admitted to our\nOncology ward for ongoing reduced dosage chemotherapy using Velcade. He\nhas reported a decline in pain sensations during this timeframe. The\noverall health status appeared satisfactory, with no skin irritation\nobserved at the irradiated sites.\n\n**Subsequent Actions:**\n\nGuidance on skincare and potential adverse effects have been provided to\nMr. Williams. The intensity of the chemotherapy will soon be escalated.\nA radio-oncological assessment has been scheduled in our outpatient\nfacility for 09/05/2018 at 12:00 PM. I kindly request the most recent\ntest results by this date.\n\n**Note:** In compliance with the Radiation Protection Act, we shall\nundertake regular evaluations and request updates on the patient\\'s\ncondition. Mr. Williams has been apprised of the necessity for\nconsistent oncological check-ups.\n\nWarm regards,\n\n\n\n### text_4\n**Dear colleague, **\n\nWe wish to update you on our mutual patient, Mr. John Williams.\n\n**Diagnosis:**\n\nCurrent multiple myeloma IgG type\n\n**Tumor Localization:**\n\nBased on a whole spine MRI dated June 20, 2018:\n\nMultiple intraosseous lesions throughout the spine without soft tissue\ninvolvement.\n\nKnown intrusion of the T4 cover plate.\n\n**Secondary Diagnoses:**\n\nRight kidney cysts\n\nDiagnosed prostate carcinoma in January 2018, Gleason score 8, initial\nPSA at 10.02.\n\nHistory of a spontaneous rib fracture related to the multiple myeloma.\n\nChronic renal insufficiency; he remains on dialysis.\n\nHistory of mitral valve reconstruction in 2015.\n\nHistory of deep vein thrombosis in 1999.\n\n**Treatment Overview:**\n\nDiagnosed with multiple myeloma type kappa in 2015 with initially normal\nrenal function.\n\nDiagnosed with prostate carcinoma in January 2018 due to spontaneous rib\nfractures, Gleason score 8.\n\nTreatment decisions in 2018 included radiation for vertebral lesions and\nhormone therapy for prostate cancer using a GnRH analogue.\n\nSystemic therapy with Velcade and Dexamethasone initiated due to\nprogressive myeloma.\n\nRadiation therapy in August 2018 for vertebral and rib lesions.\n\n**Summary:**\n\nMr. Williams had a radio-oncological follow-up on September 29, 2018.\nHis general health has improved. He remains on thrice-weekly dialysis.\nRecent CT scans show extensive osteolysis of the spine with several\nvertebral collapses. Currently, we see no urgent fracture risk or need\nfor additional radiation therapy. We have planned regular clinical\ncheck-ups with Mr. Williams. His next follow-up is scheduled in three\nmonths.\n\n**Oncologic treatment: **\n\nDaratumumab/lenalidomide/dexamethasone regimen:\n\nDaratumumab 16mg/kg: Days 1, 8, 15, 22 for cycles 1 & 2 (every 28 days\nfor 8 weeks).\n\nDays 1, 15 for cycles 3-6 (every 28 days for 16 weeks).\n\nDay 1 for subsequent cycles (every 28 days).\n\nDexamethasone 20mg on Daratumumab days, with an additional 20mg the day\nafter (totaling 40mg/week).\n\nLenalidomide 5mg from day 1-21 (every 28 days).\n\nBondronate every 4 weeks (last administered on 12/13/2016).\n\nRe-evaluation of hemodialysis and autologous peripheral blood stem cell\ntransplant (PBSCT) after 2 cycles of daratumumab.\n\n**CT Spine scan (09/30/2018): **\n\n**Technique**: Contrast-enhanced computed tomography (Omnipaque 240) of\nthe thoracic and lumbar spine was performed with axial slices, and\nmultiplanar reconstructions in sagittal and coronal orientations.\n\n**Findings**:\n\n**Thoracic Spine**:\n\nExtensive osteolytic lesions are identified in multiple thoracic\nvertebrae. Specifically, vertebral collapses are noted at T4, T7, T9,\nT11. No significant bony destruction of pedicles, lamina and spinous\nprocesses. No evidence of paravertebral or epidural soft tissue masses.\n\n**Lumbar Spine**:\n\nProminent osteolytic changes are seen in L1 (with fracture) and L4\nvertebral bodies. However, there is no significant vertebral collapse.\nPreserved pedicles, lamina, and spinous Processes without significant\nosteolysis. No evidence of abnormal masses or lymphadenopathy.\n\nNo significant central canal stenosis or neural foraminal narrowing. The\nintervertebral discs are preserved without significant discopathies.\n\n**Impression**:\n\nExtensive osteolysis in multiple vertebral bodies, specifically in the\nthoracic and lumbar spine, with vertebral collapses at levels T4, T7,\nT9, and T11 as well as L1. Also, osteolytic changes in L4 of the lumbar\nspine.\n\nCurrently, based on imaging, there does not appear to be an urgent\nfracture risk, and no radiologic signs suggesting a need for imminent\nradiation therapy. No soft tissue abnormalities identified in the\nexamined regions.\n\n**Medication: **\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ----------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg In the morning (day after Daratumumab)\n Pantoprazole (Protonix) 40 mg Daily in the morning\n Cotrimoxazole (Bactrim) 480 mg Thrice weekly (Mon, Wed, Fri)\n Valacyclovir (Valtrex) 500 mg Daily in the morning\n Acetaminophen (Tylenol) 500 mg Orally, three times daily\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly (4-week depot) subcutaneously\n Pregabalin (Lyrica) 25 mg Twice a day\n Amlodipine (Norvasc) 5 mg Daily in the morning\n Bisoprolol (Zebeta) 5 mg Daily in the morning\n Lenalidomide (Revlimid) 5 mg Nightly\n Ondansetron (Zofran) 8 mg As needed, up to twice daily\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are updating you on Mr. John Williams\\' outpatient visit on December\n13, 2018.\n\n**Diagnosis:**\n\nFebrile respiratory infection.\n\n**Underlying Conditions:**\n\nMultiple myeloma, kappa light chain, stage IIIB as classified by Salmon\nand Durie.\n\nChronic kidney disease requiring hemodialysis.\n\nProstate cancer.\n\n**Summary:**\n\nMr. Williams came to the emergency room with fever and dry cough during\nhis multiple myeloma treatment with Darzalex, Revlimid, and\nDexamethasone. His vital signs were recorded, and laboratory tests\nshowed signs of infection and confirmed chronic kidney disease. Chest\nX-ray indicated possible inflammation. Given these findings, Mr.\nWilliams was admitted for antibiotic therapy. Further observations and\ntreatments were documented.\n\n\n\n### text_6\n**Dear colleague, **\n\nThis letter pertains to Mr. John Williams, who was hospitalized from\nDecember 14 to 21st, 2018.\n\n**Oncological Diagnosis:**\n\nMultiple myeloma, kappa light chain, initially diagnosed in June 2018 as\nstage IIIB per Durie and Salmon criteria.\n\n**Treatment Details:**\n\nHe underwent various treatment regimens for multiple myeloma over the\ncourse of the year. His current condition indicates an\ninfluenza-positive pneumonia, likely with a bacterial superinfection. He\ncontinues hemodialysis thrice a week.\n\n**Secondary Diagnoses:**\n\nSeveral renal complications were documented in June 2018.\n\n**Plan of Care:**\n\nMr. Williams\\' therapy plan was discussed in a tumor board meeting. He\nremains on a regimen of Darzalex, Revlimid, and Dexamethasone.\n\n**Summary:**\n\nMr. Williams came to the emergency room on December 13, 2018, with cough\nand fever. Further details about his history can be found in previous\ncommunications. On admission, he showed signs of a respiratory\ninfection, confirmed by a chest X-ray. He was treated with antibiotics,\nwhich were later escalated. He also tested positive for influenza A and\nwas given Tamiflu. After a short in-patient stay, he has shown\nimprovement. He is scheduled to continue his therapy in our clinic on\nDecember 22, 2018. In case of any complications, he has been advised to\nreturn to our emergency room immediately.\n\nFor future consultations, please provide a referral slip for each new\nquarter.\n\nWarm regards\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to inform you about Mr. John Williams, who was an\ninpatient in our clinic from March 1, 2019, to March 3, 2019.\n\nOncological diagnosis:\n\nMr. Williams was diagnosed with Multiple Myeloma light chain kappa. He\nreceived his follow-up diagnosis in June 2018, which was at stage IIIB\nper the Durie and Salmon staging system.\n\nTreatment:\n\nIn June 2018, he was given VelDex due to impaired renal function.\nSubsequently, he received Carfilzomib (15mg/m2 on days 1-2, 8-9, 15-16),\nLenalidomide (5 mg, on days 1-21), and Dexamethasone (40mg, on days 1,\n8, 15-16, 22). In addition, he was treated with Pomalidomide (4mg on\ndays 1-21), Doxorubicin (9mg/m2 on days 1, 4), and Dexamethasone (40mg,\non days 1, 8, 15, 22). He underwent radiation therapy to T4 of the rib\nthorax in August. Between August to October 2018, he had three cycles of\nPomalidomide, Doxorubicin, and Dexamethasone, after which the disease\nprogressed. From November 2018 to February 2019, he had four cycles of\nDaratumumab, Lenalidomide, and Dexamethasone.\n\n**Outcome:**\n\nThe response to the treatment was very good partial remission (VGPR).\n\n**Present Treatment:**\n\nHe underwent mobilization chemotherapy with cyclophosphamide, with a\ndosage adjusted due to his requirement for dialysis (1500mg/m^2^ on day\n1 and 1000mg/m^2^ on day 2). He received dialysis on March 2 in our\nnephrology department.\n\n**Secondary diagnoses:**\n\nIn March 2018, he developed renal insufficiency requiring thrice-weekly\ndialysis. In January 2018, he was diagnosed with prostate carcinoma and\nwas treated with an androgen blockade using Enantone.\n\n**Future Therapy Plan:**\n\nThe tumor board\\'s decision from March 3, 2019 was to continue with\nDaratumumab, Revlimid, and Dexamethasone due to the good response. He\nwill undergo stem cell mobilization and high-dose therapy with\nautologous stem cell transplant. Monitoring is scheduled for March 14,\n2019, followed by dialysis at our dialysis center on Mondays,\nWednesdays, and Fridays.\n\n**Medications:**\n\nHis current medications include:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------------ ---------------------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL For dialysis\n Dexamethasone (Decadron) 8 mg On March 4 and 5\n Pantoprazole (Protonix) 40 mg \n Cotrimoxazole (Bactrim) 480 mg Thrice weekly on Mondays, Wednesdays, and Fridays\n Valacyclovir (Valtrex) 500 mg \n Ibandronate (Boniva) 2 mg Every four weeks\n Leuprorelin (Lupron Depot) 3.75 mg Every four weeks\n Pregabalin (Lyrica) 25 mg \n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg \n Filgrastim (Neupogen/Granix) 48 million IU \n\n**Summary:**\n\nMr. Williams was admitted on March 1, 2019, for mobilization\nchemotherapy with cyclophosphamide. Please refer to our previous letters\nfor a detailed history. His last treatment was with daratumumab,\nRevlimid, and dexamethasone. Fortunately, this treatment showed a very\ngood response. He is dialyzed three times a week at our clinic due to\nchronic renal insufficiency. He was discharged on March 3, 2019, and we\nrequest the administration of filgrastim as per the medication plan\nstarting March 6, 2019. CD34+ monitoring is scheduled for March 14,\n2019. Depending on the CD34+ count, stem cell collection may need to be\nscheduled on a dialysis-free day. We have coordinated with our\ncolleagues at the dialysis center for the collection via the atrial\ncatheter. A follow-up for blood count and Ibandronate administration has\nbeen scheduled for March 10, 2017. If his condition deteriorates or if\nhe shows signs of infection, bleeding, or any other complications, he\nshould immediately be brought to our emergency department. Please\nremember to bring a referral form during your initial visit each\nquarter.\n\nTherapy recommendation based on Transthoracic echocardiography findings:\n\nMr. Williams has a normally sized left ventricle with standard global\nfunction. There\\'s no evidence of any regional wall motion\nabnormalities. The right ventricle is also of normal size with standard\nfunction. The left atrium is not dilated. There\\'s marked concentric\nleft ventricular hypertrophy. His aortic valve shows insufficiency of I°\n(PHT 520 ms), while the mitral and tricuspid valves appear normal. There\nis no significant pericardial effusion. Overall, he has a standard left\nventricular function with no significant valvular diseases or pulmonary\nhypertension.\n\n**Surgery Report:**\n\nDiagnosis: Terminal renal failure.\n\nProcedure: Creation of a right upper arm brachialis-basilica fistula\nwith the anterior movement of the right basilic vein.\n\n**Report:**\n\nMr. Williams required dialysis due to terminal renal insufficiency. For\nthis purpose, an arteriovenous (AV) fistula was created as a dialysis\naccess. Previously, dialysis was performed using a right atrial\ncatheter. After mapping, only the basilic vein on the right arm seemed\nsuitable. Hence, a brachialis-basilica fistula was created with anterior\ntransposition of the basilica vein. A partial mobilization of the\nbasilica vein was performed. Afterward, a brachialis-basilica\nanastomosis was carried out. The operation was uncomplicated.\n\nYour collaboration has been instrumental in managing this patient\neffectively. If you have any further queries or require additional\ndetails, please do not hesitate to contact our office.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------- ------------------ ------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Change every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg Morning on 03/05 & 03/06\n Pantoprazole (Protonix) 40 mg Morning\n Cotrimoxazole (Bactrim Forte) 480 mg Morning 3x weekly on Mon, Wed, Fri\n Valacyclovir (Valtrex) 500 mg Half tablet in the morning\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly subcutaneous (Morning)\n Pregabalin (Lyrica) 25 mg Morning and Evening\n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg Morning and Evening\n Filgrastim (Neupogen/Granix) 48 million IU Morning and Evening\n\nBest regards,\n\n\n\n### text_8\n**Dear colleague, **\n\nI am writing to provide you with a detailed report on Mr. John Williams,\nwho was admitted to our facility from May 8, 2020, to May 28, 2020.\n\n**Diagnoses:**\n\nHistory of acute mitral valve endocarditis in March 2020.\n\nSubsequent re-operation entailing mitral valve replacement using a\nBioprosthesis (29 mm) coupled with the resection of all infected tissue\nfrom the mitral valve\\'s supporting apparatus on March 24, 2020.\n\nThe origin remains uncertain, but potential associations include Demers\ncatheter infection and port catheter infection (confirmed presence of\nStaphylococcus epidermidis).\n\nSurgical removal was conducted on March 21, 2020, with no findings at\nthe catheter tips.\n\n14. Antibiotic regimen included:\n\n Meropenem from April 2, 2020, to April 23, 2020.\n\n Linezolid 600 mg from April 3, 2020, to April 19, 2020.\n\n Daptomycin from April 3, 2020, to May 27, 2020.\n\n Fosfomycin from April 19, 2020, to May 28, 2020.\n\nHistory of mitral valve reconstruction via minithoracotomy in 2015.\n\nRight-side vision loss due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia in the caput nuclei caudati/lenticular nuclei\non April 5, 2020, possibly embolic in origin from mitral valve\nendocarditis.\n\nHistory of brainstem transient ischemic attack (TIA) on March 11, 2020,\npotentially embolic in relation to mitral valve endocarditis.\n\nJugular vein thrombosis.\n\n20. Hematological/oncological diagnoses comprise:\n\n Multiple myeloma with lambda light chains, stage IIIB according to\n the Salmon and Durie criteria, first diagnosed in 2015. This was\n accompanied by multiple osteolysis occurrences, history of radiation\n to Th4 and rib thorax, and treatment with Daratumumab. Current\n treatment has been paused due to remission.\n\n A prostate carcinoma diagnosis in January 2018\n\n**Other medical conditions include:**\n\n-Chronic kidney failure necessitating dialysis since 2018, history of a\nDemer catheter with explantation on March 2020, and angioplasty on the\nright V. basilica and V. brachialis due to stenosis-related shunt\ndysfunction.\n\n-History of brainstem TIA in April 2019.\n\n-Sensations of tingling paresthesias in both lower legs.\n\n-History of bilateral deep vein thrombosis.\n\n-Frequent calf muscle cramps.\n\n**Medical History Overview:**\n\nMr. Williams\\'s latest admission on May 8, 2020, was to assess remission\nstatus and determine if continuation of treatment for his known multiple\nmyeloma was necessary. Previously, until March 2020 he was under a\nDaratumumab monotherapy (as he could not tolerate Revlimid), which\nshowed stable disease progression. Prior to this, he was treated at our\nlocal hospital for mitral valve endocarditis which had a complex\ntrajectory. At the time of admission, Mr. Williams felt generally weak\nbut was otherwise in stable condition. Upon discontinuation of the\nfentanyl patch, his back pain increased. He exhibited no fevers and had\nno known allergies. His appetite was low, and he reported no nausea.\nSince his heart surgery, he has experienced numbness in his left heel\nand toes. His residual urine output was about 190 mL per day, and he was\nundergoing regular dialysis.\n\n**Physical Examination:**\n\nThe patient was alert, responsive, and fully oriented. The examination\nof the head, neck, and lungs was unremarkable. Cardiac auscultation\nrevealed clear and rhythmic heart sounds without any abnormal findings.\nThere was a non-irritated sternotomy scar. Examination of his back\nrevealed decubitus ulcers. Abdominal examination showed a soft,\nnon-tender abdomen with normal bowel sounds. Extremity examination\nrevealed minor edema.\n\n**Diagnostic Imaging and Tests:**\n\nA series of diagnostic tests, including sonography, whole body CT scan,\nophthalmological exams, and histology were conducted. The results are\ndetailed within this report. In summary, the findings indicate:\n\n-Limited abnormalities in the heart\\'s echocardiography, with potential\nmitral valve issues to monitor.\n\n-Bone scans revealed extensive osteopenia and other abnormalities\nrelated to his known multiple myeloma, but no evidence of new\nosteolysis.\n\n-Eye examinations confirmed the previously noted vision issues,\npotentially stemming from the mitral valve endocarditis, but provided no\nclear solutions.\n\n-Histological evaluation of bone marrow samples indicates largely\nregular hematopoiesis but confirms infiltration from the known multiple\nmyeloma.\n\n**Summary and Recommendations:**\n\nMr. John Williams is a 63-year-old male with a complex medical history\ninvolving multiple organ systems. His most recent admission was in\nrelation to his multiple myeloma, for which he has been in remission and\nwill be monitored closely. His mitral valve endocarditis from earlier\nthis year has been resolved and treated appropriately. Due to the\nmultiple comorbidities, it is crucial for any treating facility or\nphysician to be fully aware of his history to provide optimal care.\nContinual monitoring of his cardiovascular and renal systems is\nessential. The importance of maintaining strict adherence to his\ndialysis regimen and potential antibiotic prophylaxis is emphasized.\nGiven his weakened general condition and chronic pain, palliative care\nmight also be a suitable approach to consider, focusing on enhancing his\nquality of life and addressing his pain management needs.\n\nPlease refer to the attached files for further details and a complete\nbreakdown of tests and findings. I trust this report will help guide the\nappropriate medical care for Mr. John Williams.\n\nSincerely,\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- -------------------- -----------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Morning\n Enoxaparin (Lovenox) 0.2 mL s.c. Evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Morning and Evening\n Leuprorelin (Lupron Depot) Monthly depot Every 4 weeks via subcutaneous injection\n Fentanyl Transdermal System 12 μg/hour Changed every 3 days\n Pantoprazole (Protonix) 40 mg Morning\n Sevelamer (Renagel) 800 mg Morning\n Multivitamin One tablet Morning\n Torsemide (Torem) 200 mg Morning\n Vitamin D3 20,000 IU Once weekly\n Sodium bicarbonate (Bicanorm) One tablet Morning\n Calcitriol (Rocaltrol) 0.25 μg Morning\n Valacyclovir (Valtrex) 500 mg half-tablet Morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Morning on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Morning on day 1 and day 2 following daratumumab administration\n\n\n\n### text_9\n**Dear colleague, **\n\nI am writing to provide an update on the medical condition and treatment\nof Mr. John Williams, who has been undergoing inpatient treatment in our\nfacility since September 30, 2021.\n\n**Diagnoses**:\n\n**Present**: Acute impairment of the visual field.\n\n**Oncological Diagnosis**:\n\n1. Diagnosis of Multiple Myeloma with kappa light chains, staged at\n IIIB as per the Salmon and Durie criteria\n\n Observable multiple osteolyses.\n\n History of radiation to the T4 and thoracic rib.\n\n Starting from 2018, he required dialysis due to renal insufficiency,\n scheduled on Mondays, Wednesdays, and Fridays in our local clinic.\n\n 2018: Treatment involved Bortezomib and Dexamethasone, but he was\n refractory to this combination. The regimen of Carfilzomib,\n Lenalidomide, and Dexamethasone was also found to be ineffective.\n\n Radiation was administered to the T4 (totaling 30 Gy) and the\n thoracic rib (totaling 20 Gy) in August 2018.\n\n Between August and October 2018: Mr. Williams underwent three cycles\n of Pomalidomide, Doxorubicin, and Dexamethasone, but the disease\n showed progression.\n\n November 2018 to February 2019: He received four treatments of\n Daratumumab, Lenalidomide, and Dexamethasone, which led to a very\n good partial response (VGPR).\n\n In March 2019, he underwent stem cell mobilization due to RSV\n pneumonia complications and then started on Daratumumab monotherapy\n (VGPR was last noted in May 2018).\n\n He continued with Daratumumab treatment until November 2019, after\n which there was a pause until March 2020 due to remission (VGPR) and\n a diagnosis of endocarditis.\n\n A whole body CT scan conducted in March 2020 did not show any new\n osteolyses.\n\n By May 2020, there was an increase in LK values, prompting the\n resumption of Daratumumab, which led to a decrease in free light\n chains.\n\n As of June 2020, there was a noted increase in light chain kappa\n values to 102 mg/L.\n\n In July 2020, therapy was escalated to include Daratumumab, Revlimid\n (5 mg), and Dexamethasone.\n\n By September 2020, a further increase in light chains was observed,\n prompting a planned switch to Elotuzumab, Pomalidomide, and\n Dexamethasone.\n\n**For his heart condition:**\n\nAcute mitral valve endocarditis was diagnosed in March 2020. He\nunderwent a re-operation for mitral valve replacement with a\nbioprosthesis (29 mm). This procedure, performed in March, 2020,\ninvolved the resection of all infected tissue from the mitral valve\\'s\nholding apparatus. The cause is presumed to be associated with a Demers\ncatheter infection or possibly related to a port catheter infection\n(Staphylococcus epidermidis was found). The catheter was surgically\nremoved in March 2020. He was on a series of antibiotics, including\nMeropenem, Linezolid, Daptomycin, and Fosfomycin.\n\n**Other pertinent medical events include:**\n\nA history of radiation treatment using a minithoracotomy technique for\nmitral valve reconstruction in 2015.\n\nRight eye amaurosis due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia diagnosed in April 2020, possibly due to\nemboli from the mitral valve endocarditis.\n\nA transient ischemic attack (TIA) in the brainstem observed on in March\n2020, which could be related to emboli from the mitral valve\nendocarditis.\n\nJugular vein thrombosis.\n\nProstate cancer diagnosed in 2018.\n\nChronic renal failure necessitating dialysis since 2018.\n\nPrevious procedures include Demers catheter placement (removed on March\n2020) and angioplasty on the right basilic vein and brachial vein due to\nstenosis causing shunt dysfunction.\n\nHistory of transient ischemic attacks.\n\nBilateral tingling paresthesias in the lower legs, history of deep vein\nthrombosis, recurrent calf cramps, and hypothyroidism.\n\nPlease let me know if you require any further information on Mr.\nWilliams. I am confident that this detailed account will assist you in\nunderstanding his medical history and ensuring optimal care.\n\n**Therapy: **\n\nTherapy schedule: Daratumumab s.c. 1800mg abs. weekly in week 1-8,\n2-weekly in week 9-24, every 4 weeks from week 25. Continuation of\nBondronat. Regular monitoring and optimal adjustment of cardiovascular\nrisk factors.\n\nMedication:\n\nPlavix (Clopidogrel) 75 mg; once daily in the morning\n\nLovenox (Enoxaparin) 0.2 ml subcutaneously; once daily in the evening on\nnon-dialysis days\n\nMarinol (Dronabinol) drops; four drops in the morning and four drops in\nthe evening\n\nDuragesic (Fentanyl transdermal patch) 12 μg/hour; change every 3 days\n\nProtonix (Pantoprazole) 40 mg; dosing: Once daily in the morning and\nonce daily in the evening for 2 weeks, then once daily in the morning\n\nRenvela 800 mg; dosing: Once daily in the morning\n\nTorem 200 mg; once daily in the morning\n\nVitamin D3 20,000 IU; once weekly\n\nCalcijex (Calcitriol) 0.25 mcg; once daily in the morning\n\nValtrex (Valacyclovir) 500 mg; dosing: Half a tablet (250 mg) once daily\nin the morning\n\nBactrim (Cotrimoxazole or trimethoprim/sulfamethoxazole) 480 mg, once\ndaily\n\nWarm regards,\n\n**Clinical Update, 11/12/2022**\n\nMr. John Williams, a 66-year-old male with a known history of multiple\nmyeloma and associated complications, presented again to our facility\nwith worsening symptoms over the past three weeks.\n\n**Symptoms**:\n\nPersistent fatigue\n\nShortness of breath on minimal exertion\n\nBilateral pitting edema in the lower extremities up to the mid-calf\n\n**Preliminary Findings**:\n\n**Physical Examination**:\n\n1. Jugular venous distention\n\n Decreased breath sounds bilaterally with mild basilar crackles\n\n S3 gallop on cardiac auscultation\n\n**Chest X-ray**:\n\n4. Cardiomegaly with an enlarged cardiac silhouette. Mild pulmonary\n edema evident.\n\n**Echocardiogram**:\n\n5. Reduced left ventricular ejection fraction (LVEF) of 35% (normal \\>\n 55%)\n\n Mild mitral regurgitation\n\n**Lab Results**:\n\n7. B-type natriuretic peptide (BNP): 890 pg/mL (Normal: \\<100 pg/mL)\n\n Serum Sodium: 130 mEq/L (Normal: 135-145 mEq/L)\n\n Serum Potassium: 5.8 mEq/L (Normal: 3.5-5.1 mEq/L)\n\n Blood Urea Nitrogen (BUN): 38 mg/dL (Normal: 7-20 mg/dL)\n\n Creatinine: 2.1 mg/dL (Normal: 0.8-1.3 mg/dL)\n\n GFR: 35 mL/min (Reduced)\n\n**Diagnosis**:\n\nCongestive Heart Failure (CHF) with reduced ejection fraction\n\nRenal insufficiency\n\nMultiple Myeloma (primary diagnosis 2015)\n\nProstate cancer\n\n**Treatment Administered**:\n\nIntravenous furosemide was administered to relieve fluid overload,\nresulting in a significant reduction in edema and improvement in\nbreathlessness over the subsequent 48 hours. Lisinopril was initiated\ncautiously to manage CHF and to potentially provide renal protection.\nMetoprolol was started at a low dose, with close monitoring of blood\npressure and heart rate. Potassium levels were closely monitored given\ninitial hyperkalemia; diet and medications were adjusted accordingly.\nDietary consult emphasized a low-sodium, moderate protein, and\npotassium-restricted diet. Close monitoring of fluid balance\n(input-output) was maintained throughout the stay.\n\n**Progress**:\n\nMr. Williams showed consistent improvement over his two-week admission.\nSerial echocardiograms indicated a slight improvement in LVEF to 39%.\nThe edema receded notably, and his shortness of breath on exertion\nreduced significantly. Labs before discharge showed:\n\nSerum Sodium: 134 mEq/L\n\nSerum Potassium: 4.9 mEq/L\n\nBUN: 32 mg/dL\n\nCreatinine: 1.9 mg/dL\n\nBNP: 550 pg/mL\n\n**Discharge Recommendations**:\n\nOutpatient cardiology follow-up in two weeks and then monthly to monitor\nLVEF and adjust medications. Nephrology consultation to keep an eye on\nrenal function, given his increased susceptibility to kidney damage.\nContinue with dietary restrictions and modifications as advised.\nCommence an outpatient cardiac rehabilitation program for supervised\nexercise and lifestyle modifications. Weekly blood tests for the first\nmonth to monitor electrolytes and kidney function.\n\nMr. Williams remains at risk due to multiple comorbidities. It is\nessential to address each condition holistically while ensuring no\nsingle treatment exacerbates another condition. A collaborative and\nvigilant approach is imperative for his ongoing health management.\n\nWarm regards,\n\n --------------------------- ---------------- ---------------------\n **Parameter** **Value** **Reference Range**\n **Blood Count** \n White Blood Cells (WBC) 5.8 x 10^9^/L 4-11 x 10^9^/L\n Red Blood Cells (RBC) 3.9 x 10^12^/L 4.5-5.5 x 10^12^/L\n Hemoglobin (Hb) 9.8 g/dL 13-18 g/dL for men\n Platelets (Plt) 150 x 10^9^/L 150-450 x 10^9^/L\n \n **Biochemistry** \n Creatinine 2.8 mg/dL 0.6-1.3 mg/dL\n Blood Urea Nitrogen (BUN) 40 mg/dL 7-20 mg/dL\n Glucose 98 mg/dL 70-100 mg/dL\n \n **Electrolytes** \n Sodium (Na) 137 mEq/L 135-145 mEq/L\n Potassium (K) 5.1 mEq/L 3.5-5.0 mEq/L\n Calcium 8.6 mg/dL 8.5-10.5 mg/dL\n Phosphate 4.5 mg/dL 2.5-4.5 mg/dL\n \n **Oncologic Markers** \n Free light chain kappa 692 mg/L 3.3-19.4 mg/L\n Free light chain lambda 12 mg/L 5.7-26.3 mg/L\n \n **Other Values** \n LDL cholesterol 80 mg/dL \\<100 mg/dL\n HbA1c 6.2% \\<5.7%\n --------------------------- ---------------- ---------------------\n\n\n\n\nHere is the query:\nWhich treatment resulted in prolonged pancytopenia for Mr. Williams?\n\nChoose the correct answer from the following options:\nA. Cyclophosphamide, bortezomib and dexamethasone\nB. Combination of carfilzomib, lenalidomide, and dexamethasone\nC. Stem cell mobilization using cyclophosphamide\nD. Cyclophosphamide–carfilzomib–dexamethasone\nE. None of the above\n\n\nYour response:\n", "role": "user" }, { "content": "Cyclophosphamide, bortezomib and dexamethasone", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nHerewith we report on Mr. John Williams, born 08/08/1956, inpatient from\n10/03/2015 to 10/06/2015.\n\n**Diagnosis:**\n\nMultiple Myeloma IgG kappa.\n\n**Staging and Initial Diagnosis:**\n\nDate: 03/2015\n\nStage: IIA based on the Salmon and Durie scale, ISS II.\n\n- CT whole body 03/11/2015: Osteolysis detected in the seventh\n thoracic vertebra (T7); pathologic fracture observed in the first\n lumbar vertebra (L1).\n\n- Bone marrow infiltration: Initial histological evaluation showed\n 22%; cytomorphological assessment revealed 28%.\n\n**Histological Findings:**\n\nDate: 03/2015\n\n**FISH (Fluorescence In Situ Hybridization) Results:** Detected an\nadditional signal for both CCND1 and CCND3. Presence of one trisomy or\ntetrasomy 9. Additional signals observed for 5p15- and 5q31- as well as\n19p13- and 19q13-. 46, XY with a detected ASxL1 mutation.\n\n**Treatment Timeline:**\n\n**01-02/15:** Administered 2 cycles of\nCyclophosphamide-Bortezomib-Dexamethasone (CyBorD). Resulted in stable\ndisease but caused prolonged pancytopenia.\n\n**03/15 - 06/15:** Administered 3 cycles of a combination treatment\nincluding Carfilzomib, Lenalidomide, and Dexamethasone.\n\n**07/15:** Underwent stem cell mobilization using cyclophosphamide.\n\n**07-08/15:** Experienced extended pancytopenia and regeneration. Bone\nmarrow puncture showed progressive disease with a significant increase\nin plasma cell infiltration, reaching 92%.\n\n**09/02/15:** Received the first dosage of daratumumab at 16mg/kg.\nSubsequently developed thrombocytopenia. Treatment did not include\nRevlimid.\n\n**Histopathological report: **\n\nMultiple myeloma, IgG kappa. The evaluation is for myelodysplastic\nsyndrome in the presence of tricytopenia and an ASXL1 mutation.\n\n**Methods:** Hematoxylin and eosin (HE), periodic acid-Schiff (PAS),\niron, Giemsa, Gomori, chloroacetate esterase, step sections,\ndecalcification, and 1 block.\n\n**Microscopic Examination:**\n\nThe sample is a 2 cm long bone marrow biopsy core that contains more\nthan ten medullary canals. The cellularity is around 20-30%, which is\nconsidered normocellular for the patient\\'s age. There is evidence of\nbone marrow edema and heightened hemosiderosis. Recent stromal\nhemorrhages are also observed. There is a relative increase in\nerythropoiesis with a ratio of erythropoiesis to granulopoiesis being\napproximately 2:1. Erythropoiesis is present in well-defined zones with\nregular maturation. Only minimal nuclear rounding is observed.\nGranulopoiesis matures into segmented granulocytes. PAS staining reveals\nsome morphologically normal megakaryocytes. Occasionally there are bare\nnuclei and possible microforms. Scattered mature plasma cells are\nobserved with no signs of atypical proliferation. The argyrophilic\nfibrous network is fine, and no fibrosis is detected.\n\n**Preliminary Findings:**\n\nThe bone marrow biopsy is normocellular for the age with a relative\nincrease in erythropoiesis that shows only minimal cytological atypia.\nGranulopoiesis is slightly reduced, while megakaryopoiesis is\nnormocellular with a few cells that are hypolobulated.There is bone\nmarrow edema and enhanced hemosiderosis. Scattered mature plasma cells\nare also noted.\n\nBased solely on histomorphologic observations, it is not enough to\nconfirm a diagnosis of myelodysplastic syndrome (MDS), which is the\nsuspected clinical diagnosis. For a more thorough evaluation of\npotential atypicalities in the megakaryopoiesis (like\nmicromegakaryocytes), further immunohistochemical examination is\nrecommended. Assessing the blast content is also advised. There is no\nevidence currently of manifest infiltrates from the previously diagnosed\nmultiple myeloma.\n\n**Immunohistochemical Additional Findings (Dated 10/04/2015):**\n\n**Immunohistochemistry Stains Used:** CD3, CD79a, CD34, CD117, MUM-1,\nKappa, lambda, CyclinD1, CD61.\n\nBlast cells positive for CD34 and CD117 are below 5% of the total. CD3\nstains scattered T lymphocytes, and CD79a identifies sporadic B\nlymphocytes and some plasma cells. Plasma cells are also positive for\nMUM-1 and exhibit polytypic expression of kappa and lambda light chains.\nThere is no co-expression with CyclinD1. CD61 highlights the previously\ndescribed megakaryocytes, and no micromegakaryocytes are observed.\n\n**Final Report:**\n\nThe bone marrow biopsy is representative and normocellular for the\npatient\\'s age. There is a relative increase in erythropoiesis that\nshows only minor cytological atypia. Granulopoiesis appears slightly\nreduced, while megakaryopoiesis presents with a few hypolobulated cell\nforms. Evidence of bone marrow edema and increased hemosiderosis is\nnoted, along with scattered mature plasma cells.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe hereby report on Mr. Williams, John, born 08/08/1956, inpatient from\n11/30/2015 to 12/28/2015.\n\n**Oncological Diagnosis**:\n\nMultiple myeloma IgG kappa.\n\nInitial diagnosis 03/15: Stage IIA (Salmon and Durie), ISS II.\n\n**Sites**:\n\nOsteolysis in T7 vertebra, fracture in T1 vertebra.\n\nBone marrow: 22% histological, 28% cytomorphologic infiltration.\n\n**Histology**:\n\nBone marrow biopsy 11/16: FISH: Additional signals for CCND1, CCND3;\nTrisomy 3, 9; Additional signals on chromosomes 5 and 19. Chromosomal\nanalysis: 46, XY with ASxL1 mutation.\n\n**Treatment**:\n\n01-02/15: 2 cycles Cyclophosphamide-Bortezomib-Dexamethasone -\\>\nStable disease, prolonged low blood counts.\n\n03/15 - 06/15: 3 cycles Carfilzomib/Lenolidomide/Dexamethasone.\n\n07/15: Stem cell mobilization with Cyclophosphamide.\n\n07-08/15: Extended low blood count. Bone marrow biopsy: 92% plasma cell\ninfiltration.\n\n09/02/15: Darzalex 16mg/kg initial dose, with platelet count drop. No\nLenalidomide.\n\n09/04/15: 10 cycles of Darzalex, 1 cycle with Lenalidomide due to\nrenewed low platelet and white blood cell counts.\n\n11-12/15: Conditioning chemo with Fludarabine/Treosulfan, then\nallogeneic stem cell transplant from HLA-matched unrelated donor.\nImmunosuppression with ATG, cyclosporine, Mycophenolate Mofetil.\n\n**Complications**:\n\nMucositis, central line infection, gastrointestinal symptoms, urinary\ninfections with E. faecium and E.coli, JC virus bladder infection.\n\n**Secondary Diagnoses**:\n\nDry eye syndrome, Type 2 diabetes managed with oral meds, Hypertension.\n\n**Treatment Plan**:\n\nGradual reduction of immunosuppression based on graft vs. host disease\nsigns.\n\n**Radiology**:\n\nCT Whole Body: 12/01/15: Various areas of bone osteolysis. Degeneration\nof spine.\n\nCT Chest 12/02/15 and 12/03/15: Changes in lungs and some fluid\naccumulation.\n\n**Medication**:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------- ---------------\n Mycophenolic Acid (Myfortic) 360 mg Twice Daily\n Cyclosporine (Sandimmune) 200 mg Daily\n Artificial Tears As directed 3x Daily\n Candesartan (Atacand) 8 mg Daily\n Tamsulosin (Flomax) 0.4 mg Daily\n Pantoprazole (Protonix) 40 mg Daily\n Amlodipine (Norvasc) 5 mg Twice Daily\n Cotrimoxazole (Bactrim) 960 mg Mon/Wed/Fri\n Valacyclovir (Valtrex) 500 mg Twice Daily\n\n**Summary**:\n\nMr. Williams was admitted on 11/30/2015 for treatment related to his\nMultiple Myeloma. He underwent conditioning chemotherapy,\nimmunosuppressive therapy, and stem cell transplantation. He experienced\ncomplications, including infections and symptoms affecting multiple\nsystems. Close monitoring of blood pressure and glucose is recommended.\nHe was discharged on 12/28/2015 in good condition and will be followed\nup in the outpatient clinic. If there are worsening symptoms, he should\nvisit the emergency department immediately.\n\n**Dear Mr. Williams,**\n\nWe report on your outpatient treatment on 02/15/2016.\n\n**Diagnoses:**\n\n1. **Multiple Myeloma** IgG kappa, diagnosed 03/2015.\n\n Stage IIA as per Salmon and Durie, stage II as per ISS.\n\n Osteolysis at T7 vertebra, fracture at T1 vertebra.\n\n Bone marrow infiltration: 22% histologically, 28% cytologically.\n\n FISH: Indications of additional CCND1 and CCND3 signals; Trisomy 3,\n additional signals at various chromosomes.\n\n Chromosome analysis: 46, XY \\[20\\].\n\n**Secondary diagnoses:**\n\nType 2 diabetes mellitus\n\nHypertension\n\nCataract (surgery 06/2018)\n\nNodular goiter\n\nRSV pneumonia (03/2018)\n\n**Summary:**\n\nMr. Williams presents in good general health to our bone marrow\ntransplant (BMT) outpatient clinic. There are no signs of infection or\nchronic graft rejection. He has shown significant improvement in\nresilience and does not have any complaints. Vital signs are stable.\nBlood tests showed ongoing regeneration with normal light chains and\npersistent positive immunofixation. There is no need for\nmyeloma-specific therapy at present, but close monitoring of the\nparaprotein is required.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ---------------------- -------------------------------------------------------\n Tamsulosin (Flomax) 0.4 mg Daily in the morning\n Candesartan (Atacand) 8 mg Twice Daily\n Metformin (Glucophage) 1000 mg 0.5 tablet in the morning, 1.5 tablets in the evening\n Pantoprazole (Protonix) 20 mg Daily in the morning\n Vitamin D3 (various brands) 20,000 IU Once a week\n Allopurinol (Zyloprim) 100 mg Daily in the morning\n Insulin (various types) As per sliding scale As per sliding scale\n\nWith kind regards\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are providing an update on our shared patient, Mr. John Williams, who\nconsulted with us on June 15, 2018.\n\n**Consultation Summary:**\n\n8. **Multiple Myeloma**\n\n **Kidney biopsy scheduled for tomorrow.**\n\n **Prostate cancer**\n\n**Current Status:**\n\nAcute renal failure accompanied by proteinuria due to the recent\ndiagnosis of multiple myeloma.\n\nMultiple osteolytic lesions, including at the T4, T7, L1 vertebra and\nthe ribs.\n\n**Diagnosis:**\n\nMultiple myeloma.\n\nProstate cancer\n\n**Clinical Presentation:**\n\nOsteolytic lesion presenting as thoracic pain.\n\n**Imaging Findings:**\n\nOsteolytic lesion at T4 vertebra with involvement of the posterior edge.\n\n**Planned Procedures:**\n\nRestricted bed rest.\n\nWhole spine MRI with STIR sequences, to be presented in the upcoming\ntumor board meeting for deciding further course of action.\n\n**Previous Diagnoses:**\n\nMay, 2018, Nephrology: Enlarged kidneys noted bilaterally.\n\nJanuary, 2018, Urology: Prostate cancer\n\nDecember, 2015, Internal Medicine: Multiple myeloma without evidence of\ncomplete remission.\n\n**Previous Procedures:**\n\nTransrectal biopsy of the prostate.\n\n**Histology Report, Date: June 13, 2018:**\n\nSuspected plasmacytoma with paraproteinemia.\n\nWBC 6.47; Hb 10.8; Platelets 251,000.\n\nBone marrow biopsy: Cellularity approximated at 48%, indicating slightly\nincreased cellularity. Amidst reduced hematopoiesis, there is\nproliferation of plasmacytoid cells with certain features.\n\n**Preliminary Report:**\n\nThe bone marrow sample indicates possible infiltration due to plasma\ncell myeloma. Additional tests will be conducted to confirm and further\nelucidate this finding.\n\n**Supplementary Findings:**\n\nImmunohistochemical staining: CD138, Kappa, Lambda, CD20.\n\nMicroscopic findings confirm the presence of nodular infiltrates with\ncertain features.\n\n**Final Report:**\n\nBone marrow sample indicates infiltration by a plasma cell myeloma with\nkappa light chain restriction. Additionally, regular trilinear\nhematopoiesis is significantly reduced.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nI wish to provide an update on our mutual patient, Mr. John Williams,\nborn 08/08/1956, who presented at our clinic at 08/20/2018.\n\n**Diagnosis:**\n\nPresent condition: Multiple Myeloma IgG type, coded under ICD-10.\n\nStage: II B based on Durie and Salmon criteria; determined from Hb 9.1,\nCreatinine 4.5 mg/dL.\n\n**Histology:**\n\nBone marrow biopsy presents a strong indication of interstitial and\nfocal nodular invasion of the marrow space by plasma cell myeloma,\npredominantly of high to intermediate maturity.\n\n**Immunohistochemistry:**\n\nThe nodular infiltrates were found positive for CD138 with a kappa-light\nchain restriction (infiltration rate at 62%).\n\nCytological findings align with high-grade bone marrow infiltration by\nmultiple myeloma.\n\n**Tumor Localization:**\n\nMRI of the entire spine conducted on 06/20/2018 reveals disseminated\nbone lesions throughout the spine without any soft tissue involvement.\nThere is noted anterior vertebral body involvement at T4.\n\n**Secondary Diagnoses:**\n\nCysts in the right kidney.\n\nAs of 01/2018, a diagnosis of Prostate cancer with a Gleason score of 8\nand a PSA reading of 10.02.\n\nPrevious rib fracture, which may be associated with the multiple\nmyeloma.\n\nChronic renal failure, with ongoing dialysis treatment.\n\nDocumented mitral valve surgery in 2015.\n\nHistory of Deep Vein Thrombosis in 1999.\n\n**Prior Treatments:**\n\nInitial diagnosis of multiple myeloma IgG kappa in 2015.\n\nProstate cancer was diagnosed in 01/2018 following spontaneous rib\nfractures, Gleason score of 8.\n\nA PSMA-PET-CT scan in 05/18 showed multiple bone lesions, notably\npronounced at Th4.\n\nTumor board review in 06/2018 concluded treatment strategies for\nurological tumors, encompassing radiation therapy targeting Th4 and\nantiandrogen therapy for the identified prostate cancer, using a GnRH\nanalog.\n\nThe progression of multiple myeloma required the commencement of\nsystemic treatment with Velcade and Dexamethasone.\n\n**Study**: PSMA-PET-CT Scan\n\n**Date of Study**: 05/2018\n\n**Clinical Information**: Prostate cancer diagnosed in 01/2018 following\nspontaneous rib fractures. Gleason score of 8.\n\n**Technique**:\n\nWhole body positron emission tomography/computed tomography (PET/CT) was\nperformed following the intravenous administration of PSMA-radiotracer.\nCoronal, sagittal, and axial images were acquired and reviewed.\n\n**Findings**:\n\nBone: Notably increased PSMA uptake is seen at the level of T4 vertebral\nbody consistent with metastatic involvement. The lesion has caused\ncortical erosion and expansion with potential involvement of the\nanterior spinal canal. Multiple rib lesions are identified,\ncorresponding with the clinical history of spontaneous rib fractures.\nThese lesions exhibit no increased PSMA uptake. No other foci of\nincreased PSMA uptake throughout the axial and appendicular skeleton.\n\n**Prostate**:\n\n12. The prostate gland demonstrates diffusely increased uptake, which is\n consistent with primary prostate malignancy, especially given the\n known clinical history.\n\n**Thorax/Abdomen: **\n\n13. No abnormal PSMA avid soft tissue masses or lymphadenopathies were\n noted in the visualized fields. No pulmonary nodules or masses\n suggestive of metastatic disease were identified. Liver, spleen,\n kidneys, and adrenal glands appear unremarkable with no evidence of\n metastatic lesions.\n\n**Impression**:\n\nOsseous metastasis from prostate cancer with involvement of the T4\nvertebral body. No evidence of soft tissue, lymph node, or pulmonary\nmetastases in the visualized fields. Prostate gland showing evidence\nconsistent with primary malignancy.\n\n**Current Radiation Therapy:**\n\n**Indication:** Radiotherapy became a consideration due to a sizable\nosteolytic lesion at T4, both for pain alleviation and stabilization.\nConcurrent treatment of the aching ribs on the right side (7th-9th) was\nalso performed.\n\n**Technique:** 6 MeV photons from a linear accelerator, administering a\ncumulative dose of 30 Gy to thoracic vertebra 4 and 20 Gy to the ribs\nwith respective daily doses.\n\n1. **Treatment Duration:**\n\n Th4: 08/21/2018 to 08/27/2018\n\n Rib area: 08/21/2018 to 08/27/2018\n\n**Clinical Update:**\n\nThroughout the therapy period, Mr. Williams remained admitted to our\nOncology ward for ongoing reduced dosage chemotherapy using Velcade. He\nhas reported a decline in pain sensations during this timeframe. The\noverall health status appeared satisfactory, with no skin irritation\nobserved at the irradiated sites.\n\n**Subsequent Actions:**\n\nGuidance on skincare and potential adverse effects have been provided to\nMr. Williams. The intensity of the chemotherapy will soon be escalated.\nA radio-oncological assessment has been scheduled in our outpatient\nfacility for 09/05/2018 at 12:00 PM. I kindly request the most recent\ntest results by this date.\n\n**Note:** In compliance with the Radiation Protection Act, we shall\nundertake regular evaluations and request updates on the patient\\'s\ncondition. Mr. Williams has been apprised of the necessity for\nconsistent oncological check-ups.\n\nWarm regards,\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe wish to update you on our mutual patient, Mr. John Williams.\n\n**Diagnosis:**\n\nCurrent multiple myeloma IgG type\n\n**Tumor Localization:**\n\nBased on a whole spine MRI dated June 20, 2018:\n\nMultiple intraosseous lesions throughout the spine without soft tissue\ninvolvement.\n\nKnown intrusion of the T4 cover plate.\n\n**Secondary Diagnoses:**\n\nRight kidney cysts\n\nDiagnosed prostate carcinoma in January 2018, Gleason score 8, initial\nPSA at 10.02.\n\nHistory of a spontaneous rib fracture related to the multiple myeloma.\n\nChronic renal insufficiency; he remains on dialysis.\n\nHistory of mitral valve reconstruction in 2015.\n\nHistory of deep vein thrombosis in 1999.\n\n**Treatment Overview:**\n\nDiagnosed with multiple myeloma type kappa in 2015 with initially normal\nrenal function.\n\nDiagnosed with prostate carcinoma in January 2018 due to spontaneous rib\nfractures, Gleason score 8.\n\nTreatment decisions in 2018 included radiation for vertebral lesions and\nhormone therapy for prostate cancer using a GnRH analogue.\n\nSystemic therapy with Velcade and Dexamethasone initiated due to\nprogressive myeloma.\n\nRadiation therapy in August 2018 for vertebral and rib lesions.\n\n**Summary:**\n\nMr. Williams had a radio-oncological follow-up on September 29, 2018.\nHis general health has improved. He remains on thrice-weekly dialysis.\nRecent CT scans show extensive osteolysis of the spine with several\nvertebral collapses. Currently, we see no urgent fracture risk or need\nfor additional radiation therapy. We have planned regular clinical\ncheck-ups with Mr. Williams. His next follow-up is scheduled in three\nmonths.\n\n**Oncologic treatment: **\n\nDaratumumab/lenalidomide/dexamethasone regimen:\n\nDaratumumab 16mg/kg: Days 1, 8, 15, 22 for cycles 1 & 2 (every 28 days\nfor 8 weeks).\n\nDays 1, 15 for cycles 3-6 (every 28 days for 16 weeks).\n\nDay 1 for subsequent cycles (every 28 days).\n\nDexamethasone 20mg on Daratumumab days, with an additional 20mg the day\nafter (totaling 40mg/week).\n\nLenalidomide 5mg from day 1-21 (every 28 days).\n\nBondronate every 4 weeks (last administered on 12/13/2016).\n\nRe-evaluation of hemodialysis and autologous peripheral blood stem cell\ntransplant (PBSCT) after 2 cycles of daratumumab.\n\n**CT Spine scan (09/30/2018): **\n\n**Technique**: Contrast-enhanced computed tomography (Omnipaque 240) of\nthe thoracic and lumbar spine was performed with axial slices, and\nmultiplanar reconstructions in sagittal and coronal orientations.\n\n**Findings**:\n\n**Thoracic Spine**:\n\nExtensive osteolytic lesions are identified in multiple thoracic\nvertebrae. Specifically, vertebral collapses are noted at T4, T7, T9,\nT11. No significant bony destruction of pedicles, lamina and spinous\nprocesses. No evidence of paravertebral or epidural soft tissue masses.\n\n**Lumbar Spine**:\n\nProminent osteolytic changes are seen in L1 (with fracture) and L4\nvertebral bodies. However, there is no significant vertebral collapse.\nPreserved pedicles, lamina, and spinous Processes without significant\nosteolysis. No evidence of abnormal masses or lymphadenopathy.\n\nNo significant central canal stenosis or neural foraminal narrowing. The\nintervertebral discs are preserved without significant discopathies.\n\n**Impression**:\n\nExtensive osteolysis in multiple vertebral bodies, specifically in the\nthoracic and lumbar spine, with vertebral collapses at levels T4, T7,\nT9, and T11 as well as L1. Also, osteolytic changes in L4 of the lumbar\nspine.\n\nCurrently, based on imaging, there does not appear to be an urgent\nfracture risk, and no radiologic signs suggesting a need for imminent\nradiation therapy. No soft tissue abnormalities identified in the\nexamined regions.\n\n**Medication: **\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ----------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg In the morning (day after Daratumumab)\n Pantoprazole (Protonix) 40 mg Daily in the morning\n Cotrimoxazole (Bactrim) 480 mg Thrice weekly (Mon, Wed, Fri)\n Valacyclovir (Valtrex) 500 mg Daily in the morning\n Acetaminophen (Tylenol) 500 mg Orally, three times daily\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly (4-week depot) subcutaneously\n Pregabalin (Lyrica) 25 mg Twice a day\n Amlodipine (Norvasc) 5 mg Daily in the morning\n Bisoprolol (Zebeta) 5 mg Daily in the morning\n Lenalidomide (Revlimid) 5 mg Nightly\n Ondansetron (Zofran) 8 mg As needed, up to twice daily\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are updating you on Mr. John Williams\\' outpatient visit on December\n13, 2018.\n\n**Diagnosis:**\n\nFebrile respiratory infection.\n\n**Underlying Conditions:**\n\nMultiple myeloma, kappa light chain, stage IIIB as classified by Salmon\nand Durie.\n\nChronic kidney disease requiring hemodialysis.\n\nProstate cancer.\n\n**Summary:**\n\nMr. Williams came to the emergency room with fever and dry cough during\nhis multiple myeloma treatment with Darzalex, Revlimid, and\nDexamethasone. His vital signs were recorded, and laboratory tests\nshowed signs of infection and confirmed chronic kidney disease. Chest\nX-ray indicated possible inflammation. Given these findings, Mr.\nWilliams was admitted for antibiotic therapy. Further observations and\ntreatments were documented.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nThis letter pertains to Mr. John Williams, who was hospitalized from\nDecember 14 to 21st, 2018.\n\n**Oncological Diagnosis:**\n\nMultiple myeloma, kappa light chain, initially diagnosed in June 2018 as\nstage IIIB per Durie and Salmon criteria.\n\n**Treatment Details:**\n\nHe underwent various treatment regimens for multiple myeloma over the\ncourse of the year. His current condition indicates an\ninfluenza-positive pneumonia, likely with a bacterial superinfection. He\ncontinues hemodialysis thrice a week.\n\n**Secondary Diagnoses:**\n\nSeveral renal complications were documented in June 2018.\n\n**Plan of Care:**\n\nMr. Williams\\' therapy plan was discussed in a tumor board meeting. He\nremains on a regimen of Darzalex, Revlimid, and Dexamethasone.\n\n**Summary:**\n\nMr. Williams came to the emergency room on December 13, 2018, with cough\nand fever. Further details about his history can be found in previous\ncommunications. On admission, he showed signs of a respiratory\ninfection, confirmed by a chest X-ray. He was treated with antibiotics,\nwhich were later escalated. He also tested positive for influenza A and\nwas given Tamiflu. After a short in-patient stay, he has shown\nimprovement. He is scheduled to continue his therapy in our clinic on\nDecember 22, 2018. In case of any complications, he has been advised to\nreturn to our emergency room immediately.\n\nFor future consultations, please provide a referral slip for each new\nquarter.\n\nWarm regards\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about Mr. John Williams, who was an\ninpatient in our clinic from March 1, 2019, to March 3, 2019.\n\nOncological diagnosis:\n\nMr. Williams was diagnosed with Multiple Myeloma light chain kappa. He\nreceived his follow-up diagnosis in June 2018, which was at stage IIIB\nper the Durie and Salmon staging system.\n\nTreatment:\n\nIn June 2018, he was given VelDex due to impaired renal function.\nSubsequently, he received Carfilzomib (15mg/m2 on days 1-2, 8-9, 15-16),\nLenalidomide (5 mg, on days 1-21), and Dexamethasone (40mg, on days 1,\n8, 15-16, 22). In addition, he was treated with Pomalidomide (4mg on\ndays 1-21), Doxorubicin (9mg/m2 on days 1, 4), and Dexamethasone (40mg,\non days 1, 8, 15, 22). He underwent radiation therapy to T4 of the rib\nthorax in August. Between August to October 2018, he had three cycles of\nPomalidomide, Doxorubicin, and Dexamethasone, after which the disease\nprogressed. From November 2018 to February 2019, he had four cycles of\nDaratumumab, Lenalidomide, and Dexamethasone.\n\n**Outcome:**\n\nThe response to the treatment was very good partial remission (VGPR).\n\n**Present Treatment:**\n\nHe underwent mobilization chemotherapy with cyclophosphamide, with a\ndosage adjusted due to his requirement for dialysis (1500mg/m^2^ on day\n1 and 1000mg/m^2^ on day 2). He received dialysis on March 2 in our\nnephrology department.\n\n**Secondary diagnoses:**\n\nIn March 2018, he developed renal insufficiency requiring thrice-weekly\ndialysis. In January 2018, he was diagnosed with prostate carcinoma and\nwas treated with an androgen blockade using Enantone.\n\n**Future Therapy Plan:**\n\nThe tumor board\\'s decision from March 3, 2019 was to continue with\nDaratumumab, Revlimid, and Dexamethasone due to the good response. He\nwill undergo stem cell mobilization and high-dose therapy with\nautologous stem cell transplant. Monitoring is scheduled for March 14,\n2019, followed by dialysis at our dialysis center on Mondays,\nWednesdays, and Fridays.\n\n**Medications:**\n\nHis current medications include:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------------ ---------------------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL For dialysis\n Dexamethasone (Decadron) 8 mg On March 4 and 5\n Pantoprazole (Protonix) 40 mg \n Cotrimoxazole (Bactrim) 480 mg Thrice weekly on Mondays, Wednesdays, and Fridays\n Valacyclovir (Valtrex) 500 mg \n Ibandronate (Boniva) 2 mg Every four weeks\n Leuprorelin (Lupron Depot) 3.75 mg Every four weeks\n Pregabalin (Lyrica) 25 mg \n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg \n Filgrastim (Neupogen/Granix) 48 million IU \n\n**Summary:**\n\nMr. Williams was admitted on March 1, 2019, for mobilization\nchemotherapy with cyclophosphamide. Please refer to our previous letters\nfor a detailed history. His last treatment was with daratumumab,\nRevlimid, and dexamethasone. Fortunately, this treatment showed a very\ngood response. He is dialyzed three times a week at our clinic due to\nchronic renal insufficiency. He was discharged on March 3, 2019, and we\nrequest the administration of filgrastim as per the medication plan\nstarting March 6, 2019. CD34+ monitoring is scheduled for March 14,\n2019. Depending on the CD34+ count, stem cell collection may need to be\nscheduled on a dialysis-free day. We have coordinated with our\ncolleagues at the dialysis center for the collection via the atrial\ncatheter. A follow-up for blood count and Ibandronate administration has\nbeen scheduled for March 10, 2017. If his condition deteriorates or if\nhe shows signs of infection, bleeding, or any other complications, he\nshould immediately be brought to our emergency department. Please\nremember to bring a referral form during your initial visit each\nquarter.\n\nTherapy recommendation based on Transthoracic echocardiography findings:\n\nMr. Williams has a normally sized left ventricle with standard global\nfunction. There\\'s no evidence of any regional wall motion\nabnormalities. The right ventricle is also of normal size with standard\nfunction. The left atrium is not dilated. There\\'s marked concentric\nleft ventricular hypertrophy. His aortic valve shows insufficiency of I°\n(PHT 520 ms), while the mitral and tricuspid valves appear normal. There\nis no significant pericardial effusion. Overall, he has a standard left\nventricular function with no significant valvular diseases or pulmonary\nhypertension.\n\n**Surgery Report:**\n\nDiagnosis: Terminal renal failure.\n\nProcedure: Creation of a right upper arm brachialis-basilica fistula\nwith the anterior movement of the right basilic vein.\n\n**Report:**\n\nMr. Williams required dialysis due to terminal renal insufficiency. For\nthis purpose, an arteriovenous (AV) fistula was created as a dialysis\naccess. Previously, dialysis was performed using a right atrial\ncatheter. After mapping, only the basilic vein on the right arm seemed\nsuitable. Hence, a brachialis-basilica fistula was created with anterior\ntransposition of the basilica vein. A partial mobilization of the\nbasilica vein was performed. Afterward, a brachialis-basilica\nanastomosis was carried out. The operation was uncomplicated.\n\nYour collaboration has been instrumental in managing this patient\neffectively. If you have any further queries or require additional\ndetails, please do not hesitate to contact our office.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------- ------------------ ------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Change every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg Morning on 03/05 & 03/06\n Pantoprazole (Protonix) 40 mg Morning\n Cotrimoxazole (Bactrim Forte) 480 mg Morning 3x weekly on Mon, Wed, Fri\n Valacyclovir (Valtrex) 500 mg Half tablet in the morning\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly subcutaneous (Morning)\n Pregabalin (Lyrica) 25 mg Morning and Evening\n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg Morning and Evening\n Filgrastim (Neupogen/Granix) 48 million IU Morning and Evening\n\nBest regards,\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nI am writing to provide you with a detailed report on Mr. John Williams,\nwho was admitted to our facility from May 8, 2020, to May 28, 2020.\n\n**Diagnoses:**\n\nHistory of acute mitral valve endocarditis in March 2020.\n\nSubsequent re-operation entailing mitral valve replacement using a\nBioprosthesis (29 mm) coupled with the resection of all infected tissue\nfrom the mitral valve\\'s supporting apparatus on March 24, 2020.\n\nThe origin remains uncertain, but potential associations include Demers\ncatheter infection and port catheter infection (confirmed presence of\nStaphylococcus epidermidis).\n\nSurgical removal was conducted on March 21, 2020, with no findings at\nthe catheter tips.\n\n14. Antibiotic regimen included:\n\n Meropenem from April 2, 2020, to April 23, 2020.\n\n Linezolid 600 mg from April 3, 2020, to April 19, 2020.\n\n Daptomycin from April 3, 2020, to May 27, 2020.\n\n Fosfomycin from April 19, 2020, to May 28, 2020.\n\nHistory of mitral valve reconstruction via minithoracotomy in 2015.\n\nRight-side vision loss due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia in the caput nuclei caudati/lenticular nuclei\non April 5, 2020, possibly embolic in origin from mitral valve\nendocarditis.\n\nHistory of brainstem transient ischemic attack (TIA) on March 11, 2020,\npotentially embolic in relation to mitral valve endocarditis.\n\nJugular vein thrombosis.\n\n20. Hematological/oncological diagnoses comprise:\n\n Multiple myeloma with lambda light chains, stage IIIB according to\n the Salmon and Durie criteria, first diagnosed in 2015. This was\n accompanied by multiple osteolysis occurrences, history of radiation\n to Th4 and rib thorax, and treatment with Daratumumab. Current\n treatment has been paused due to remission.\n\n A prostate carcinoma diagnosis in January 2018\n\n**Other medical conditions include:**\n\n-Chronic kidney failure necessitating dialysis since 2018, history of a\nDemer catheter with explantation on March 2020, and angioplasty on the\nright V. basilica and V. brachialis due to stenosis-related shunt\ndysfunction.\n\n-History of brainstem TIA in April 2019.\n\n-Sensations of tingling paresthesias in both lower legs.\n\n-History of bilateral deep vein thrombosis.\n\n-Frequent calf muscle cramps.\n\n**Medical History Overview:**\n\nMr. Williams\\'s latest admission on May 8, 2020, was to assess remission\nstatus and determine if continuation of treatment for his known multiple\nmyeloma was necessary. Previously, until March 2020 he was under a\nDaratumumab monotherapy (as he could not tolerate Revlimid), which\nshowed stable disease progression. Prior to this, he was treated at our\nlocal hospital for mitral valve endocarditis which had a complex\ntrajectory. At the time of admission, Mr. Williams felt generally weak\nbut was otherwise in stable condition. Upon discontinuation of the\nfentanyl patch, his back pain increased. He exhibited no fevers and had\nno known allergies. His appetite was low, and he reported no nausea.\nSince his heart surgery, he has experienced numbness in his left heel\nand toes. His residual urine output was about 190 mL per day, and he was\nundergoing regular dialysis.\n\n**Physical Examination:**\n\nThe patient was alert, responsive, and fully oriented. The examination\nof the head, neck, and lungs was unremarkable. Cardiac auscultation\nrevealed clear and rhythmic heart sounds without any abnormal findings.\nThere was a non-irritated sternotomy scar. Examination of his back\nrevealed decubitus ulcers. Abdominal examination showed a soft,\nnon-tender abdomen with normal bowel sounds. Extremity examination\nrevealed minor edema.\n\n**Diagnostic Imaging and Tests:**\n\nA series of diagnostic tests, including sonography, whole body CT scan,\nophthalmological exams, and histology were conducted. The results are\ndetailed within this report. In summary, the findings indicate:\n\n-Limited abnormalities in the heart\\'s echocardiography, with potential\nmitral valve issues to monitor.\n\n-Bone scans revealed extensive osteopenia and other abnormalities\nrelated to his known multiple myeloma, but no evidence of new\nosteolysis.\n\n-Eye examinations confirmed the previously noted vision issues,\npotentially stemming from the mitral valve endocarditis, but provided no\nclear solutions.\n\n-Histological evaluation of bone marrow samples indicates largely\nregular hematopoiesis but confirms infiltration from the known multiple\nmyeloma.\n\n**Summary and Recommendations:**\n\nMr. John Williams is a 63-year-old male with a complex medical history\ninvolving multiple organ systems. His most recent admission was in\nrelation to his multiple myeloma, for which he has been in remission and\nwill be monitored closely. His mitral valve endocarditis from earlier\nthis year has been resolved and treated appropriately. Due to the\nmultiple comorbidities, it is crucial for any treating facility or\nphysician to be fully aware of his history to provide optimal care.\nContinual monitoring of his cardiovascular and renal systems is\nessential. The importance of maintaining strict adherence to his\ndialysis regimen and potential antibiotic prophylaxis is emphasized.\nGiven his weakened general condition and chronic pain, palliative care\nmight also be a suitable approach to consider, focusing on enhancing his\nquality of life and addressing his pain management needs.\n\nPlease refer to the attached files for further details and a complete\nbreakdown of tests and findings. I trust this report will help guide the\nappropriate medical care for Mr. John Williams.\n\nSincerely,\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- -------------------- -----------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Morning\n Enoxaparin (Lovenox) 0.2 mL s.c. Evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Morning and Evening\n Leuprorelin (Lupron Depot) Monthly depot Every 4 weeks via subcutaneous injection\n Fentanyl Transdermal System 12 μg/hour Changed every 3 days\n Pantoprazole (Protonix) 40 mg Morning\n Sevelamer (Renagel) 800 mg Morning\n Multivitamin One tablet Morning\n Torsemide (Torem) 200 mg Morning\n Vitamin D3 20,000 IU Once weekly\n Sodium bicarbonate (Bicanorm) One tablet Morning\n Calcitriol (Rocaltrol) 0.25 μg Morning\n Valacyclovir (Valtrex) 500 mg half-tablet Morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Morning on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Morning on day 1 and day 2 following daratumumab administration\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nI am writing to provide an update on the medical condition and treatment\nof Mr. John Williams, who has been undergoing inpatient treatment in our\nfacility since September 30, 2021.\n\n**Diagnoses**:\n\n**Present**: Acute impairment of the visual field.\n\n**Oncological Diagnosis**:\n\n1. Diagnosis of Multiple Myeloma with kappa light chains, staged at\n IIIB as per the Salmon and Durie criteria\n\n Observable multiple osteolyses.\n\n History of radiation to the T4 and thoracic rib.\n\n Starting from 2018, he required dialysis due to renal insufficiency,\n scheduled on Mondays, Wednesdays, and Fridays in our local clinic.\n\n 2018: Treatment involved Bortezomib and Dexamethasone, but he was\n refractory to this combination. The regimen of Carfilzomib,\n Lenalidomide, and Dexamethasone was also found to be ineffective.\n\n Radiation was administered to the T4 (totaling 30 Gy) and the\n thoracic rib (totaling 20 Gy) in August 2018.\n\n Between August and October 2018: Mr. Williams underwent three cycles\n of Pomalidomide, Doxorubicin, and Dexamethasone, but the disease\n showed progression.\n\n November 2018 to February 2019: He received four treatments of\n Daratumumab, Lenalidomide, and Dexamethasone, which led to a very\n good partial response (VGPR).\n\n In March 2019, he underwent stem cell mobilization due to RSV\n pneumonia complications and then started on Daratumumab monotherapy\n (VGPR was last noted in May 2018).\n\n He continued with Daratumumab treatment until November 2019, after\n which there was a pause until March 2020 due to remission (VGPR) and\n a diagnosis of endocarditis.\n\n A whole body CT scan conducted in March 2020 did not show any new\n osteolyses.\n\n By May 2020, there was an increase in LK values, prompting the\n resumption of Daratumumab, which led to a decrease in free light\n chains.\n\n As of June 2020, there was a noted increase in light chain kappa\n values to 102 mg/L.\n\n In July 2020, therapy was escalated to include Daratumumab, Revlimid\n (5 mg), and Dexamethasone.\n\n By September 2020, a further increase in light chains was observed,\n prompting a planned switch to Elotuzumab, Pomalidomide, and\n Dexamethasone.\n\n**For his heart condition:**\n\nAcute mitral valve endocarditis was diagnosed in March 2020. He\nunderwent a re-operation for mitral valve replacement with a\nbioprosthesis (29 mm). This procedure, performed in March, 2020,\ninvolved the resection of all infected tissue from the mitral valve\\'s\nholding apparatus. The cause is presumed to be associated with a Demers\ncatheter infection or possibly related to a port catheter infection\n(Staphylococcus epidermidis was found). The catheter was surgically\nremoved in March 2020. He was on a series of antibiotics, including\nMeropenem, Linezolid, Daptomycin, and Fosfomycin.\n\n**Other pertinent medical events include:**\n\nA history of radiation treatment using a minithoracotomy technique for\nmitral valve reconstruction in 2015.\n\nRight eye amaurosis due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia diagnosed in April 2020, possibly due to\nemboli from the mitral valve endocarditis.\n\nA transient ischemic attack (TIA) in the brainstem observed on in March\n2020, which could be related to emboli from the mitral valve\nendocarditis.\n\nJugular vein thrombosis.\n\nProstate cancer diagnosed in 2018.\n\nChronic renal failure necessitating dialysis since 2018.\n\nPrevious procedures include Demers catheter placement (removed on March\n2020) and angioplasty on the right basilic vein and brachial vein due to\nstenosis causing shunt dysfunction.\n\nHistory of transient ischemic attacks.\n\nBilateral tingling paresthesias in the lower legs, history of deep vein\nthrombosis, recurrent calf cramps, and hypothyroidism.\n\nPlease let me know if you require any further information on Mr.\nWilliams. I am confident that this detailed account will assist you in\nunderstanding his medical history and ensuring optimal care.\n\n**Therapy: **\n\nTherapy schedule: Daratumumab s.c. 1800mg abs. weekly in week 1-8,\n2-weekly in week 9-24, every 4 weeks from week 25. Continuation of\nBondronat. Regular monitoring and optimal adjustment of cardiovascular\nrisk factors.\n\nMedication:\n\nPlavix (Clopidogrel) 75 mg; once daily in the morning\n\nLovenox (Enoxaparin) 0.2 ml subcutaneously; once daily in the evening on\nnon-dialysis days\n\nMarinol (Dronabinol) drops; four drops in the morning and four drops in\nthe evening\n\nDuragesic (Fentanyl transdermal patch) 12 μg/hour; change every 3 days\n\nProtonix (Pantoprazole) 40 mg; dosing: Once daily in the morning and\nonce daily in the evening for 2 weeks, then once daily in the morning\n\nRenvela 800 mg; dosing: Once daily in the morning\n\nTorem 200 mg; once daily in the morning\n\nVitamin D3 20,000 IU; once weekly\n\nCalcijex (Calcitriol) 0.25 mcg; once daily in the morning\n\nValtrex (Valacyclovir) 500 mg; dosing: Half a tablet (250 mg) once daily\nin the morning\n\nBactrim (Cotrimoxazole or trimethoprim/sulfamethoxazole) 480 mg, once\ndaily\n\nWarm regards,\n\n**Clinical Update, 11/12/2022**\n\nMr. John Williams, a 66-year-old male with a known history of multiple\nmyeloma and associated complications, presented again to our facility\nwith worsening symptoms over the past three weeks.\n\n**Symptoms**:\n\nPersistent fatigue\n\nShortness of breath on minimal exertion\n\nBilateral pitting edema in the lower extremities up to the mid-calf\n\n**Preliminary Findings**:\n\n**Physical Examination**:\n\n1. Jugular venous distention\n\n Decreased breath sounds bilaterally with mild basilar crackles\n\n S3 gallop on cardiac auscultation\n\n**Chest X-ray**:\n\n4. Cardiomegaly with an enlarged cardiac silhouette. Mild pulmonary\n edema evident.\n\n**Echocardiogram**:\n\n5. Reduced left ventricular ejection fraction (LVEF) of 35% (normal \\>\n 55%)\n\n Mild mitral regurgitation\n\n**Lab Results**:\n\n7. B-type natriuretic peptide (BNP): 890 pg/mL (Normal: \\<100 pg/mL)\n\n Serum Sodium: 130 mEq/L (Normal: 135-145 mEq/L)\n\n Serum Potassium: 5.8 mEq/L (Normal: 3.5-5.1 mEq/L)\n\n Blood Urea Nitrogen (BUN): 38 mg/dL (Normal: 7-20 mg/dL)\n\n Creatinine: 2.1 mg/dL (Normal: 0.8-1.3 mg/dL)\n\n GFR: 35 mL/min (Reduced)\n\n**Diagnosis**:\n\nCongestive Heart Failure (CHF) with reduced ejection fraction\n\nRenal insufficiency\n\nMultiple Myeloma (primary diagnosis 2015)\n\nProstate cancer\n\n**Treatment Administered**:\n\nIntravenous furosemide was administered to relieve fluid overload,\nresulting in a significant reduction in edema and improvement in\nbreathlessness over the subsequent 48 hours. Lisinopril was initiated\ncautiously to manage CHF and to potentially provide renal protection.\nMetoprolol was started at a low dose, with close monitoring of blood\npressure and heart rate. Potassium levels were closely monitored given\ninitial hyperkalemia; diet and medications were adjusted accordingly.\nDietary consult emphasized a low-sodium, moderate protein, and\npotassium-restricted diet. Close monitoring of fluid balance\n(input-output) was maintained throughout the stay.\n\n**Progress**:\n\nMr. Williams showed consistent improvement over his two-week admission.\nSerial echocardiograms indicated a slight improvement in LVEF to 39%.\nThe edema receded notably, and his shortness of breath on exertion\nreduced significantly. Labs before discharge showed:\n\nSerum Sodium: 134 mEq/L\n\nSerum Potassium: 4.9 mEq/L\n\nBUN: 32 mg/dL\n\nCreatinine: 1.9 mg/dL\n\nBNP: 550 pg/mL\n\n**Discharge Recommendations**:\n\nOutpatient cardiology follow-up in two weeks and then monthly to monitor\nLVEF and adjust medications. Nephrology consultation to keep an eye on\nrenal function, given his increased susceptibility to kidney damage.\nContinue with dietary restrictions and modifications as advised.\nCommence an outpatient cardiac rehabilitation program for supervised\nexercise and lifestyle modifications. Weekly blood tests for the first\nmonth to monitor electrolytes and kidney function.\n\nMr. Williams remains at risk due to multiple comorbidities. It is\nessential to address each condition holistically while ensuring no\nsingle treatment exacerbates another condition. A collaborative and\nvigilant approach is imperative for his ongoing health management.\n\nWarm regards,\n\n --------------------------- ---------------- ---------------------\n **Parameter** **Value** **Reference Range**\n **Blood Count** \n White Blood Cells (WBC) 5.8 x 10^9^/L 4-11 x 10^9^/L\n Red Blood Cells (RBC) 3.9 x 10^12^/L 4.5-5.5 x 10^12^/L\n Hemoglobin (Hb) 9.8 g/dL 13-18 g/dL for men\n Platelets (Plt) 150 x 10^9^/L 150-450 x 10^9^/L\n \n **Biochemistry** \n Creatinine 2.8 mg/dL 0.6-1.3 mg/dL\n Blood Urea Nitrogen (BUN) 40 mg/dL 7-20 mg/dL\n Glucose 98 mg/dL 70-100 mg/dL\n \n **Electrolytes** \n Sodium (Na) 137 mEq/L 135-145 mEq/L\n Potassium (K) 5.1 mEq/L 3.5-5.0 mEq/L\n Calcium 8.6 mg/dL 8.5-10.5 mg/dL\n Phosphate 4.5 mg/dL 2.5-4.5 mg/dL\n \n **Oncologic Markers** \n Free light chain kappa 692 mg/L 3.3-19.4 mg/L\n Free light chain lambda 12 mg/L 5.7-26.3 mg/L\n \n **Other Values** \n LDL cholesterol 80 mg/dL \\<100 mg/dL\n HbA1c 6.2% \\<5.7%\n --------------------------- ---------------- ---------------------\n", "title": "text_9" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\n\nWe are writing to report on the outpatient treatment of Mrs. Laura\nMiller, born on 04/03/1967, on 05/22/2020.\n\n**Diagnosis**: Osteoporotic vertebral body sintering (lumbar vertebra 2\nand thoracic vertebra 8).\n\n**Medical History**: Mrs. Miller presents with pain in her back, legs\nradiating, after fall on the back 6 weeks ago. The complaints were\nprogressive with intermittent paresthesia in both legs.\n\n**Other Diagnoses** (not fully collectible):\n\n- Status post apoplexy\n\n**Current Medication (**not ascertainable):\n\n- Blood pressure medication\n\n- Osteoporosis medication\n\n- No anticoagulation.\n\n**Physical Examination: Lumbar spine:** Skin without pathological\nfindings. No redness, no evidence of infection.\n\nTapping pain over thoracic spine/lumbar spine, no compression pain, no\ntorsion pain, no pressure pain over spinous process.\n\nRadiation of pain into the right and left leg, paravertebral muscle\nhardness.\n\nNo paresthesias in the genital area, no breech anesthesia, no peripheral\nneurologic deficits, No bladder or rectal dysfunction.\n\nPeripheral Circulation/Motor function/Sensitivity intact.\n\nStrength grade on all sides: Hip Flex/Ex: 5/5, Knee Flex/Ex: 5/5,\n\nFoot extensor muscles of the lower leg/flexor muscles of the lower leg:\n3/5.\n\nBig toe extensor muscles of the lower leg/big toe flexor muscles of the\nlower leg: 2/5.\n\n**Thoracic Spine 2 levels from 05/22/2020, Lumbar spine in 2 planes from\n05/22/2020:**\n\nClinical indication: Status post fall\n\nQuestion: new fracture?\n\nPreliminary images: none comparable\n\n**Findings**\n\n1\\) [Thoracic Spine]{.underline}: Multiple thoracic vertebral bodies\nexhibit decreased height, most notably at the central region where a\nmeasurement of approximately 17 mm suggests significant height loss and\npotential acute fracture. Additionally, there are endplate impressions\nin individual vertebrae of the lower thoracic spine. Aortic sclerosis is\npresent, along with degenerative changes throughout the thoracic\nvertebrae. The osseous structure presents osteoporotic features. A\nsuspected hemangioma is identified in a vertebral body of the lower\nthoracic spine.\n\n2\\) [Lumbar Spine]{.underline}: In a presumed five-segment lumbar spine,\nthe L1 vertebra shows a subtle reduction in height with a questionable\nendplate impression. Osteoporotic features are evident in the bony\nstructure.\n\n**Assessment:** Multiple fractures are evident in both thoracic\nvertebrae and the first lumbar vertebra, some of which may be acute. MRI\nis recommended for further evaluation. Osseous structure displays\npronounced osteoporotic features.\n\nGrade III esophageal varices present without definitive high-risk\nstigmata. Varices also noted at the gastroesophageal junction,\nclassified as GOV 1 according to Sarin\\'s classification. Band ligation\nof the varices is not performed, as no unambiguous source of bleeding is\nidentifiable and a significant portion of the stomach remains outside\nthe field of view.\n\n**Recommendation**: Terlipressin, monitor surveillance, Erythromycin\n\n**Computed Tomography Thoracic spine from 05/22/2020:**\n\nFracture at the base plate of lumbar vertebra 2 with involvement of the\nposterior margin. Left lateral, no significant reduction in height of\nthe vertebral body. No tension of the spine.\n\nSuspicion of new small fracture also at the cover plate at thoracic\nvertebra 8.\n\nMultiple, older, osteoporotic compression fractures at the thoracic\nspine and\n\nupper lumbar spine.\n\n**Additional Finding:**\n\nLiver cirrhosis with multiple nodules, low ascites, and portal vein\ncongestion. Splenomegaly. If not already known, further workup of liver\nlesions is recommended. Hydrops of the gallbladder.\n\n**Current Recommendations**: There is a general indication for admission\nof the patient and further diagnostics before surgical treatment of the\nfractures. Mrs. Miller is generally opposed to surgical care. She was\nthoroughly informed about the risks (progression, cross-section, death).\n\nRe-presentation with current bone densitometry and update of\nosteoporosis medication, as well as current holospinal MRI. In the\nmeantime, analgesia as needed using Acetaminophen 500mg 1-1-1 under\ngastric protection.\n\n**Esophagogastroduodenoscopy from 05/22/2020:**\n\n[Esophagus]{.underline}: Unobstructed intubation of the esophageal\nopening was achieved under direct visualization. In the upper third of\nthe esophagus, multiple prominent varices protrude into the lumen,\nunaltered by air insufflation. In the middle third, there are areas with\nwhitish overlying material that do not resemble the typical white nipple\nsign. Despite meticulous inspection, no active bleeding sites were\nidentified. The Z-line reveals isolated minor erosions. Cardiac\nsphincter closure is complete.\n\n[Stomach]{.underline}: Full distension of the gastric lumen was\naccomplished with air insufflation. The major curvature of the stomach\ncontained food mixed with hematin. The mucosal surface was similarly\ncoated with hematin, but no active bleeding was discernible in the\nvisualized areas. Peristaltic movement was widespread. Upon\nretroflexion, pronounced varices were noted near the cardiac region on\nthe lesser curvature. The pylorus was unremarkable and easily\ntraversable.\n\n[Duodenum]{.underline}: Adequate distension of the duodenal bulb was\nachieved, providing a clear view up to the descending part of the\nduodenum. Overall, the mucosa appeared normal with minor remnants of\nhematin, and no source of bleeding was identified.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about Mrs. Laura Miller, born on 04/03/1967, who was in\nour inpatient treatment from 05/27/2020 to 06/22/2020.\n\n**Diagnoses**: Initial diagnosis of hepatocellular carcinoma.\n\n- MRI liver: disseminated HCC foci in all segments, the largest foci\n is localized in segments 5 / 7 / 8\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: sophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: Residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Physical Examination:** Patient in mildly reduced general and normal\nnutritional status (BMI 20.3).\n\n- Lungs: Vesicular breath sound, no pathological secondary sounds.\n SpO2 96%.\n\n- Heart: Pure, rhythmic. Systolic with maximum at Erb\\'s point and\n continuation into the carotids. HR: 87/min. BP: 124/54mmHg\n\n- Abdomen: Lively bowel sounds, no tenderness, no guarding, no\n resistance, no peritonism. Soft abdomen. Liver not enlarged,\n palpable. Renal bed not palpable.\n\n- Extremities: Edema of the lower extremities on both sides, foot\n pulses bilaterally well palpable.\n\n- Spine: No tap pain.\n\n- Orienting neurological examination: Right leg weakness, known\n paresis of the extensor muscles of the lower leg/flexor muscles of\n the lower leg.\n\n**Therapy and Progression:** Mrs. Miller was taken over for suspected\nupper GI bleeding. Initially, the patient had presented with increasing\nback pain since approximately 6 weeks at status post fall in the Park\nClinic on 04/26/2020. The patient was known there for her stroke in\n2016. On the day of admission to the Park Clinic, normochromic\nnormocytic anemia (Hemoglobin 3 g/dL) was noticed, which is why the\ntransfer to our clinic was made.\n\nOn inpatient admission, the patient presented in slightly reduced\ngeneral condition. She reported having black stools once. In addition,\nMs. Miller had coffee ground-like emesis once. Dyspnea, angina pectoris\ncomplaints, and B symptoms were denied. There were no problems with\nmicturition. Recently, there were no abnormalities in bowel movements.\nSo far, no colonoscopy has been performed. There were no known\nintestinal diseases in the family.\n\n[Noxae]{.underline}: Ex-nicotine use (since 1996, previously cumulative\nca. 3 PY), occasional alcohol consumption (probably abstinent for about\n5 years).\n\nLaboratory results showed that the patient had elevated infectious\nparameters. The\n\nurinalysis was unremarkable. X-ray chest showed no clear picture of\npneumonia. In a first emergency esophagogastroduodenoscopy on\n05/28/2020, esophageal varices °III were found without clear signs of\nrisk. Furthermore, varices in the area of the cardia (GOV 1 after Sarin)\nwere seen. When the source of bleeding was inconclusive, it was referred\nto a banding initially waived. In a renewed esophagogastroduodenoscopy\nin the morning of 05/30/2020, 2 ampoules of Histoacryl were applied to\nthe cardia varices. In addition, the picture of an incipient\nportal-hypertensive gastropathy. Antibiotic intravenous therapy with\nceftriaxone was initiated. At 06/13/2020, a\nre-esophagogastroduodenoscopy took place, during which a renewed twofold\nbanding of the esophageal varices was performed with injection of 0.5 ml\nHistoacryl. Abdominal ultrasound showed a picture of liver cirrhosis\nwith splenomegaly and perihepatic ascites. In addition, the liver showed\nmultiple echo-poor nodes in the right lobe and a suspicious\n2.4x3.6x4.4cm echo-poor area with a halo in SII. This was followed by an\nMRI of the liver, in which the HCC in segment II was confirmed by\nimaging.\n\nMultiple additional arterial hypervascularized areas/round foci in all\nliver lobes without definite washout. There is no evidence of suspicious\nnodular changes on CT chest/abdomen/pelvis. At an in-house liver\nconference, systemic therapy (Lenvatinib or Sorafenib in Child B7) was\nrecommended.\n\nDue to the back pain, a holospinal MRI was performed, which showed a\nsubacute cover plate compression fracture in the thoracic vertebra 8 as\nwell as multiple older compression fractures of the thoracic spine and\nupper lumbar spine. The colleagues of neurosurgery were consulted, who\ngave the indication for surgery. On 06/14/2020, the planned surgery with\nkyphoplasty thoracic vertebra 8 under C-arm fluoroscopy could be\nperformed without complications. Postoperatively, the patient remained\ncirculatory stable.\n\nDue to auscultatory suspicion of aortic valve stenosis, further\nclarification was performed by cardiac echography, showing no\nhigher-grade valvular vitiation.\n\nWe are transferring Mrs. Miller in improved general condition to the\nSenior Citizens\\' Residence Seaview. If you have any questions, please\ndo not hesitate to contact us.\n\n**Addition:**\n\n**Ultrasound of the upper abdomen on 05/27/2020:**\n\nLimited assessable due to meteorism.\n\n**Liver**: Liver dimensions are within normal limits, measuring 15.9 cm\nin the craniocaudal axis. Echotexture demonstrates inhomogeneous\ngranularity. There is hepatic margin convexity and nodular surface\nappearance. Rarification of hepatic veins. Segment III reveals two\nhypoechoic lesions measuring 3 cm and 1 cm in diameter. Portal vein\ndemonstrates orthograde flow with a maximum velocity of 17 cm/s.\n\n**Gallbladder:** Gallbladder is partially contracted; its wall appears\nunremarkable without sonographic evidence of cholecystitis. No\ntenderness elicited upon sonographic examination.\n\n**Biliary Tract**: Intrahepatic bile ducts are patent. Common hepatic\nduct measures 6 mm in diameter. Common bile duct appears transiently\ndilated up to 9 mm and is otherwise unremarkable as far as can be\nvisualized prepapillary.\n\n**Pancreas**: Limited visualization of the pancreas; however, the\nvisible parenchyma appears homogeneously echoic.\n\n**Spleen**: Spleen is enlarged, measuring 13 x 4 cm, with homogeneous\nparenchyma.\n\n**Kidneys**: Kidneys are morphologically unremarkable, without evidence\nof pelvicalyceal system dilation.\n\n**Abdominal Vessels**: Aorta is partially visualized and appears within\nnormal calibers.\n\nIntestinal/Peritoneal Cavity: No evidence of free intraperitoneal fluid.\n\nUrinary Bladder/Genitalia: Urinary bladder is adequately distended,\nappearing unremarkable upon limited assessment. Uterus is not\nvisualized.\n\n**Virology from 05/28/2020:**\n\n- SARS CoV-2 PCR PCR negative Geq/ml\n\n- Findings: No detection of SARS-CoV-2 by PCR in the submitted\n material.\n\n**Chest X-ray a.p. from 05/28/2020:**\n\nLimited assessability in supine position, malrotation. The diaphragmatic\ncrests are smooth. The marginal sinuses are free of effusions and\ncalluses. Heart and mediastinum lie cryptically. The aorta is sclerosed.\nCranialization of the vessels as well as slightly elevated vascular\nmarkings in the supine position, especially in the right upper field.\nDystelectasis on the right. Sharply defined vertical shadowing in the\nleft upper field. The upper mediastinum is narrow, the trachea is in the\nmidline and is not constricted. Degenerative changes in the cervical\nspine. Overlying foreign material.\n\n**Assessment**: Sharply defined vertical shadowing in the left upper\nfield. Dystelectasis on the right side. Conventional radiographic\nexamination No evidence of a mass. No effusion.\n\n**Esophagogastroduodenoscopy of 05/28/2020:**\n\n**Esophagus**: Successful intubation of the esophageal orifice under\ndirect visualization. Multiple intraluminal protrusions noted in the\nupper third of the esophagus. Non-collapsible variceal strands observed\nupon air insufflation, beginning from the middle third. Whitish\nproliferations seen at multiple sites, not consistent with typical white\nnipple signs. No evidence of active bleeding on close inspection. Z-line\nobserved with isolated minor erosions. Cardiac sphincter fully\ncompetent.\n\n**Stomach**: Gastric lumen fully distended under air insufflation.\nCorpus predominantly contains hematin-laden food remnants. Mucosal\nsurface also stained with hematin but without visible active bleeding.\nPeristalsis noted throughout. Distinct coronary vasculature observed on\nthe lesser curvature. Pylorus unremarkable, offering no resistance to\npassage.\n\n**Duodenum**: Bulbus duodeni well-formed. Pars descendens duodeni\nvisualized clearly. Overall mucosa appears unremarkable, with scattered\nhematin remnants observed without an identifiable bleeding source.\n\n**Assessment**: Esophageal varices graded as °III, with no definitive\nhigh-risk stigmata. Varices also noted in the cardia, classified as GOV\n1 according to Sarin\\'s classification. Ligation of varices was not\nperformed due to the absence of an identifiable bleeding source and\nincomplete visualization of the gastric lumen.\n\n**Ultrasound of the abdomen on 05/29/2020:**\n\n**Quality of Exam**: Limited due to patient non-cooperation and\nmeteorism.\n\n**Liver**: Liver size is paradoxically reported both as normal at 15.9\ncm and enlarged at 18.7 cm. Margins are rounded. Echotexture is markedly\ninhomogeneous with nodular surface. Multiple hypoechoic nodules are\npresent in the right lobe, along with a suspicious hypoechoic area\nmeasuring 2.4 x 3.6 x 4.4 cm with peripheral halo in segment II. Hepatic\nveins are rarified. Portal vein shows orthograde flow with a vmax of 28\ncm/s.\n\n**Gallbladder**: Morphologically unremarkable with no wall thickening.\nCholelithiasis noted with concretions measuring at least 2 to 1.6 cm.\n\n**Biliary Tract:** Intrahepatic bile ducts are not dilated; Common\nhepatic duct measures up to 8.5 mm and common bile duct measures 6.6 mm\nin diameter.\n\n**Pancreas**: Partially visualized; adequacy of assessment is\ncompromised.\n\n**Spleen**: Enlarged with homogeneous internal echotexture.\n\n**Kidneys**: Morphologically unremarkable; no evidence of\nhydronephrosis.\n\n**Abdominal Vessels:** Aorta is not dilated.\n\n**Gastrointestinal**: Perihepatic ascites noted. Both small and large\nintestines appear unremarkable upon limited assessment.\n\n**Urinary Bladder/Genitalia:** Bladder is moderately filled and\nunremarkable in shape and size.\n\n**Assessment**: Limited study due to patient non-cooperation and\nmeteorism. Findings are suggestive of liver cirrhosis and grade I\nascites. Additional findings include suspected hepatic space-occupying\nlesions, splenomegaly, and cholelithiasis. Mild dilation of DHC and DC\nobserved without signs of intrahepatic cholestasis.\n\n**Virology from 06/01/2020:**\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HAV IgG 0.73 negative\n Anti HAV IgM \\<0.1 negative\n\n**Interpretation:** Serologically no evidence of fresh or expired\ninfection with\n\nHepatitis A virus, no immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n HBs antigen 0.21 negative\n Anti HBs \\<0.1 negative\n Anti HBc 0.1 negative\n\n**Interpretation:** Serologically no evidence of acute, chronic or\nexpired Hepatitis B virus infection. No immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HCV 0.06 negative\n\n**Interpretation:** Serologically no evidence of hepatitis C virus\ninfection. At possible fresh infection resubmission in 2-4 weeks and HCV\nPCR recommended.\n\n**MRI total spine plain from 06/04/2020:**\n\n**Technique**: T2 Dixon Sagittal and T2 Axial MRI Sequences. Coverage\nextends from the craniocervical junction to the sacrum.\n\n**Findings:**\n\n**General Spine:** Full extent from craniocervical junction to sacrum\nvisualized. Conus medullaris appropriately located at T12-L1 level.\nMyelon demonstrates uniform width and homogeneous signal. Evaluation of\nthoracolumbar transition and lumbar spine is compromised by artifact\nsuperimposition from ascites.\n\n**Cervical Spine:** Irregular alignment of the posterior vertebral body\nmargins noted, with evidence of disc protrusions and ligamentum flavum\nhypertrophy. Focal T2 hyperintensity observed at C5 level. No evidence\nof prevertebral soft tissue proliferation.\n\n**Thoracic Spine**: Maintained alignment of the posterior vertebral body\nmargins. Multiple anterior endplate compression fractures noted at T5,\nT8, T9, T11, T12 levels. Focal T2 hyperintensity near the anterior\nendplate of T8 involving the posterior margin, indicative of a\nnon-displaced fracture without spinal canal compromise. Hypertrophic\nfacet joint arthrosis at T10-T11 levels resulting in relative spinal\nnarrowing. Bilateral pleural effusions noted, more pronounced on the\nright, with a maximum width of approximately 2 cm. No evidence of\nsignificant neuroforaminal stenosis.\n\n**Lumbar Spine:** Maintained alignment of posterior vertebral body\nmargins. Known anterior endplate compression fractures at L1 and\nbaseplate compression fracture at L2. No evidence of pathological T2\nedema within the vertebral bodies, although assessment is limited due to\nsuperimposed artifacts from ascites. Spinal canal dimensions appear\nadequate throughout. Moderate fatty degeneration of sacral bone noted.\n\n**Assessment**: Evaluation limited due to ascites-related artifacts.\nSubacute anterior endplate compression fracture at T8, along with\nseveral other likely older compression fractures in the thoracic and\nupper lumbar spine. Bilateral pleural effusions observed. Multiple\nneuroforaminal narrowings as detailed above.\n\n**MR Liver plain + contast agent from 06/06/2020**\n\n**Findings:**\n\n1) [Lesion 1]{.underline}\n\n- Size of the lesion 41 mm\n\n- Segment 2\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: yes\n\n- Pseudocapsule: yes\n\n- Behavior delayed leaching: yes\n\n- pseudocapsule macrovascular invasion: no\n\n2) [Lesion 2]{.underline}\n\n- Size of the lesion 104 mm\n\n- Segment 5 / 7 / 8\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: no\n\n- Pseudocapsule: no\n\n- Behavior delayed washing out: no\n\n- Pseudocapsule: no\n\n- Macrovascular invasion: yes\n\n**Comments:**\n\n- MRI with Gadovist intravenous.\n\n- Multiple other satellite foci in all liver segments.\n\n- Signs of liver cirrhosis with nodular liver parenchyma and\n hypertrophy of the left lobe.\n\n- Cholecystolithiasis and gallbladder hydrops. No cholestasis.\n\n- Varices of the esophagus and fundus. Splenomegaly. Ascites. Pleural\n effusions on both sides.\n\n- Lymph node (approximately 8 mm) between the small curvature of the\n Stomach and S1 of the liver.\n\n- Axial hernia.\n\n**Assessment:** Milan fulfilled**.** Dissiminated HCC foci in all\nsegments, the largest foci being in segments 5 / 7 / 8 localized. Portal\nhypertension with bypass circulation and splenomegaly. Ascites and\npleural effusions.\n\n**Microbiology from 06/09/2020:**\n\n[Material]{.underline}: Ascites in blood culture bottles\n\n[Microscopic]{.underline}: No cells, no germs\n\n- Anaerobic culture negative after 48 hours\n\n- So far, no growth in the anaerobic cultures. The cultures are\n incubated for a total of 5 days. In case of growth of anaerobes we\n will send you a follow-up report.\n\n- No growth after 48 hours\n\n**Esophagogastroduodenoscopy of 06/11/2020:**\n\n**Esophagus**: In the distal esophagus, multiple band-like ulcerations\nas well as residual varices with risk signs that may not completely pass\nair insufflation. Z-line without erosions.\n\n**Stomach**: Mosaic-like occupancy of the gastric mucosa. With inversion\nthe\n\nknown small-curved lateral cardiavarii, which is hard on palpation with\nclosed forceps after histoacryl injection. Directly next to it, another\ncardiavarice can now be seen, which has not yet been injected with\nhistoacryl and is soft on palpation.\n\n**Duodenum**: Endoscopic therapy: Injection of 0.5 mL Histoacryl (+0.5\nmL Lipoidol) in the new cardiavarice. Application of 3 rubber band\nligatures to the residual varices in the esophagus.\n\n**Assessment:** Residual varices in the esophagus, application of 3\nrubber band ligations; portal hypertensive gastropathy\n\n**Spine-whole: 2 planes from 06/13/2020**\n\nThe perpendicular of C7 protrudes about 15 mm laterally to the left of\nsacral vertebra 1 in the anterior-posterior image and about 9.3 cm in\nfront of sacral vertebra 1 in the lateral ray path. Slight left convex\nscoliosis thoracolumbally with thoracic counter-swing (Cobb angle \\< 10°\nin each case). The lungs are unremarkable as far as technically\nassessable.\n\n**Assessment**: decompensated positive sagittal spinal imbalance. There\nis no relevant lateral trunk overhang.\n\n**Critical Findings Report:**\n\nA conspicuous single cell population of cells with partial signet ring\ncell character is detected in the smears. A cell block is prepared from\nthe remaining liquid material for further typing of these cells. A\nfollow-up report will follow.\n\n**Thoracic spine in 2 planes from 06/15/2020:**\n\n**Findings**: Thoracic vertebra 8: Post-kyphoplasty status with notable\nimprovement in vertebral height, now measuring 21 mm compared to a\npreoperative height of 13 mm. Mild straightening of the vertebral column\nobserved at this level.\n\nThoracic vertebra 9: Known older anterior endplate collapse.\n\nThoracolumbar spine: Multisegmental height reduction in vertebral bodies\nconsistent with osteoporotic changes. No signs of contrast\nextravasation.\n\nAdditional Finding: Pre-existing calcified structure projecting onto the\nleft upper abdomen; likely unrelated to current surgical site.\n\n**Assessment**: Unremarkable postoperative imaging following kyphoplasty\nof T8. No evidence of postoperative sintering or newly identifiable\nfractures. Overall, the surgical intervention appears successful in\nincreasing vertebral height and stabilizing the fracture site.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 06/18/2020:**\n\n**Technique**: Multislice spiral CT of the chest, abdomen, and pelvis\nwas performed post-bolus intravenous injection of 120 ml of Imeron 400.\nImaging conducted in arterial, portal venous, and venous phases. Oral\ncontrast agent administered with Micropaque 1:7 in water and Gastrolux\n1:33 in water. Thin-slice reconstructions and secondary coronal and\nsagittal reformats were performed.\n\n**Chest**: Presence of struma nodosa. Bilateral minor pleural effusions\nwith adjacent atelectasis, more pronounced on the right and extending\ninto the interlobar region. No signs of infiltrative changes. Isolated\nsmall nodular opacities in the right lung. Few small bullae noted.\nMediastinal lymph nodes mildly enlarged up to 0.5 cm; axillary and hilar\nnodes are not enlarged. No pericardial effusion observed.\n\n**Abdomen/Pelvis**: Known esophageal and fundal varices present. Liver\ndemonstrates nodular changes in the context of known Child-Pugh B stage\ncirrhosis. A solid hepatic cellular carcinoma lesion in segment II and\ndiffuse HCC nodules in segments V/VII/VIII visualized, corroborating\nprior MRI findings. They show pronounced arterial enhancement and\ncentral washout. Splenomegaly noted. Adrenal glands unremarkable. Renal\nand urinary systems are inconspicuous. No intestinal motility\nabnormalities detected. Marked ascites present; no pathologically\nenlarged abdominal lymph nodes noted upon limited assessment.\n\n**Skeletal**: Moderate coxarthrosis bilaterally. An old, minimally\ndisplaced fracture of the right 7th rib noted. Advanced degenerative\nchanges in thoracic vertebrae 10, 12, and lumbar spine.\nPost-vertebroplasty status at thoracic vertebra 9. Hemangioma at\nthoracic vertebra 11.\n\n**Assessment**:\n\n- Marked ascites in the setting of liver cirrhosis with multifocal HCC\n lesions, as corroborated by prior MRI. No evidence of extrahepatic\n or lymphatic spread.\n\n- Bilateral minor pleural effusions with associated atelectasis.\n\n- Skeletal findings include moderate coxarthrosis and degenerative\n changes in the spine.\n\nOverall, the scan provides vital information that aligns with and\nelaborates upon existing clinical and imaging data.\n\n**Histology**:\n\n**Pathology from 06/19/2020:**\n\n[Clinical Data:]{.underline} Hepatocellular carcinoma, hydropic\ndecompensated liver cirrhosis Child B,\n\n[Extraction date:]{.underline} 06/13/2020\n\n[Material:]{.underline} 1 Liquid material 7 ml light yellow\n\n[Editing]{.underline}: Papanicolaou and MGG staining\n\n\\+ Protein precipitation\n\n\\+ Erythrocytes\n\n\\+ Lymphocytes\n\n(+) Granulocytes Eosinophils\n\n\\+ Histiocytic cell forms\n\n\\+ Mesothelium\n\n\\+ Active mesothelium\n\n**Other**: Single mononuclear cells with large, eccentric nuclei with\nnucleoli and a narrow cytoplasmic space, partly with signet ring cells.\n\n**Supplementary findings from 06/19/2020**\n\n[Processing]{.underline}: Cell block, HE\n\n**Microscopic:**\n\nAs announced, from the remaining liquid material a cell block was\nprepared. In the HE stain only isolated evidence of mononuclear Cells\nand some blood. No cell atypia.\n\n**Critical Findings Report:** After examination of the remaining liquid\nmaterial in the cell block no Extension of the initial findings in the\nabsence of further diagnostic cell material. The finding is thus based\nexclusively on the Smear material:\n\n- Detection of a single-cell population consisting of cells with\n partial signet ring cell character. Differentially it could be The\n mesothelium may be a reactive change of the approaching mesothelium.\n Cells of an epithelial neoplasia are not visible on the present\n material. to be ruled out with certainty.\n\n**Diagnostic classification:** Suspicious\n\n**Current Recommendations:**\n\n- An appointment at our outpatient clinic to start therapy was\n organized for 06/26/2020.\n\n- An appointment for a health department check-up with varicose vein\n status survey and, if necessary, repeat rubber band ligation has\n been scheduled for 07/22/2020. Please come to the endoscopy on this\n day at 08:30 am fasting with current lab results. incl. coagulation,\n signed consent form as well as SARS-CoV-2 PCR not older than 48h.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report to you on Mrs. Laura Miller, born 04/03/1967, whom we examined\non 06/08/2020 in the course of a consultation.\n\n**Consilar Request:**\n\n- Liver cirrhosis, Child-Pugh B, ethyltoxic genesis\n\n- HCC\n\n- Laboratory albumin: 2.6\n\n- Nutritional advice requested\n\n**Nutritional counseling in cirrhosis of the liver:**\n\n- Albumin at 2.6\n\n- 70kg at admission (stable weight in recent years).\n\n- Height: 1.72m\n\n- BMI falsified by ascites\n\n- Patient reports that she always a \\\"bad eater\\\"\n\n- She reports to eat less due to numerous medication intake\n\n- Patient is noticeably overwhelmed and seems very burdened by\n diagnosis\n\n**Assessment:**\n\n- Protein malnutrition with inadequate oral nutrition\n\n- Patient appears desperate and overwhelmed, questionable compliance\n\n**Recommendations: **\n\n- High-calorie food for more choices (already ordered)\n\n- High-calorie drinks (contains more protein)\n\n- Incorporate protein-rich snacks such as yogurt, sippy cups,\n crispbread\n\n- with cheese.\n\n- A high-energy, high-protein food choice was made with the patient\\'s\n discussed in detail\n\n- Contact details were handed out\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 08/21/2020 to\n08/23/2020.\n\n**Diagnoses**:\n\n- MRI of the liver: disseminated HCC foci in all segments, the largest\n foci is localized in segments 5 / 7 / 8\n\n<!-- -->\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: esophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Current Presentation:** Mrs. Miller presented electively for\ngastroscopy for variceal screening with continuation of banding therapy\ndue to esophageal variceal bleeding.\n\n**Medical History**: For a detailed medical history, we refer to\nprevious reports from our department. In summary, we present a liver\ncirrhosis due to ethyl toxicity leading to the development of multifocal\nHCC. Similar to the liver board decision of 06/13/20, a recommendation\nfor systemic therapy with Lenvatinib or Sorafenib was made in the\nsetting of partially compensated Child B7 cirrhosis with multifocal HCC\nin both lobes of the liver.\n\n**Therapy and Course:** Upon admission, the patient was in\nage-appropriate general condition and largely symptom-free. There were\nno signs of acute infection, jaundice, encephalopathic symptoms, or GI\nbleeding. No irregularities in bowel movements or urination were\nreported. The patient denied abdominal pain and dyspnea. There were no\nknown allergies.\n\nOn the day of admission, an uncomplicated gastroscopy was performed,\nincluding the application of 4 rubber band ligations for residual\nesophageal varices. Post-interventional pain was adequately controlled\nwith double-standard doses of Pantoprazole and intravenous analgesic\ntherapy. The further inpatient course was uneventful, and the patient\ntolerated the post-interventional diet without signs of GI bleeding.\n\nBased on laboratory findings and clinical evaluation, particularly with\nregressed ascites, a compensated Child A6 cirrhosis was confirmed.\nTherefore, a re-presentation at our interdisciplinary liver board was\ninitiated for discussion of potential treatment options in the context\nof compensated liver function.\n\nAs per the consensus recommendation from the liver board, a follow-up\ngastroscopy is scheduled within the next two weeks. Depending on the\nvariceal status, systemic therapy with Atezolizumab/Bevacizumab or\nLenvatinib will follow.\n\nThroughout the monitoring period, the patient remained stable in terms\nof circulation and hemoglobin levels. Therefore, on 08/23/20, we\ndischarged Mrs. Miller for outpatient follow-up care. The patient was\nthoroughly informed about reasons that necessitate immediate\nre-presentation. Please note the listed procedural appointments.\n\n**Physical Examination:** Awake, alert, oriented\n\n- Heart: Regular heart tones, no murmurs\n\n- Lungs: Clear vesicular breath sounds, no crackles or wheezes\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, palpable firm liver edge under the rib cage, no palpable\n spleen enlargement, non-painful renal angle\n\n- Extremities: Good peripheral pulses, no edema\n\n- Neurology: No focal neurological deficits.\n\n**EGD on 08/21/2020:**\n\n**Findings:**\n\n**Esophagus**: Unobstructed intubation of the esophagus under direct\nvision. Multiple variceal cords and scarring changes due to banding were\nobserved in the lower half of the esophagus. Z-line at 35 cm\ndiaphragmatic passage at 39 cm. Two variceal cords extend along the\nsmall curve into the stomach, two of the varices show alarm signs (red\nspots). 4 rubber band ligations were performed.\n\n**Stomach**: In the proximal corpus a picture of portal hypertensive\ngastropathy, otherwise unremarkable. No fundus varices.\n\n**Duodenum**: Good unfolding of the duodenal bulb, contact-sensitive\nmucosa. Good insight into the descending part of the duodenum. Overall,\nunremarkable mucosa.\n\n**Assessment:** Esophageal varices, Gastroesophageal varices Type I.\nBanding therapy.\n\n**Current Recommendations:**\n\n- Regular clinical and laboratory checks by the primary care\n physician.\n\n- In case of fever, acute deterioration of the general condition, or\n clinical signs of bleeding such as melena or hematemesis, we request\n immediate re-presentation, even at night and on weekends, through\n our interdisciplinary emergency department.\n\n- Decision of the liver board: Improvement of liver function with\n alcohol abstinence, but also progression of multifocal HCC over 2\n months without tumor-specific therapy. Consensus: Repeat EGD in 7-14\n days, depending on variceal status, Atezolizumab/Bevacizumab, or\n Lenvatinib.\n\n- Follow-up appointment on 09/11/20 in our HCC outpatient clinic for\n clinical control and explanation of the EGD.\n\n- Follow-up in our endoscopy for EGD to determine variceal status and\n possible banding -\\> Please bring a COVID PCR test (maximum 48 hours\n old) for inpatient admission.\n\nIf complaints persist or worsen, we recommend immediate re-presentation.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 09/18/2020 to\n09/20/2020.\n\n**Diagnoses:**\n\n- 4-time banding therapy with 4 rubber band ligations for residual\n esophageal varices without alarm signs\n\n- Hepatocellular Carcinoma (HCC)\n\n- MR Liver: Disseminated HCC lesions in all segments, with the largest\n lesion located in segments 5/7/8\n\n- Decompensated cirrhosis of the liver (Child B) since 05/20 due to\n ethyltoxic origin.\n\n- Transfusion-dependent anemia due to a history of variceal bleeding.\n\n- Osteoporotic thoracic vertebral fracture of vertebra BWK8 (OF3) with\n kyphoplasty.\n\n- Portal hypertension with portosystemic collaterals\n\n- Splenomegaly\n\n- Cholelithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- History of stroke (2016)\n\n- Allergies: Amalgam\n\n**Presentation:** Mrs. Miller\\'s elective presentation was for a\nfollow-up examination for known esophageal varices.\n\n**Medical History:** For a detailed medical history, please refer to\nprevious reports from our department. In summary, in June 2020, the\npatient was diagnosed with decompensated liver cirrhosis attributed to\nethyltoxicity. MR imaging showed multifocal HCC. According to the liver\nboard decision on 06/15/20, initial therapy was recommended with\nLenvatinib or Sorafenib for partially compensated Child B7 cirrhosis\nwith multifocal HCC in both liver lobes. Despite improvement in liver\nfunction with alcohol cessation, there was a short-term progression of\nmultifocal HCC without tumor-specific therapy, leading to a\nrecommendation for a repeat variceal screening on 08/28/20. Depending on\nthe findings, therapy with Atezolizumab/Bevacizumab or Lenvatinib was\nadvised. The last EGD was performed on 08/21/20, revealing esophageal\nvarices with alarm signs, and a 4-time banding was performed.\n\n**Physical Examination upon Admission:** Blood pressure: 80/150 mmHg,\nheart rate 88/min, temperature 36.4°C, SpO2 97% in room air.\n\nPatient in good general condition and normal mental status. Mrs. Miller\nis fully oriented. Pupils are equal and reactive.\n\n- Cardiovascular: Clear heart sounds, no murmurs.\n\n- Lungs: Equal breath sounds bilaterally, no crackles, resonant\n percussion.\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, liver and spleen not palpable.\n\n- Extremities: No edema, good peripheral pulses. No focal neurological\n deficits.\n\n**Course and Therapy:** On the day of admission, the EGD was performed\nwithout complications. Residual varices without warning signs were\nobserved, and a 4-time rubber band ligation was performed. Portal\nhypertensive gastropathy was also diagnosed. After the procedure, the\npatient was transferred to our gastroenterological normal ward.\n\nThe post-interventional course was uneventful. There were no clinical or\nlaboratory signs of post-interventional bleeding. The diet was\nreintroduced without any issues. Therefore, on 09/20/2020, we discharged\nMrs. Miller for outpatient care. We request a follow-up appointment at\nour in-house HCC outpatient clinic. Additionally, we request a follow-up\nEGD with variceal control.\n\n\n\n\nHere is the query:\nWhich medication was not ascertainably part of Mrs. Miller's regimen?\n\nChoose the correct answer from the following options:\nA. Blood pressure medication\nB. Osteoporosis medication\nC. Anticoagulation medication\nD. Pain relief medication\nE. Antibiotics\n\n\nYour response:\n", "role": "user" }, { "content": "Anticoagulation medication", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\n\nWe are writing to report on the outpatient treatment of Mrs. Laura\nMiller, born on 04/03/1967, on 05/22/2020.\n\n**Diagnosis**: Osteoporotic vertebral body sintering (lumbar vertebra 2\nand thoracic vertebra 8).\n\n**Medical History**: Mrs. Miller presents with pain in her back, legs\nradiating, after fall on the back 6 weeks ago. The complaints were\nprogressive with intermittent paresthesia in both legs.\n\n**Other Diagnoses** (not fully collectible):\n\n- Status post apoplexy\n\n**Current Medication (**not ascertainable):\n\n- Blood pressure medication\n\n- Osteoporosis medication\n\n- No anticoagulation.\n\n**Physical Examination: Lumbar spine:** Skin without pathological\nfindings. No redness, no evidence of infection.\n\nTapping pain over thoracic spine/lumbar spine, no compression pain, no\ntorsion pain, no pressure pain over spinous process.\n\nRadiation of pain into the right and left leg, paravertebral muscle\nhardness.\n\nNo paresthesias in the genital area, no breech anesthesia, no peripheral\nneurologic deficits, No bladder or rectal dysfunction.\n\nPeripheral Circulation/Motor function/Sensitivity intact.\n\nStrength grade on all sides: Hip Flex/Ex: 5/5, Knee Flex/Ex: 5/5,\n\nFoot extensor muscles of the lower leg/flexor muscles of the lower leg:\n3/5.\n\nBig toe extensor muscles of the lower leg/big toe flexor muscles of the\nlower leg: 2/5.\n\n**Thoracic Spine 2 levels from 05/22/2020, Lumbar spine in 2 planes from\n05/22/2020:**\n\nClinical indication: Status post fall\n\nQuestion: new fracture?\n\nPreliminary images: none comparable\n\n**Findings**\n\n1\\) [Thoracic Spine]{.underline}: Multiple thoracic vertebral bodies\nexhibit decreased height, most notably at the central region where a\nmeasurement of approximately 17 mm suggests significant height loss and\npotential acute fracture. Additionally, there are endplate impressions\nin individual vertebrae of the lower thoracic spine. Aortic sclerosis is\npresent, along with degenerative changes throughout the thoracic\nvertebrae. The osseous structure presents osteoporotic features. A\nsuspected hemangioma is identified in a vertebral body of the lower\nthoracic spine.\n\n2\\) [Lumbar Spine]{.underline}: In a presumed five-segment lumbar spine,\nthe L1 vertebra shows a subtle reduction in height with a questionable\nendplate impression. Osteoporotic features are evident in the bony\nstructure.\n\n**Assessment:** Multiple fractures are evident in both thoracic\nvertebrae and the first lumbar vertebra, some of which may be acute. MRI\nis recommended for further evaluation. Osseous structure displays\npronounced osteoporotic features.\n\nGrade III esophageal varices present without definitive high-risk\nstigmata. Varices also noted at the gastroesophageal junction,\nclassified as GOV 1 according to Sarin\\'s classification. Band ligation\nof the varices is not performed, as no unambiguous source of bleeding is\nidentifiable and a significant portion of the stomach remains outside\nthe field of view.\n\n**Recommendation**: Terlipressin, monitor surveillance, Erythromycin\n\n**Computed Tomography Thoracic spine from 05/22/2020:**\n\nFracture at the base plate of lumbar vertebra 2 with involvement of the\nposterior margin. Left lateral, no significant reduction in height of\nthe vertebral body. No tension of the spine.\n\nSuspicion of new small fracture also at the cover plate at thoracic\nvertebra 8.\n\nMultiple, older, osteoporotic compression fractures at the thoracic\nspine and\n\nupper lumbar spine.\n\n**Additional Finding:**\n\nLiver cirrhosis with multiple nodules, low ascites, and portal vein\ncongestion. Splenomegaly. If not already known, further workup of liver\nlesions is recommended. Hydrops of the gallbladder.\n\n**Current Recommendations**: There is a general indication for admission\nof the patient and further diagnostics before surgical treatment of the\nfractures. Mrs. Miller is generally opposed to surgical care. She was\nthoroughly informed about the risks (progression, cross-section, death).\n\nRe-presentation with current bone densitometry and update of\nosteoporosis medication, as well as current holospinal MRI. In the\nmeantime, analgesia as needed using Acetaminophen 500mg 1-1-1 under\ngastric protection.\n\n**Esophagogastroduodenoscopy from 05/22/2020:**\n\n[Esophagus]{.underline}: Unobstructed intubation of the esophageal\nopening was achieved under direct visualization. In the upper third of\nthe esophagus, multiple prominent varices protrude into the lumen,\nunaltered by air insufflation. In the middle third, there are areas with\nwhitish overlying material that do not resemble the typical white nipple\nsign. Despite meticulous inspection, no active bleeding sites were\nidentified. The Z-line reveals isolated minor erosions. Cardiac\nsphincter closure is complete.\n\n[Stomach]{.underline}: Full distension of the gastric lumen was\naccomplished with air insufflation. The major curvature of the stomach\ncontained food mixed with hematin. The mucosal surface was similarly\ncoated with hematin, but no active bleeding was discernible in the\nvisualized areas. Peristaltic movement was widespread. Upon\nretroflexion, pronounced varices were noted near the cardiac region on\nthe lesser curvature. The pylorus was unremarkable and easily\ntraversable.\n\n[Duodenum]{.underline}: Adequate distension of the duodenal bulb was\nachieved, providing a clear view up to the descending part of the\nduodenum. Overall, the mucosa appeared normal with minor remnants of\nhematin, and no source of bleeding was identified.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about Mrs. Laura Miller, born on 04/03/1967, who was in\nour inpatient treatment from 05/27/2020 to 06/22/2020.\n\n**Diagnoses**: Initial diagnosis of hepatocellular carcinoma.\n\n- MRI liver: disseminated HCC foci in all segments, the largest foci\n is localized in segments 5 / 7 / 8\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: sophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: Residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Physical Examination:** Patient in mildly reduced general and normal\nnutritional status (BMI 20.3).\n\n- Lungs: Vesicular breath sound, no pathological secondary sounds.\n SpO2 96%.\n\n- Heart: Pure, rhythmic. Systolic with maximum at Erb\\'s point and\n continuation into the carotids. HR: 87/min. BP: 124/54mmHg\n\n- Abdomen: Lively bowel sounds, no tenderness, no guarding, no\n resistance, no peritonism. Soft abdomen. Liver not enlarged,\n palpable. Renal bed not palpable.\n\n- Extremities: Edema of the lower extremities on both sides, foot\n pulses bilaterally well palpable.\n\n- Spine: No tap pain.\n\n- Orienting neurological examination: Right leg weakness, known\n paresis of the extensor muscles of the lower leg/flexor muscles of\n the lower leg.\n\n**Therapy and Progression:** Mrs. Miller was taken over for suspected\nupper GI bleeding. Initially, the patient had presented with increasing\nback pain since approximately 6 weeks at status post fall in the Park\nClinic on 04/26/2020. The patient was known there for her stroke in\n2016. On the day of admission to the Park Clinic, normochromic\nnormocytic anemia (Hemoglobin 3 g/dL) was noticed, which is why the\ntransfer to our clinic was made.\n\nOn inpatient admission, the patient presented in slightly reduced\ngeneral condition. She reported having black stools once. In addition,\nMs. Miller had coffee ground-like emesis once. Dyspnea, angina pectoris\ncomplaints, and B symptoms were denied. There were no problems with\nmicturition. Recently, there were no abnormalities in bowel movements.\nSo far, no colonoscopy has been performed. There were no known\nintestinal diseases in the family.\n\n[Noxae]{.underline}: Ex-nicotine use (since 1996, previously cumulative\nca. 3 PY), occasional alcohol consumption (probably abstinent for about\n5 years).\n\nLaboratory results showed that the patient had elevated infectious\nparameters. The\n\nurinalysis was unremarkable. X-ray chest showed no clear picture of\npneumonia. In a first emergency esophagogastroduodenoscopy on\n05/28/2020, esophageal varices °III were found without clear signs of\nrisk. Furthermore, varices in the area of the cardia (GOV 1 after Sarin)\nwere seen. When the source of bleeding was inconclusive, it was referred\nto a banding initially waived. In a renewed esophagogastroduodenoscopy\nin the morning of 05/30/2020, 2 ampoules of Histoacryl were applied to\nthe cardia varices. In addition, the picture of an incipient\nportal-hypertensive gastropathy. Antibiotic intravenous therapy with\nceftriaxone was initiated. At 06/13/2020, a\nre-esophagogastroduodenoscopy took place, during which a renewed twofold\nbanding of the esophageal varices was performed with injection of 0.5 ml\nHistoacryl. Abdominal ultrasound showed a picture of liver cirrhosis\nwith splenomegaly and perihepatic ascites. In addition, the liver showed\nmultiple echo-poor nodes in the right lobe and a suspicious\n2.4x3.6x4.4cm echo-poor area with a halo in SII. This was followed by an\nMRI of the liver, in which the HCC in segment II was confirmed by\nimaging.\n\nMultiple additional arterial hypervascularized areas/round foci in all\nliver lobes without definite washout. There is no evidence of suspicious\nnodular changes on CT chest/abdomen/pelvis. At an in-house liver\nconference, systemic therapy (Lenvatinib or Sorafenib in Child B7) was\nrecommended.\n\nDue to the back pain, a holospinal MRI was performed, which showed a\nsubacute cover plate compression fracture in the thoracic vertebra 8 as\nwell as multiple older compression fractures of the thoracic spine and\nupper lumbar spine. The colleagues of neurosurgery were consulted, who\ngave the indication for surgery. On 06/14/2020, the planned surgery with\nkyphoplasty thoracic vertebra 8 under C-arm fluoroscopy could be\nperformed without complications. Postoperatively, the patient remained\ncirculatory stable.\n\nDue to auscultatory suspicion of aortic valve stenosis, further\nclarification was performed by cardiac echography, showing no\nhigher-grade valvular vitiation.\n\nWe are transferring Mrs. Miller in improved general condition to the\nSenior Citizens\\' Residence Seaview. If you have any questions, please\ndo not hesitate to contact us.\n\n**Addition:**\n\n**Ultrasound of the upper abdomen on 05/27/2020:**\n\nLimited assessable due to meteorism.\n\n**Liver**: Liver dimensions are within normal limits, measuring 15.9 cm\nin the craniocaudal axis. Echotexture demonstrates inhomogeneous\ngranularity. There is hepatic margin convexity and nodular surface\nappearance. Rarification of hepatic veins. Segment III reveals two\nhypoechoic lesions measuring 3 cm and 1 cm in diameter. Portal vein\ndemonstrates orthograde flow with a maximum velocity of 17 cm/s.\n\n**Gallbladder:** Gallbladder is partially contracted; its wall appears\nunremarkable without sonographic evidence of cholecystitis. No\ntenderness elicited upon sonographic examination.\n\n**Biliary Tract**: Intrahepatic bile ducts are patent. Common hepatic\nduct measures 6 mm in diameter. Common bile duct appears transiently\ndilated up to 9 mm and is otherwise unremarkable as far as can be\nvisualized prepapillary.\n\n**Pancreas**: Limited visualization of the pancreas; however, the\nvisible parenchyma appears homogeneously echoic.\n\n**Spleen**: Spleen is enlarged, measuring 13 x 4 cm, with homogeneous\nparenchyma.\n\n**Kidneys**: Kidneys are morphologically unremarkable, without evidence\nof pelvicalyceal system dilation.\n\n**Abdominal Vessels**: Aorta is partially visualized and appears within\nnormal calibers.\n\nIntestinal/Peritoneal Cavity: No evidence of free intraperitoneal fluid.\n\nUrinary Bladder/Genitalia: Urinary bladder is adequately distended,\nappearing unremarkable upon limited assessment. Uterus is not\nvisualized.\n\n**Virology from 05/28/2020:**\n\n- SARS CoV-2 PCR PCR negative Geq/ml\n\n- Findings: No detection of SARS-CoV-2 by PCR in the submitted\n material.\n\n**Chest X-ray a.p. from 05/28/2020:**\n\nLimited assessability in supine position, malrotation. The diaphragmatic\ncrests are smooth. The marginal sinuses are free of effusions and\ncalluses. Heart and mediastinum lie cryptically. The aorta is sclerosed.\nCranialization of the vessels as well as slightly elevated vascular\nmarkings in the supine position, especially in the right upper field.\nDystelectasis on the right. Sharply defined vertical shadowing in the\nleft upper field. The upper mediastinum is narrow, the trachea is in the\nmidline and is not constricted. Degenerative changes in the cervical\nspine. Overlying foreign material.\n\n**Assessment**: Sharply defined vertical shadowing in the left upper\nfield. Dystelectasis on the right side. Conventional radiographic\nexamination No evidence of a mass. No effusion.\n\n**Esophagogastroduodenoscopy of 05/28/2020:**\n\n**Esophagus**: Successful intubation of the esophageal orifice under\ndirect visualization. Multiple intraluminal protrusions noted in the\nupper third of the esophagus. Non-collapsible variceal strands observed\nupon air insufflation, beginning from the middle third. Whitish\nproliferations seen at multiple sites, not consistent with typical white\nnipple signs. No evidence of active bleeding on close inspection. Z-line\nobserved with isolated minor erosions. Cardiac sphincter fully\ncompetent.\n\n**Stomach**: Gastric lumen fully distended under air insufflation.\nCorpus predominantly contains hematin-laden food remnants. Mucosal\nsurface also stained with hematin but without visible active bleeding.\nPeristalsis noted throughout. Distinct coronary vasculature observed on\nthe lesser curvature. Pylorus unremarkable, offering no resistance to\npassage.\n\n**Duodenum**: Bulbus duodeni well-formed. Pars descendens duodeni\nvisualized clearly. Overall mucosa appears unremarkable, with scattered\nhematin remnants observed without an identifiable bleeding source.\n\n**Assessment**: Esophageal varices graded as °III, with no definitive\nhigh-risk stigmata. Varices also noted in the cardia, classified as GOV\n1 according to Sarin\\'s classification. Ligation of varices was not\nperformed due to the absence of an identifiable bleeding source and\nincomplete visualization of the gastric lumen.\n\n**Ultrasound of the abdomen on 05/29/2020:**\n\n**Quality of Exam**: Limited due to patient non-cooperation and\nmeteorism.\n\n**Liver**: Liver size is paradoxically reported both as normal at 15.9\ncm and enlarged at 18.7 cm. Margins are rounded. Echotexture is markedly\ninhomogeneous with nodular surface. Multiple hypoechoic nodules are\npresent in the right lobe, along with a suspicious hypoechoic area\nmeasuring 2.4 x 3.6 x 4.4 cm with peripheral halo in segment II. Hepatic\nveins are rarified. Portal vein shows orthograde flow with a vmax of 28\ncm/s.\n\n**Gallbladder**: Morphologically unremarkable with no wall thickening.\nCholelithiasis noted with concretions measuring at least 2 to 1.6 cm.\n\n**Biliary Tract:** Intrahepatic bile ducts are not dilated; Common\nhepatic duct measures up to 8.5 mm and common bile duct measures 6.6 mm\nin diameter.\n\n**Pancreas**: Partially visualized; adequacy of assessment is\ncompromised.\n\n**Spleen**: Enlarged with homogeneous internal echotexture.\n\n**Kidneys**: Morphologically unremarkable; no evidence of\nhydronephrosis.\n\n**Abdominal Vessels:** Aorta is not dilated.\n\n**Gastrointestinal**: Perihepatic ascites noted. Both small and large\nintestines appear unremarkable upon limited assessment.\n\n**Urinary Bladder/Genitalia:** Bladder is moderately filled and\nunremarkable in shape and size.\n\n**Assessment**: Limited study due to patient non-cooperation and\nmeteorism. Findings are suggestive of liver cirrhosis and grade I\nascites. Additional findings include suspected hepatic space-occupying\nlesions, splenomegaly, and cholelithiasis. Mild dilation of DHC and DC\nobserved without signs of intrahepatic cholestasis.\n\n**Virology from 06/01/2020:**\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HAV IgG 0.73 negative\n Anti HAV IgM \\<0.1 negative\n\n**Interpretation:** Serologically no evidence of fresh or expired\ninfection with\n\nHepatitis A virus, no immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n HBs antigen 0.21 negative\n Anti HBs \\<0.1 negative\n Anti HBc 0.1 negative\n\n**Interpretation:** Serologically no evidence of acute, chronic or\nexpired Hepatitis B virus infection. No immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HCV 0.06 negative\n\n**Interpretation:** Serologically no evidence of hepatitis C virus\ninfection. At possible fresh infection resubmission in 2-4 weeks and HCV\nPCR recommended.\n\n**MRI total spine plain from 06/04/2020:**\n\n**Technique**: T2 Dixon Sagittal and T2 Axial MRI Sequences. Coverage\nextends from the craniocervical junction to the sacrum.\n\n**Findings:**\n\n**General Spine:** Full extent from craniocervical junction to sacrum\nvisualized. Conus medullaris appropriately located at T12-L1 level.\nMyelon demonstrates uniform width and homogeneous signal. Evaluation of\nthoracolumbar transition and lumbar spine is compromised by artifact\nsuperimposition from ascites.\n\n**Cervical Spine:** Irregular alignment of the posterior vertebral body\nmargins noted, with evidence of disc protrusions and ligamentum flavum\nhypertrophy. Focal T2 hyperintensity observed at C5 level. No evidence\nof prevertebral soft tissue proliferation.\n\n**Thoracic Spine**: Maintained alignment of the posterior vertebral body\nmargins. Multiple anterior endplate compression fractures noted at T5,\nT8, T9, T11, T12 levels. Focal T2 hyperintensity near the anterior\nendplate of T8 involving the posterior margin, indicative of a\nnon-displaced fracture without spinal canal compromise. Hypertrophic\nfacet joint arthrosis at T10-T11 levels resulting in relative spinal\nnarrowing. Bilateral pleural effusions noted, more pronounced on the\nright, with a maximum width of approximately 2 cm. No evidence of\nsignificant neuroforaminal stenosis.\n\n**Lumbar Spine:** Maintained alignment of posterior vertebral body\nmargins. Known anterior endplate compression fractures at L1 and\nbaseplate compression fracture at L2. No evidence of pathological T2\nedema within the vertebral bodies, although assessment is limited due to\nsuperimposed artifacts from ascites. Spinal canal dimensions appear\nadequate throughout. Moderate fatty degeneration of sacral bone noted.\n\n**Assessment**: Evaluation limited due to ascites-related artifacts.\nSubacute anterior endplate compression fracture at T8, along with\nseveral other likely older compression fractures in the thoracic and\nupper lumbar spine. Bilateral pleural effusions observed. Multiple\nneuroforaminal narrowings as detailed above.\n\n**MR Liver plain + contast agent from 06/06/2020**\n\n**Findings:**\n\n1) [Lesion 1]{.underline}\n\n- Size of the lesion 41 mm\n\n- Segment 2\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: yes\n\n- Pseudocapsule: yes\n\n- Behavior delayed leaching: yes\n\n- pseudocapsule macrovascular invasion: no\n\n2) [Lesion 2]{.underline}\n\n- Size of the lesion 104 mm\n\n- Segment 5 / 7 / 8\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: no\n\n- Pseudocapsule: no\n\n- Behavior delayed washing out: no\n\n- Pseudocapsule: no\n\n- Macrovascular invasion: yes\n\n**Comments:**\n\n- MRI with Gadovist intravenous.\n\n- Multiple other satellite foci in all liver segments.\n\n- Signs of liver cirrhosis with nodular liver parenchyma and\n hypertrophy of the left lobe.\n\n- Cholecystolithiasis and gallbladder hydrops. No cholestasis.\n\n- Varices of the esophagus and fundus. Splenomegaly. Ascites. Pleural\n effusions on both sides.\n\n- Lymph node (approximately 8 mm) between the small curvature of the\n Stomach and S1 of the liver.\n\n- Axial hernia.\n\n**Assessment:** Milan fulfilled**.** Dissiminated HCC foci in all\nsegments, the largest foci being in segments 5 / 7 / 8 localized. Portal\nhypertension with bypass circulation and splenomegaly. Ascites and\npleural effusions.\n\n**Microbiology from 06/09/2020:**\n\n[Material]{.underline}: Ascites in blood culture bottles\n\n[Microscopic]{.underline}: No cells, no germs\n\n- Anaerobic culture negative after 48 hours\n\n- So far, no growth in the anaerobic cultures. The cultures are\n incubated for a total of 5 days. In case of growth of anaerobes we\n will send you a follow-up report.\n\n- No growth after 48 hours\n\n**Esophagogastroduodenoscopy of 06/11/2020:**\n\n**Esophagus**: In the distal esophagus, multiple band-like ulcerations\nas well as residual varices with risk signs that may not completely pass\nair insufflation. Z-line without erosions.\n\n**Stomach**: Mosaic-like occupancy of the gastric mucosa. With inversion\nthe\n\nknown small-curved lateral cardiavarii, which is hard on palpation with\nclosed forceps after histoacryl injection. Directly next to it, another\ncardiavarice can now be seen, which has not yet been injected with\nhistoacryl and is soft on palpation.\n\n**Duodenum**: Endoscopic therapy: Injection of 0.5 mL Histoacryl (+0.5\nmL Lipoidol) in the new cardiavarice. Application of 3 rubber band\nligatures to the residual varices in the esophagus.\n\n**Assessment:** Residual varices in the esophagus, application of 3\nrubber band ligations; portal hypertensive gastropathy\n\n**Spine-whole: 2 planes from 06/13/2020**\n\nThe perpendicular of C7 protrudes about 15 mm laterally to the left of\nsacral vertebra 1 in the anterior-posterior image and about 9.3 cm in\nfront of sacral vertebra 1 in the lateral ray path. Slight left convex\nscoliosis thoracolumbally with thoracic counter-swing (Cobb angle \\< 10°\nin each case). The lungs are unremarkable as far as technically\nassessable.\n\n**Assessment**: decompensated positive sagittal spinal imbalance. There\nis no relevant lateral trunk overhang.\n\n**Critical Findings Report:**\n\nA conspicuous single cell population of cells with partial signet ring\ncell character is detected in the smears. A cell block is prepared from\nthe remaining liquid material for further typing of these cells. A\nfollow-up report will follow.\n\n**Thoracic spine in 2 planes from 06/15/2020:**\n\n**Findings**: Thoracic vertebra 8: Post-kyphoplasty status with notable\nimprovement in vertebral height, now measuring 21 mm compared to a\npreoperative height of 13 mm. Mild straightening of the vertebral column\nobserved at this level.\n\nThoracic vertebra 9: Known older anterior endplate collapse.\n\nThoracolumbar spine: Multisegmental height reduction in vertebral bodies\nconsistent with osteoporotic changes. No signs of contrast\nextravasation.\n\nAdditional Finding: Pre-existing calcified structure projecting onto the\nleft upper abdomen; likely unrelated to current surgical site.\n\n**Assessment**: Unremarkable postoperative imaging following kyphoplasty\nof T8. No evidence of postoperative sintering or newly identifiable\nfractures. Overall, the surgical intervention appears successful in\nincreasing vertebral height and stabilizing the fracture site.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 06/18/2020:**\n\n**Technique**: Multislice spiral CT of the chest, abdomen, and pelvis\nwas performed post-bolus intravenous injection of 120 ml of Imeron 400.\nImaging conducted in arterial, portal venous, and venous phases. Oral\ncontrast agent administered with Micropaque 1:7 in water and Gastrolux\n1:33 in water. Thin-slice reconstructions and secondary coronal and\nsagittal reformats were performed.\n\n**Chest**: Presence of struma nodosa. Bilateral minor pleural effusions\nwith adjacent atelectasis, more pronounced on the right and extending\ninto the interlobar region. No signs of infiltrative changes. Isolated\nsmall nodular opacities in the right lung. Few small bullae noted.\nMediastinal lymph nodes mildly enlarged up to 0.5 cm; axillary and hilar\nnodes are not enlarged. No pericardial effusion observed.\n\n**Abdomen/Pelvis**: Known esophageal and fundal varices present. Liver\ndemonstrates nodular changes in the context of known Child-Pugh B stage\ncirrhosis. A solid hepatic cellular carcinoma lesion in segment II and\ndiffuse HCC nodules in segments V/VII/VIII visualized, corroborating\nprior MRI findings. They show pronounced arterial enhancement and\ncentral washout. Splenomegaly noted. Adrenal glands unremarkable. Renal\nand urinary systems are inconspicuous. No intestinal motility\nabnormalities detected. Marked ascites present; no pathologically\nenlarged abdominal lymph nodes noted upon limited assessment.\n\n**Skeletal**: Moderate coxarthrosis bilaterally. An old, minimally\ndisplaced fracture of the right 7th rib noted. Advanced degenerative\nchanges in thoracic vertebrae 10, 12, and lumbar spine.\nPost-vertebroplasty status at thoracic vertebra 9. Hemangioma at\nthoracic vertebra 11.\n\n**Assessment**:\n\n- Marked ascites in the setting of liver cirrhosis with multifocal HCC\n lesions, as corroborated by prior MRI. No evidence of extrahepatic\n or lymphatic spread.\n\n- Bilateral minor pleural effusions with associated atelectasis.\n\n- Skeletal findings include moderate coxarthrosis and degenerative\n changes in the spine.\n\nOverall, the scan provides vital information that aligns with and\nelaborates upon existing clinical and imaging data.\n\n**Histology**:\n\n**Pathology from 06/19/2020:**\n\n[Clinical Data:]{.underline} Hepatocellular carcinoma, hydropic\ndecompensated liver cirrhosis Child B,\n\n[Extraction date:]{.underline} 06/13/2020\n\n[Material:]{.underline} 1 Liquid material 7 ml light yellow\n\n[Editing]{.underline}: Papanicolaou and MGG staining\n\n\\+ Protein precipitation\n\n\\+ Erythrocytes\n\n\\+ Lymphocytes\n\n(+) Granulocytes Eosinophils\n\n\\+ Histiocytic cell forms\n\n\\+ Mesothelium\n\n\\+ Active mesothelium\n\n**Other**: Single mononuclear cells with large, eccentric nuclei with\nnucleoli and a narrow cytoplasmic space, partly with signet ring cells.\n\n**Supplementary findings from 06/19/2020**\n\n[Processing]{.underline}: Cell block, HE\n\n**Microscopic:**\n\nAs announced, from the remaining liquid material a cell block was\nprepared. In the HE stain only isolated evidence of mononuclear Cells\nand some blood. No cell atypia.\n\n**Critical Findings Report:** After examination of the remaining liquid\nmaterial in the cell block no Extension of the initial findings in the\nabsence of further diagnostic cell material. The finding is thus based\nexclusively on the Smear material:\n\n- Detection of a single-cell population consisting of cells with\n partial signet ring cell character. Differentially it could be The\n mesothelium may be a reactive change of the approaching mesothelium.\n Cells of an epithelial neoplasia are not visible on the present\n material. to be ruled out with certainty.\n\n**Diagnostic classification:** Suspicious\n\n**Current Recommendations:**\n\n- An appointment at our outpatient clinic to start therapy was\n organized for 06/26/2020.\n\n- An appointment for a health department check-up with varicose vein\n status survey and, if necessary, repeat rubber band ligation has\n been scheduled for 07/22/2020. Please come to the endoscopy on this\n day at 08:30 am fasting with current lab results. incl. coagulation,\n signed consent form as well as SARS-CoV-2 PCR not older than 48h.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report to you on Mrs. Laura Miller, born 04/03/1967, whom we examined\non 06/08/2020 in the course of a consultation.\n\n**Consilar Request:**\n\n- Liver cirrhosis, Child-Pugh B, ethyltoxic genesis\n\n- HCC\n\n- Laboratory albumin: 2.6\n\n- Nutritional advice requested\n\n**Nutritional counseling in cirrhosis of the liver:**\n\n- Albumin at 2.6\n\n- 70kg at admission (stable weight in recent years).\n\n- Height: 1.72m\n\n- BMI falsified by ascites\n\n- Patient reports that she always a \\\"bad eater\\\"\n\n- She reports to eat less due to numerous medication intake\n\n- Patient is noticeably overwhelmed and seems very burdened by\n diagnosis\n\n**Assessment:**\n\n- Protein malnutrition with inadequate oral nutrition\n\n- Patient appears desperate and overwhelmed, questionable compliance\n\n**Recommendations: **\n\n- High-calorie food for more choices (already ordered)\n\n- High-calorie drinks (contains more protein)\n\n- Incorporate protein-rich snacks such as yogurt, sippy cups,\n crispbread\n\n- with cheese.\n\n- A high-energy, high-protein food choice was made with the patient\\'s\n discussed in detail\n\n- Contact details were handed out\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 08/21/2020 to\n08/23/2020.\n\n**Diagnoses**:\n\n- MRI of the liver: disseminated HCC foci in all segments, the largest\n foci is localized in segments 5 / 7 / 8\n\n<!-- -->\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: esophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Current Presentation:** Mrs. Miller presented electively for\ngastroscopy for variceal screening with continuation of banding therapy\ndue to esophageal variceal bleeding.\n\n**Medical History**: For a detailed medical history, we refer to\nprevious reports from our department. In summary, we present a liver\ncirrhosis due to ethyl toxicity leading to the development of multifocal\nHCC. Similar to the liver board decision of 06/13/20, a recommendation\nfor systemic therapy with Lenvatinib or Sorafenib was made in the\nsetting of partially compensated Child B7 cirrhosis with multifocal HCC\nin both lobes of the liver.\n\n**Therapy and Course:** Upon admission, the patient was in\nage-appropriate general condition and largely symptom-free. There were\nno signs of acute infection, jaundice, encephalopathic symptoms, or GI\nbleeding. No irregularities in bowel movements or urination were\nreported. The patient denied abdominal pain and dyspnea. There were no\nknown allergies.\n\nOn the day of admission, an uncomplicated gastroscopy was performed,\nincluding the application of 4 rubber band ligations for residual\nesophageal varices. Post-interventional pain was adequately controlled\nwith double-standard doses of Pantoprazole and intravenous analgesic\ntherapy. The further inpatient course was uneventful, and the patient\ntolerated the post-interventional diet without signs of GI bleeding.\n\nBased on laboratory findings and clinical evaluation, particularly with\nregressed ascites, a compensated Child A6 cirrhosis was confirmed.\nTherefore, a re-presentation at our interdisciplinary liver board was\ninitiated for discussion of potential treatment options in the context\nof compensated liver function.\n\nAs per the consensus recommendation from the liver board, a follow-up\ngastroscopy is scheduled within the next two weeks. Depending on the\nvariceal status, systemic therapy with Atezolizumab/Bevacizumab or\nLenvatinib will follow.\n\nThroughout the monitoring period, the patient remained stable in terms\nof circulation and hemoglobin levels. Therefore, on 08/23/20, we\ndischarged Mrs. Miller for outpatient follow-up care. The patient was\nthoroughly informed about reasons that necessitate immediate\nre-presentation. Please note the listed procedural appointments.\n\n**Physical Examination:** Awake, alert, oriented\n\n- Heart: Regular heart tones, no murmurs\n\n- Lungs: Clear vesicular breath sounds, no crackles or wheezes\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, palpable firm liver edge under the rib cage, no palpable\n spleen enlargement, non-painful renal angle\n\n- Extremities: Good peripheral pulses, no edema\n\n- Neurology: No focal neurological deficits.\n\n**EGD on 08/21/2020:**\n\n**Findings:**\n\n**Esophagus**: Unobstructed intubation of the esophagus under direct\nvision. Multiple variceal cords and scarring changes due to banding were\nobserved in the lower half of the esophagus. Z-line at 35 cm\ndiaphragmatic passage at 39 cm. Two variceal cords extend along the\nsmall curve into the stomach, two of the varices show alarm signs (red\nspots). 4 rubber band ligations were performed.\n\n**Stomach**: In the proximal corpus a picture of portal hypertensive\ngastropathy, otherwise unremarkable. No fundus varices.\n\n**Duodenum**: Good unfolding of the duodenal bulb, contact-sensitive\nmucosa. Good insight into the descending part of the duodenum. Overall,\nunremarkable mucosa.\n\n**Assessment:** Esophageal varices, Gastroesophageal varices Type I.\nBanding therapy.\n\n**Current Recommendations:**\n\n- Regular clinical and laboratory checks by the primary care\n physician.\n\n- In case of fever, acute deterioration of the general condition, or\n clinical signs of bleeding such as melena or hematemesis, we request\n immediate re-presentation, even at night and on weekends, through\n our interdisciplinary emergency department.\n\n- Decision of the liver board: Improvement of liver function with\n alcohol abstinence, but also progression of multifocal HCC over 2\n months without tumor-specific therapy. Consensus: Repeat EGD in 7-14\n days, depending on variceal status, Atezolizumab/Bevacizumab, or\n Lenvatinib.\n\n- Follow-up appointment on 09/11/20 in our HCC outpatient clinic for\n clinical control and explanation of the EGD.\n\n- Follow-up in our endoscopy for EGD to determine variceal status and\n possible banding -\\> Please bring a COVID PCR test (maximum 48 hours\n old) for inpatient admission.\n\nIf complaints persist or worsen, we recommend immediate re-presentation.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 09/18/2020 to\n09/20/2020.\n\n**Diagnoses:**\n\n- 4-time banding therapy with 4 rubber band ligations for residual\n esophageal varices without alarm signs\n\n- Hepatocellular Carcinoma (HCC)\n\n- MR Liver: Disseminated HCC lesions in all segments, with the largest\n lesion located in segments 5/7/8\n\n- Decompensated cirrhosis of the liver (Child B) since 05/20 due to\n ethyltoxic origin.\n\n- Transfusion-dependent anemia due to a history of variceal bleeding.\n\n- Osteoporotic thoracic vertebral fracture of vertebra BWK8 (OF3) with\n kyphoplasty.\n\n- Portal hypertension with portosystemic collaterals\n\n- Splenomegaly\n\n- Cholelithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- History of stroke (2016)\n\n- Allergies: Amalgam\n\n**Presentation:** Mrs. Miller\\'s elective presentation was for a\nfollow-up examination for known esophageal varices.\n\n**Medical History:** For a detailed medical history, please refer to\nprevious reports from our department. In summary, in June 2020, the\npatient was diagnosed with decompensated liver cirrhosis attributed to\nethyltoxicity. MR imaging showed multifocal HCC. According to the liver\nboard decision on 06/15/20, initial therapy was recommended with\nLenvatinib or Sorafenib for partially compensated Child B7 cirrhosis\nwith multifocal HCC in both liver lobes. Despite improvement in liver\nfunction with alcohol cessation, there was a short-term progression of\nmultifocal HCC without tumor-specific therapy, leading to a\nrecommendation for a repeat variceal screening on 08/28/20. Depending on\nthe findings, therapy with Atezolizumab/Bevacizumab or Lenvatinib was\nadvised. The last EGD was performed on 08/21/20, revealing esophageal\nvarices with alarm signs, and a 4-time banding was performed.\n\n**Physical Examination upon Admission:** Blood pressure: 80/150 mmHg,\nheart rate 88/min, temperature 36.4°C, SpO2 97% in room air.\n\nPatient in good general condition and normal mental status. Mrs. Miller\nis fully oriented. Pupils are equal and reactive.\n\n- Cardiovascular: Clear heart sounds, no murmurs.\n\n- Lungs: Equal breath sounds bilaterally, no crackles, resonant\n percussion.\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, liver and spleen not palpable.\n\n- Extremities: No edema, good peripheral pulses. No focal neurological\n deficits.\n\n**Course and Therapy:** On the day of admission, the EGD was performed\nwithout complications. Residual varices without warning signs were\nobserved, and a 4-time rubber band ligation was performed. Portal\nhypertensive gastropathy was also diagnosed. After the procedure, the\npatient was transferred to our gastroenterological normal ward.\n\nThe post-interventional course was uneventful. There were no clinical or\nlaboratory signs of post-interventional bleeding. The diet was\nreintroduced without any issues. Therefore, on 09/20/2020, we discharged\nMrs. Miller for outpatient care. We request a follow-up appointment at\nour in-house HCC outpatient clinic. Additionally, we request a follow-up\nEGD with variceal control.\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n\n\n\n\nHere is the query:\nWhat condition did Mr. Chapman NOT have a history of prior to his admission on 04/03/2017?\n\nChoose the correct answer from the following options:\nA. Rib fracture\nB. Appendectomy\nC. Diabetes Mellitus\nD. Distal radius fracture\nE. Elbow fracture\n\n\nYour response:\n", "role": "user" }, { "content": "Diabetes Mellitus", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on Mr. Ben Harder, born on 08/02/1940, who was admitted\nto our hospital from 12/17/2015 to 12/27/2015.\n\n**Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Status post excision on the nose with suspicion of basal cell\n carcinoma\n\n- Status post laparoscopic cholecystectomy\n\n- Retropubic radical prostatectomy without nerve preservation and with\n bilateral pelvic lymphadenectomy was performed on 12/17/2015.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------- ---------------------------------------------------\n Valsartan (Diovan) 160 mg 1-0-1\n Aspirin 100 mg 1-0-1\n Simvastatin (Zocor) 15 mg 0-0-1\n Doxazosin (Cardura) 1 mg 0-0-1\n Enoxaparin (Lovenox) 0.6 mL s.c. Administer subcutaneously for a total of 4 weeks.\n Acetaminophen (Tylenol) 500 mg 1-1-1 (for 4 days)\n\n**Histopathology:**\n\n1. 2 adenocarcinoma metastases in 2 out of 4 lymph nodes, left external\n iliac region.\n\n2. 3 adenocarcinoma metastases in 3 out of 6 lymph nodes, right pelvic\n region.\n\n3. 7 adenocarcinoma metastases in 7 out of 7 lymph nodes, right lumbar\n para-aortic region.\n\n4. Acinar adenocarcinoma of the prostate is observed bilaterally, with\n a Gleason score of 4 (70%) + 5 (25%) = 9 and a tertiary Gleason\n grade of 3 (5%) according to the modified Gleason grading of the\n ISUP 2005. The tumor is multifocal and encompasses the entire\n prostate with a maximum extrapolated tumor extension of 60 mm. There\n is extracapsular tumor growth, with focal involvement at the dorsal\n right base. Vascular invasion is not noted, but perineural invasion\n is extensive. Both seminal vesicles are heavily infiltrated, and the\n resection margin of the left seminal vesicle is involved. Before\n tissue embedding, the margins of the specimen show focal\n infiltration by the tumor, in the right anterior region near the\n base (section 7) with a total contact area of 2 mm wide, and the\n primary Gleason grade at the positive margin is 4. In addition to\n the carcinoma, other prostatic tissue shows features of myoglandular\n hyperplasia and high-grade prostatic intraepithelial neoplasia\n (HGPIN). The prostatic urethra is free of tumors or dysplasia.\n\n5. **Tumor classification:** pT3bpN1(12/17), R1L0V0, Gleason: 4 + 5 = 9\n\n**Medical History:** Mr. Harder was admitted for open prostatectomy due\nto biopsy-confirmed prostate carcinoma.\n\nInitial PSA value: 5.42 ng/ml. Gleason score of biopsy: 4+5=9 in 11 out\nof 12 biopsy samples. Clinical tumor stage: cT2c PSMA PET-CT + MRI from\n12/23/2015: Left capsular penetration without rectal infiltration.\nSeminal vesicles are infiltrated on both sides. Evidence of multiple\nlymph nodes; intrapelvic locoregional and two lymph nodes on the right\nparailiacal and lumbar interaortocaval region.\n\nTRUS: 88 cc Digital Rectal Examination: Abnormal findings on the left\nside\n\n**Physical Examination:** The patient is in good general condition, has\na lean nutritional status, and reports feeling well. The abdomen is\nsoft, with no tenderness, masses, resistance, or guarding, and the\nexternal genitalia are unremarkable.\n\n**Ultrasound upon admission:** Both kidneys are not dilated and show no\nspace-occupying lesions. The bladder is minimally filled and appears\nunremarkable to the extent assessable.\n\n**Pretherapeutic Tumor Conference:** The findings were discussed\ninterdisciplinary, and the possible treatment options were explained.\nThe patient opted for radical prostatectomy.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complications. The postoperative course was uneventful. Blood\ntransfusions were not required. Unfortunately, a cystogram on revealed\nextravasation, requiring the indwelling catheter to be retained. The\nwound drain was lifted once with serum-identical creatinine values and\nretained with persistent output (approximately 400 ml daily). Both\nkidneys were not dilated, and there were no signs of lymphocele or\nhematoma in the pelvic region on ultrasound. A follow-up rehabilitation\ntreatment has been organized through our social services. We discharged\nthe patient with absorbable intracutaneous sutures for further\noutpatient care.\n\n**Current Recommendations:** The patient was discharged with a permanent\ncatheter and will present on 01/03/2016 for cystogram and possibly\ncatheter removal. If catheter removal is indicated, we recommend\nconsidering a trial of voiding with subsequent admission if the\ncystogram is normal. The wound drain was also retained, and we request\ndocumentation of output. If output regresses and remains persistently \\<\n30-40 ml, and there is no ultrasound evidence of lymphocele, it could be\nremoved on an outpatient basis or during the follow-up appointment.\n\nWe recommend the first PSA check 6 -- 8 weeks postoperatively, followed\nby quarterly intervals. If the PSA level does not reach the zero range\nor rises again from the zero range, the patient can be offered\nradiotherapy of the prostatic bed and lymphatic drainage pathways in\ncombination with a 2-year hormonal ablative therapy as an individual\ntherapeutic trial. Alternatively, primary hormonal ablative therapy is\nan option. If the PSA level reaches the zero range, the patient may be\noffered adjuvant hormonal ablative therapy for 2 years, possibly\ncombined with radiotherapy. Additional findings will be discussed in our\npost-therapeutic conference. In case of changes in the recommended\nprocedure mentioned above, we will inform you again.\n\n**Course of the lab results:**\n\n **Parameter** **12/18/15** **12/19/15** **12/20/15** **12/23/15** **Reference Range**\n --------------------------- --------------- ---------------- --------------- -------------- ---------------------\n Sodium 135 mEq/L 138 mEq/L 136-145 mEq/L\n Potassium 5.1 mEq/L 4.4 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffe method) 0.93 mg/dL 1.05 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 83 65 \n Hemoglobin 11.4 g/dL 12.4 g/dL 12.5-17.2 g/dL\n Hematocrit 0.323 L/L 0.361 L/L 0.370-0.490 L/L\n Red Blood Cells 3.8 x10\\^12/L 4.3 x10\\^12/L 4.2 x10\\^12/L 4.0-5.7 x10\\^12/L\n White Blood Cells 9.57 x10\\^9/L 11.51 x10\\^9/L 9.65 x10\\^9/L 3.90-10.50 x10\\^9/L\n Platelets 216 x10\\^9/L 239 x10\\^9/L 285 x10\\^9/L 150-370 x10\\^9/L\n MCV 88.1 fL 86.0 fL 88.3 fL 80.0-101.0 fL\n MCH 30.2 pg 30.1 pg 29.5 pg 27.0-34.0 pg\n MCHC 34.5 g/dL 35.3 g/dL 33.8 g/dL 31.5-36.0 g/dL\n MPV 10.2 fL 10.4 fL 10.3 fL 7.0-12.0 fL\n RDW-CV 12.1% 12.2% 12.8% 11.6-14.4%\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about Mr. Ben Harder, born on 08/02/1940 who received\ninpatient treatment from 01/13/2016 to 01/19/2016.\n\n**Diagnosis:** Urinary Tract Infection in Patient with indwelling\ncatheter\n\n**Other Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n- Arterial hypertension\n\n- History of excision on the nose with suspicion of basal cell\n carcinoma\n\n- History of laparoscopic cholecystectomy\n\n**Medication upon Admission: **\n\n **Medication (Brand)** **Dosage** **Frequency**\n ------------------------------ ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan (Atacand) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multivitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Selenium 999 mcg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Thiamine 200 mg 1x/Week\n Pyridoxine 25 mg 2-3x/Week\n\n**Current presentation:** Mr. Harder returned to our clinic on\n01/13/2016, complaining of new-onset symptoms including increased\nurgency and frequency of urination, discomfort, lower abdominal pain,\nand fever. Given his recent surgery and indwelling catheter, concerns\nwere raised about a possible urinary tract infection.\n\n**Clinical Examination:** On physical examination, Mr. Harder appeared\nunwell. He had a temperature of 38.8°C, elevated heart rate\n(tachycardia), and mild lower abdominal tenderness on palpation. The\nindwelling urinary catheter was in situ, and no signs of catheter\ndislodgment or leakage were observed.\n\n**Ultrasound of the Abdomen upon admission:** Bilateral, no urinary\ntransport obstruction, approximately 4x2 cm-sized fluid collection noted\nin the right inguinal area, suggestive of possible lymphocele.\n\n**CT Scan Abdomen/Pelvic from 01/13/2016:** The liver displays a smooth\ncontour, with homogeneous parenchymal contrast enhancement, and no\nevidence of focal intrahepatic lesions. There is no indication of\nintrahepatic or extrahepatic cholestasis. History of previous\ncholecystectomy with an accentuated common hepatic duct. Spleen,\npancreas, and adrenal glands appear unremarkable. Both orthotopically\nlocated kidneys exhibit simultaneous and equal contrast enhancement. No\nintrarenal structural abnormalities or signs of urinary obstruction are\nobserved. The colonic frame and small intestine show adequate perfusion,\nwithout focal wall thickening. The stomach is distended. The urinary\nbladder contains a catheter. Two intraluminal air pockets are seen.\nKnown circumferential, uniform bladder wall thickening from previous\nexaminations. No free intrabdominal air is detected. No evidence of\nascites. Bilateral iliac and inguinal operative clips from prior\nlymphadenectomy. Right iliac region shows a serous fluid collection\nmeasuring approximately 3 x 2 cm. Para-aortic lymph nodes, up to 14 mm\nin size, are consistent with findings from previous evaluations. No\nsuspicious malignancy-related bone destruction is noted. A drainage tube\nhas been placed through the right lower abdominal wall, with its tip\nlocated in the left pelvic area.\n\n**Assessment:** No evidence of abscess formation. A lymphocele measuring\napproximately 3 x 2 cm is noted in the right iliac region, without signs\nof acute inflammation.\n\n**Microbiological Examination**\n\n**Material**: Catheter Urine Examination Request: Identification of\nPathogens and Resistance Results: Organism 1: Growth of 100,000 CFU/mL\nEnterococcus faecalis Possible ICD-10 Coding Suggestion: Enterococci as\nPathogen.\n\n- Acute Cystitis\n\n- Pyelonephritis\n\n- Urinary Tract Infection related to Catheter/Implant\n\n- Urinary Tract Infection, Unspecified Location\n\n**Antibiogram**\n\n- Gentamicin HL: S\n\n- Levofloxacin: R 1\n\n- Teicoplanin: S \\<=0.5\n\n- Ampicillin: S \\<=2\n\n- Piperacillin: S\n\n- Ampicillin/Sulbactam: S \\<=2\n\n- Piperacillin/Tazobactam: S\n\n- Imipenem: S \\<=1\n\n- Cefuroxim: R \\>=64\n\n- Gentamicin: R\n\n- Cotrimoxazole: R \\<=10\n\n- Ciprofloxacin: R \\<=0.5\n\n- Vancomycin: S 2\n\n- Linezolid: S 2\n\n- Tigecyclin: S \\<=0.12\n\n**Therapy and Progression:** After CT morphological exclusion of an\nabscess formation or retention, the wound drainage was removed under\nantibiotic coverage. Initially, empirical antibiotic therapy with\nCefuroxim was administered, followed by targeted treatment with oral\nUnacid based on resistance testing. The drainage insertion site healed\nprimarily. The bladder catheter was removed, after which urination was\nfree of residual urine. The patient has primary continence. We\ndischarged the patient to further outpatient treatment, with the patient\nreporting subjective well-being.\n\nMr. Harder showed gradual clinical improvement after initiating\nantibiotic therapy. His fever subsided, and lower abdominal tenderness\ndiminished. The IV fluids were discontinued, and he remained on oral\nantibiotics.\n\n**Urine Culture Results:** The urine culture results returned positive\nfor Escherichia coli (E. coli), a common uropathogen. The sensitivity\nprofile indicated susceptibility to ciprofloxacin.\n\n**Follow-Up:** Mr. Harder was closely monitored for the duration of his\nantibiotic course. He was advised to complete the full course of\nantibiotics and maintain adequate hydration. The urinary catheter was\nremoved on the fifth day of hospitalization after demonstrating improved\nurine output and resolution of symptoms. No further complications\nrelated to the catheter removal were observed.\n\n**Current Recommendations:**\n\n1. Please refer to the previous discharge letter for the procedure\n regarding prostate cancer.\n\n2. He was educated on the signs and symptoms of UTIs and instructed to\n seek prompt medical attention if symptoms recurred.\n\n**\\\n**\n\n\n\n### text_2\n**Dear colleague, **\n\nThank you for assigning Mr. Ben Harder, born on 08/02/1940 to the PET/CT\ncombination scanner examination on 12/11/2022.\n\n**Diagnoses:**\n\n- Initial diagnosis of prostate cancer in December 2015, confirmed by\n prostate biopsy.\n\n- Tumor detected in 11 out of 12 biopsy samples\n\n- Maximum Gleason score of 9\n\n- Preoperative PSA level: 5.42 ng/ml\n\n- In the initial PET/CT examination (preoperative) on 12/23/2015\n evidence of prostate cancer extending beyond the capsule in both\n prostatic lobes was found.\n\n- Infiltration of the left seminal vesicles and beginning infiltration\n of the right seminal vesicles\n\n- Multiple retroperitoneal lymph node metastases and bilateral pelvic\n lymph nodes.\n\n- Radical prostatectomy\n\n- Current PSA level: 1.23 ng/ml\n\n- Radiation therapy planned at our facility\n\n**Technique**: To expedite renal-urinary activity elimination, the\npatient was adequately hydrated. The examination was conducted using the\nPET/CT combination scanner BIOGRAPH 64 with CT parameters set at 120 kV\nand 1 mm slice thickness. PET emission data were acquired with 5 bed\npositions on a radiation therapy-compatible table for whole-body\nexamination in the caudocranial direction with transverse slices at 3.0\nmm intervals over the same axial range as the CT scan. Iterative\nreconstruction was performed. A whole-body scan was conducted 90 minutes\nafter the administration of 278 MBq Ga-68-PSMA (prostate-specific\nmembrane antigen). Transmissions-corrected and non-corrected PET scans,\nCT scans, fusion images, and the determination of the SUV value\n(standard uptake value, a measure of activity uptake per volume) were\nused for evaluation.\n\n**PET Findings:** The 3D whole-body images documented in 3 planes using\nPET and PET/CT technology showed the following changes compared to the\nprior examination on 12/23/2015:\n\n- Post-radical prostatectomy, there is diffuse activity accumulation\n in the region dorsal to the bladder, on the left side.\n\n- Regarding the known retroperitoneal lymph node metastases, the\n following changes were observed: New retrocrural nodule on the\n right. SUV 6.6, diameter: 6 mm.\n\n- Known interaortocaval lymph node, dorsally at the level of L3/4,\n showed increased metabolic activity from SUV 4.7 to 11.5. Slightly\n increased in size, measuring 7 to 8 mm. Additionally, two new\n metabolically active nodules cranially, up to the level of L2/3.\n\n- Slightly increased metabolic activity in the known right iliaca\n communis lymph node, located between the fifth lumbar vertebra and\n the psoas muscle, from 4.0 to 4.6, with the same size of 5 mm.\n\n- Progressive enlargement of the known confluent lymph nodes on the\n right parailiacal externa proximal side, now having a combined size\n of 10 x 26 mm (width x height), previously individual nodules of 10\n and 12 mm. SUV 18.2, previously max 11.5.\n\n- New paraaortic lymph nodes on the left, mostly small, SUV 11.2.\n\n- Newly added lymph nodes in both biiliac communal areas. Maximum size\n on the left is 15 mm, SUV 17.2.\n\n- New retrocrural lymph node on the right, measuring 6 mm, SUV 6.6.\n\n- Known lymph node on the right perirectal, slightly progressive from\n 8 to 10 mm. SUV 6.9, previously 6.4.\n\n- Known lymph node on the left iliaca externa not currently\n verifiable, possibly postoperative scarring.\n\n- Newly added focus in the bone at the level of the spinous\n process/dorsal arch of the fifth lumbar vertebra. In CT, a 7 mm\n focal sclerosis is noted. Normal activity accumulation in the soft\n tissues of the neck, axillae, and chest. Physiological accumulation\n in the parenchymal upper abdominal organs. Kidneys and urinary tract\n appear functionally normal. Whole-body CT following bolus-like\n peripheral venous machine injection of 100 ml of Optiray 350: No\n suspicious lymph nodes in the cervical, axillary, or mediastinal\n regions. Normal-sized thyroid gland. No pleuropulmonary infiltrates\n or round lesions. Scarred changes in the left lower lobe.\n Normal-sized liver without focal lesions. Spleen, pancreas, adrenal\n glands, and kidneys appear regular. No urinary obstruction..\n\n**Results**: In the postoperative PET/CT compared to the preoperative\nexamination on, there is now malignancy-typical PSMA receptor binding in\nthe former prostate lodge, indicating a local recurrence. Progression of\nretroperitoneal lymph node metastases, with further extension cranially,\nextending to the interaortocaval region up to the level of L2/3. Newly\nadded metastases on the left paraaortic and biiliac communal areas.\nProgression of known right iliaca externa lymph node metastases. The\nleft iliaca externa nodule is not verifiable, likely removed. New small\nretrocrural nodule on the right. New osteosclerotic metastasis in the\ndorsal arch of LWK 5. Minimal activity accumulation in the 8th rib on\nthe right lateral aspect. A developing metastasis cannot be conclusively\nruled out here. We kindly request information on the patient\\'s further\nclinical course (submission of medical reports, etc.).\n\n**Lab results**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Glucose (Plasma) 91 mg/dL 55-100 mg/dL\n Alkaline Phosphatase 93 U/L \\< 130 U/L\n Total Cholesterol 152 mg/dL \\< 200 mg/dL\n LDL-Cholesterol 89 mg/dL \\< 130 mg/dL\n HDL-Cholesterol 50 mg/dL 40-60 mg/dL\n Non-HDL Cholesterol 101.8 mg/dL \\< 200 mg/dL\n Triglycerides 64 mg/dL \\< 150 mg/dL\n White Blood Cells 4.1 K/uL 4.5-11 K/uL\n Red Blood Cells 4.68 M/uL 4.0-5.5 M/uL\n Hemoglobin 13.6 g/dL 12.5-17.2 g/dL\n Hematocrit 39.5% 37.0-49.0%\n MCH 29.1 pg 27.0-34.0 pg\n MCHC 34.4 g/dL 31.5-36.0 g/dL\n MCV 84.4 fL 80.0-101.0 fL\n RDW 13.0% 11.6-14.4%\n Platelets 238 K/uL 150-370 K/uL\n\n**\\\n**\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to provide an update on Mr. Ben Harder, born on\n08/02/1940, who received inpatient treatment at our facility from\n06/23/2023 to 06/26/2023.\n\n**Diagnosis:**\n\nProstate Cancer pT3b pN1 R1 L0 V0 Gleason Score: 4 + 5 = 9 (Initial\ndiagnosis in December 2015)\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015. Currently, lymph node and bone metastasis\n\n**Other Diagnoses:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015.\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n (thora 11 and 12) with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT in 06/2023 scan indicated new extensive metastasis in\n the sacrum and diffuse lung metastases, accompanied by a PSA level\n of 1.35 ng/ml.\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n**Medications on Admission:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Candesartan (Atacand) 16 mg 1-0-1-0\n Aspirin 100 mg 1-0-0-0\n Chlorthalidone (Thalitone) 25 mg 1-0-0-0\n\n**Physical Examination:** The patient was in good general condition and\nhad normal orientation to all qualities. There were no edemas, dyspnea,\nfever, or cough.\n\n**Medical History:** Mr. Hader presents himself for the 1st cycle of RLT\nwith Ac-225-PSMA/Lu-177-I&T-PSMA for lymph node and bone metastatic\nprostate cancer on an inpatient basis. In the presence of progressive\nimaging findings under guideline-compliant therapy, the indication for\nRLT tandem therapy was confirmed according to the tumor conference on.\nUpon admission, the patient reports feeling well, denies any B-symptoms.\nThere is no fever or nausea, and the weight is currently stable. There\nhas been a tendency to fall for some time. The rest of the medical\nhistory is assumed to be known.\n\n**Neurological Consultation on 06/25/2023: **\n\nClinically neurological examination revealed a polyneuropathy syndrome\nof the lower extremities, predominantly on the right side, as well as a\nknown right-sided foot drop. In summary, we consider the falls to be\nmultifactorial due to foot weakness as well as polyneuropathy syndrome\nwith impaired proprioception as the cause of the balance disorder.\nRecommended further procedure: In the presence of a known PNP syndrome\nthat has occurred during chemotherapy, consider outpatient neurological\nevaluation and objectification by means of Electromyography and\npolyneuropathy laboratory tests.\n\n**Salivary Gland Scintigraphy on 06/26/2023**\n\n**Assessment**: Normal function of the submandibular and parotid glands\nbilaterally.\n\nPost-therapeutic imaging with Lu-177-PSMA imaging using\nSPECT/low-dose-CT\n\n**Assessment:** Consistent with the PET-CT, there is no tracer uptake in\nthe area of the prostate. Intensive accumulation of the therapeutic\nagent in the area of lymph node metastases, especially mediastinal.\nCorresponding to the PET/CT, there are clear focal tracer accumulations\nin the left upper lobe of the lung in the area of nodular or diffuse\ntissue condensations, possibly metastases or, secondarily,\npost-inflammatory. Intensive tracer uptake in the area of known bone\nmetastases from the previous examination. No newly appearing\ntracer-enhancing lesions. In addition, physiological accumulation in the\norgan systems involved in tracer metabolism and excretion. NB: Small\npleural effusions on both sides. Known pronounced peribronchial cuffs in\nthe upper lobes on both sides, possibly scarred, or indicative of\npulmonary venous congestion. Known atrophic kidney on the right.\n\n**Current Recommendations:**\n\n- Blood count checks and determination of kidney and liver parameters\n 1, 2, 4, and 8 weeks after therapy\n\n- Outpatient neurologic assessment for the evaluation of\n polyneuropathy\n\n- PSA determination 6-8 weeks after therapy\n\n- Appointment for a 2nd cycle of radioligand therapy\n (Ac-225-/Lu-177-PSMA)\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Neutrophils (%) 72.2 % 42.0-77.0 %\n Lymphocytes (%) 8.6 % 20.0-44.0 %\n Monocytes (%) 11.6 % 2.0-9.5 %\n Basophils (%) 1.4 % 0.0-1.8 %\n Eosinophils (%) 6.0 % 0.5-5.5 %\n Immature Granulocytes (%) 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 2.31 mEq/L 2.20-2.55 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n C-reactive Protein 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 µg/L \\< 4.40 µg/L\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 µg/L 1.32-8.92 µg/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 0.285 L/L 0.370-0.490 L/L\n RBC 3.3 /pL 4.0-5.6 /pL\n WBC 4.98 /nL 3.90-10.50 /nL\n Platelets 281 /nL 150-370 /nL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Neutrophils (Absolute) 3.59 /nL 1.50-7.70 /nL\n Immature Granulocytes (Absolute) 0.010 /nL \\< 0.050 /nL\n Lymphocytes (Absolute) 0.43 /nL 1.10-4.50 /nL\n Monocytes (Absolute) 0.58 /nL 0.10-0.90 /nL\n Eosinophils (Absolute) 0.30 /nL 0.02-0.50 /nL\n Basophils (Absolute) 0.07 /nL 0.00-0.20 /nL\n Reticulocytes 31.3 /nL 25.0-105.0 /nL\n Reticulocyte (%) 0.94 % 0.50-2.00 %\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to report on our mutual patient, Mr. Ben Harder, born on\n08/02/1940, who presented himself to our outpatient clinic on 1/8/2023.\n\n**Diagnoses:**\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9 (initial\n diagnosis in 11/2015)\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally on\n 11/16/2015\n\n- Currently, there are lymph node and bone metastases\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Initial PSA level was 4.8 ng/ml\n\n- History of Docetaxel therapy\n\n- History of Cabazitaxel therapy\n\n- History of 4 cycles of Lutetium-Radioligand therapy\n\n- Subsequently, radiation therapy was initiated for the lymph node\n metastasis but discontinued after 11 sessions due to dyspnea and G3\n esophagitis.\n\n- Arterial hypertension\n\n- Chronic renal insufficiency\n\n- Type 2 diabetes mellitus\n\n**Treatment and Progression:** The patient presents for a second opinion\non his prostate cancer, which has metastasized to the bones and lymph\nnodes and has become castration-resistant. He recently received\nLutetium-Radioligand therapy. Genetic sequencing from the tissue biopsy\ndid not reveal any significant gene mutations. The patient wishes to\nundergo further evaluation for the diagnosis of relevant genetic\nmutations. A previously punctured subdiaphragmatic lymph node metastasis\nhas not yet undergone genetic testing, which may be justified based on\nthe available data and publications in specific cases. A chemotherapy\nsession with Cabazitaxel is planned for the end of January in the\ntreating urological practice. In cases of DNA repair gene alterations, a\nplatinum combination could also be considered. Further possible\ndiagnostic and therapeutic steps were discussed with the patient. An\napplication for a repeat genetic sequencing will be submitted by our\ncolleagues from the genetics department.\n\n**Current Recommendations:**\n\n- Application for genetic sequencing for the punctured lymph node\n metastasis through the genetics department and DNA-med\n\n- Subsequent re-genetic sequencing of the subdiaphragmatic lymph node\n metastasis for relevant mutations\n\n- After receiving the results, a follow-up appointment can be\n scheduled in our uro-oncology outpatient clinic.\n\n.\n\n**\\\n**\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting to you regarding the inpatient stay of our patient Mr.\nBen Harder, born on 08/02/1940. He was under our care from 09/16/2023 to\n09/23/2023.\n\n**Diagnosis**: Prostate Cancer pT3b pN1 R1 L0 V0\n\n- Gleason Score: 4 + 5 = 9\n\n- Postoperative status following retropubic radical prostatectomy\n without nerve preservation and with pelvic lymphadenectomy.\n\n- Currently presenting with lymph node and bone metastases, mCRPC\n (metastatic castration-resistant prostate cancer)\n\n- Initial PSA level: 4.8 ng/ml\n\n**Previous Treatment and Course:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects in 01/2023.\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT scan indicated new extensive metastasis in the sacrum\n and diffuse lung metastases, accompanied by a PSA level of 1.35\n ng/ml.\n\n- Current PET-CT not available. Recommendations for further treatment\n options are as follows, based on externally described\n image-morphological progression in the recent CT:\n\n 1. Actinium-225-PSMA Therapy (Lu-177 Tandem Therapy), provided that\n all vital metastases are PSMA-positive (mandatory exclusion of\n post-renal urinary flow obstruction)\n\n 2. Alternatively, consider initiating therapy with Abiraterone +\n Prednisolone or a Cabazitaxel re-challenge (if there was a\n favorable response to the last 2 cycles of Cabazitaxel\n\n 3. Evaluation of pre-screening for CAR-T cell studies in oncology\n at CBF (contact will be made)\n\n**Other Diagnoses:**\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n- Type 2 Diabetes Mellitus\n\n**Current Presentation:** Mr. Ben Harder is presenting for his 2nd cycle\nof Radioligand Therapy (RLT) with Ac-225-PSMA/Lu-177-I&T-PSMA for lymph\nnode and bone metastatic prostate cancer. In light of progressive\nimage-morphological findings despite guideline-compliant treatment, the\nindication for RLT tandem therapy was determined in the tumor\nconference.\n\n**Medical History:** Mr. Harder reports that after the last treatment\ncycle, he experienced pronounced fatigue symptoms. He particularly\nstruggled with climbing stairs and walking longer distances. However, he\nmanaged to fully recover from these symptoms through targeted training.\nAdditionally, he developed pain in the area of the right ribcage\nfollowing the last treatment cycle. The pain occurs intermittently and\nis accompanied by increased salivation and nausea, sometimes leading to\nvomiting. Mr. Ben Harder also reports newly developed swallowing\ndifficulties. He feels that food gets stuck in his throat after\nswallowing.\n\n**Therapy and Progression:**\n\nIn the case of Mr. Ben Harder, due to metastatic prostate cancer with\nradiographic progression despite previous guideline-recommended therapy,\naccording to the recommendations, there was an indication for the 2nd\nradioligand therapy with Ac-225-PSMA/Lu-177-I&T-PSMA. The\npost-therapeutic imaging showed targeted accumulation of the therapeutic\nagent within the tumor. The therapy was administered due to elevated\nrenal retention parameters with reduced activity of Lu-177-PSMA. The\ncourse of therapy and the entire hospital stay were uncomplicated, so we\ncan now transition the patient to your outpatient care. We recommend\nclose laboratory monitoring (blood count, liver and kidney parameters)\nat 1, 2, 4, and 8 weeks, as well as a PSA determination 6-8 weeks after\ntherapy.\n\nIn the case of significant fatigue symptoms after the 1st cycle of\ntandem RLT, if there are blood count changes indicating a decrease in\nhemoglobin levels and recurrent fatigue symptoms, the administration of\nerythropoietin or the indication for blood product transfusion should be\nconsidered. Depending on the PSA value 6 weeks post-therapy and the\nfindings of the PSMA-PET/CT, the further course of action will be\ndetermined in the interdisciplinary Tumor Conference.\n\nIf the patient desires, they can seek a second opinion on further\ntherapeutic procedures in the specialized clinic of the Uro-Oncology\ncolleagues. In case of pronounced rib pain, if requested by the patient,\nthe possibility of undergoing radiation therapy can be evaluated. To do\nso, Mr. Harder can schedule an appointment at the Radio-Oncology clinic.\nPsycho-oncological counseling has been offered to the patient.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan Cilexetil (Atacan) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multi-Vitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Sodium Selenite 999 µg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B Complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Vitamin B1 200 mg 1x/Week\n Vitamin B6 25 mg 2-3x/Week\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------------- ---------------------\n Neutrophils % 80.3 % 42.0-77.0 %\n Lymphocytes % 6.7 % 20.0-44.0 %\n Monocytes % 8.9 % 2.0-9.5 %\n Basophils % 1.3 % 0.0-1.8 %\n Eosinophils % 2.4 % 0.5-5.5 %\n Immature Granulocytes % 0.4 % 0.0-1.0 %\n I:T Ratio 0.005 \n HFLC Absolute 0.0 /µL \n Sodium 140 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Calcium 9.36 mg/dL 8.8-10.2 mg/dL\n Chloride 102 mEq/L 98-107 mEq/L\n Creatinine 1.25 P+ mg/dL 0.70-1.20 mg/dL\n Estimated GFR 52 mL/min/1.73m\\^2 \n BUN (Urea) 44 mg/dL 17-48 mg/dL\n Uric Acid 3.8 mg/dL 3.6-8.2 mg/dL\n CRP 1.3 mg/L \\< 5.0 mg/L\n PSA 2.98 ng/mL \\< 4.4 ng/mL\n ALT (GPT) 22 U/L \\< 41 U/L\n AST (GOT) 49 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 19 U/L 8-61 U/L\n LDH 404 P+ U/L 135-250 U/L\n Testosterone \\<0.03 P- ng/mL 1.32-8.92 ng/mL\n TSH 1.14 mIU/L 0.27-4.20 mIU/L\n Complete Blood Count \n Differential Count \n Hemoglobin 10.6 g/dL 12.5-17.2 g/dL\n Hematocrit 30.5 % 37.0-49.0 %\n RBC 3.4 M/µL 4.0-5.6 M/µL\n WBC 5.49 K/µL 3.90-10.50 K/µL\n Platelets 279 K/µL 150-370 K/µL\n MCV 88.7 fL 80.0-101.0 fL\n MCH 30.8 pg 27.0-34.0 pg\n MCHC 34.8 g/dL 31.5-36.0 g/dL\n MPV 10.1 fL 7.0-12.0 fL\n RDW-CV 14.1 % 11.5-15.0 %\n Absolute Neutrophils 4.41 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.020 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.37 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.49 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.13 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 37.8 K/µL 25.0-105.0 K/µL\n Reticulocyte Percentage 1.10 % 0.50-2.00 %\n Reticulocyte Production Index 0.4 \n Ret-Hb 35.0 pg 28.5-34.5 pg\n Prothrombin Time 117 % \\> 78 %\n INR 0.94 \\< 1.25\n aPTT 30.2 sec 25.0-38.0 sec\n\n\n\n\nHere is the query:\nWhat complication was identified in Mr. Harder during the neurological consultation on 06/25/2023?\n\nChoose the correct answer from the following options:\nA. Polyneuropathy syndrome of the upper extremities\nB. Acute renal failure\nC. Polyneuropathy syndrome of the lower extremities\nD. Myocardial infarction\nE. Stroke\n\n\nYour response:\n", "role": "user" }, { "content": "Polyneuropathy syndrome of the lower extremities", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Ben Harder, born on 08/02/1940, who was admitted\nto our hospital from 12/17/2015 to 12/27/2015.\n\n**Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Status post excision on the nose with suspicion of basal cell\n carcinoma\n\n- Status post laparoscopic cholecystectomy\n\n- Retropubic radical prostatectomy without nerve preservation and with\n bilateral pelvic lymphadenectomy was performed on 12/17/2015.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------- ---------------------------------------------------\n Valsartan (Diovan) 160 mg 1-0-1\n Aspirin 100 mg 1-0-1\n Simvastatin (Zocor) 15 mg 0-0-1\n Doxazosin (Cardura) 1 mg 0-0-1\n Enoxaparin (Lovenox) 0.6 mL s.c. Administer subcutaneously for a total of 4 weeks.\n Acetaminophen (Tylenol) 500 mg 1-1-1 (for 4 days)\n\n**Histopathology:**\n\n1. 2 adenocarcinoma metastases in 2 out of 4 lymph nodes, left external\n iliac region.\n\n2. 3 adenocarcinoma metastases in 3 out of 6 lymph nodes, right pelvic\n region.\n\n3. 7 adenocarcinoma metastases in 7 out of 7 lymph nodes, right lumbar\n para-aortic region.\n\n4. Acinar adenocarcinoma of the prostate is observed bilaterally, with\n a Gleason score of 4 (70%) + 5 (25%) = 9 and a tertiary Gleason\n grade of 3 (5%) according to the modified Gleason grading of the\n ISUP 2005. The tumor is multifocal and encompasses the entire\n prostate with a maximum extrapolated tumor extension of 60 mm. There\n is extracapsular tumor growth, with focal involvement at the dorsal\n right base. Vascular invasion is not noted, but perineural invasion\n is extensive. Both seminal vesicles are heavily infiltrated, and the\n resection margin of the left seminal vesicle is involved. Before\n tissue embedding, the margins of the specimen show focal\n infiltration by the tumor, in the right anterior region near the\n base (section 7) with a total contact area of 2 mm wide, and the\n primary Gleason grade at the positive margin is 4. In addition to\n the carcinoma, other prostatic tissue shows features of myoglandular\n hyperplasia and high-grade prostatic intraepithelial neoplasia\n (HGPIN). The prostatic urethra is free of tumors or dysplasia.\n\n5. **Tumor classification:** pT3bpN1(12/17), R1L0V0, Gleason: 4 + 5 = 9\n\n**Medical History:** Mr. Harder was admitted for open prostatectomy due\nto biopsy-confirmed prostate carcinoma.\n\nInitial PSA value: 5.42 ng/ml. Gleason score of biopsy: 4+5=9 in 11 out\nof 12 biopsy samples. Clinical tumor stage: cT2c PSMA PET-CT + MRI from\n12/23/2015: Left capsular penetration without rectal infiltration.\nSeminal vesicles are infiltrated on both sides. Evidence of multiple\nlymph nodes; intrapelvic locoregional and two lymph nodes on the right\nparailiacal and lumbar interaortocaval region.\n\nTRUS: 88 cc Digital Rectal Examination: Abnormal findings on the left\nside\n\n**Physical Examination:** The patient is in good general condition, has\na lean nutritional status, and reports feeling well. The abdomen is\nsoft, with no tenderness, masses, resistance, or guarding, and the\nexternal genitalia are unremarkable.\n\n**Ultrasound upon admission:** Both kidneys are not dilated and show no\nspace-occupying lesions. The bladder is minimally filled and appears\nunremarkable to the extent assessable.\n\n**Pretherapeutic Tumor Conference:** The findings were discussed\ninterdisciplinary, and the possible treatment options were explained.\nThe patient opted for radical prostatectomy.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complications. The postoperative course was uneventful. Blood\ntransfusions were not required. Unfortunately, a cystogram on revealed\nextravasation, requiring the indwelling catheter to be retained. The\nwound drain was lifted once with serum-identical creatinine values and\nretained with persistent output (approximately 400 ml daily). Both\nkidneys were not dilated, and there were no signs of lymphocele or\nhematoma in the pelvic region on ultrasound. A follow-up rehabilitation\ntreatment has been organized through our social services. We discharged\nthe patient with absorbable intracutaneous sutures for further\noutpatient care.\n\n**Current Recommendations:** The patient was discharged with a permanent\ncatheter and will present on 01/03/2016 for cystogram and possibly\ncatheter removal. If catheter removal is indicated, we recommend\nconsidering a trial of voiding with subsequent admission if the\ncystogram is normal. The wound drain was also retained, and we request\ndocumentation of output. If output regresses and remains persistently \\<\n30-40 ml, and there is no ultrasound evidence of lymphocele, it could be\nremoved on an outpatient basis or during the follow-up appointment.\n\nWe recommend the first PSA check 6 -- 8 weeks postoperatively, followed\nby quarterly intervals. If the PSA level does not reach the zero range\nor rises again from the zero range, the patient can be offered\nradiotherapy of the prostatic bed and lymphatic drainage pathways in\ncombination with a 2-year hormonal ablative therapy as an individual\ntherapeutic trial. Alternatively, primary hormonal ablative therapy is\nan option. If the PSA level reaches the zero range, the patient may be\noffered adjuvant hormonal ablative therapy for 2 years, possibly\ncombined with radiotherapy. Additional findings will be discussed in our\npost-therapeutic conference. In case of changes in the recommended\nprocedure mentioned above, we will inform you again.\n\n**Course of the lab results:**\n\n **Parameter** **12/18/15** **12/19/15** **12/20/15** **12/23/15** **Reference Range**\n --------------------------- --------------- ---------------- --------------- -------------- ---------------------\n Sodium 135 mEq/L 138 mEq/L 136-145 mEq/L\n Potassium 5.1 mEq/L 4.4 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffe method) 0.93 mg/dL 1.05 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 83 65 \n Hemoglobin 11.4 g/dL 12.4 g/dL 12.5-17.2 g/dL\n Hematocrit 0.323 L/L 0.361 L/L 0.370-0.490 L/L\n Red Blood Cells 3.8 x10\\^12/L 4.3 x10\\^12/L 4.2 x10\\^12/L 4.0-5.7 x10\\^12/L\n White Blood Cells 9.57 x10\\^9/L 11.51 x10\\^9/L 9.65 x10\\^9/L 3.90-10.50 x10\\^9/L\n Platelets 216 x10\\^9/L 239 x10\\^9/L 285 x10\\^9/L 150-370 x10\\^9/L\n MCV 88.1 fL 86.0 fL 88.3 fL 80.0-101.0 fL\n MCH 30.2 pg 30.1 pg 29.5 pg 27.0-34.0 pg\n MCHC 34.5 g/dL 35.3 g/dL 33.8 g/dL 31.5-36.0 g/dL\n MPV 10.2 fL 10.4 fL 10.3 fL 7.0-12.0 fL\n RDW-CV 12.1% 12.2% 12.8% 11.6-14.4%\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Ben Harder, born on 08/02/1940 who received\ninpatient treatment from 01/13/2016 to 01/19/2016.\n\n**Diagnosis:** Urinary Tract Infection in Patient with indwelling\ncatheter\n\n**Other Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n- Arterial hypertension\n\n- History of excision on the nose with suspicion of basal cell\n carcinoma\n\n- History of laparoscopic cholecystectomy\n\n**Medication upon Admission: **\n\n **Medication (Brand)** **Dosage** **Frequency**\n ------------------------------ ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan (Atacand) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multivitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Selenium 999 mcg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Thiamine 200 mg 1x/Week\n Pyridoxine 25 mg 2-3x/Week\n\n**Current presentation:** Mr. Harder returned to our clinic on\n01/13/2016, complaining of new-onset symptoms including increased\nurgency and frequency of urination, discomfort, lower abdominal pain,\nand fever. Given his recent surgery and indwelling catheter, concerns\nwere raised about a possible urinary tract infection.\n\n**Clinical Examination:** On physical examination, Mr. Harder appeared\nunwell. He had a temperature of 38.8°C, elevated heart rate\n(tachycardia), and mild lower abdominal tenderness on palpation. The\nindwelling urinary catheter was in situ, and no signs of catheter\ndislodgment or leakage were observed.\n\n**Ultrasound of the Abdomen upon admission:** Bilateral, no urinary\ntransport obstruction, approximately 4x2 cm-sized fluid collection noted\nin the right inguinal area, suggestive of possible lymphocele.\n\n**CT Scan Abdomen/Pelvic from 01/13/2016:** The liver displays a smooth\ncontour, with homogeneous parenchymal contrast enhancement, and no\nevidence of focal intrahepatic lesions. There is no indication of\nintrahepatic or extrahepatic cholestasis. History of previous\ncholecystectomy with an accentuated common hepatic duct. Spleen,\npancreas, and adrenal glands appear unremarkable. Both orthotopically\nlocated kidneys exhibit simultaneous and equal contrast enhancement. No\nintrarenal structural abnormalities or signs of urinary obstruction are\nobserved. The colonic frame and small intestine show adequate perfusion,\nwithout focal wall thickening. The stomach is distended. The urinary\nbladder contains a catheter. Two intraluminal air pockets are seen.\nKnown circumferential, uniform bladder wall thickening from previous\nexaminations. No free intrabdominal air is detected. No evidence of\nascites. Bilateral iliac and inguinal operative clips from prior\nlymphadenectomy. Right iliac region shows a serous fluid collection\nmeasuring approximately 3 x 2 cm. Para-aortic lymph nodes, up to 14 mm\nin size, are consistent with findings from previous evaluations. No\nsuspicious malignancy-related bone destruction is noted. A drainage tube\nhas been placed through the right lower abdominal wall, with its tip\nlocated in the left pelvic area.\n\n**Assessment:** No evidence of abscess formation. A lymphocele measuring\napproximately 3 x 2 cm is noted in the right iliac region, without signs\nof acute inflammation.\n\n**Microbiological Examination**\n\n**Material**: Catheter Urine Examination Request: Identification of\nPathogens and Resistance Results: Organism 1: Growth of 100,000 CFU/mL\nEnterococcus faecalis Possible ICD-10 Coding Suggestion: Enterococci as\nPathogen.\n\n- Acute Cystitis\n\n- Pyelonephritis\n\n- Urinary Tract Infection related to Catheter/Implant\n\n- Urinary Tract Infection, Unspecified Location\n\n**Antibiogram**\n\n- Gentamicin HL: S\n\n- Levofloxacin: R 1\n\n- Teicoplanin: S \\<=0.5\n\n- Ampicillin: S \\<=2\n\n- Piperacillin: S\n\n- Ampicillin/Sulbactam: S \\<=2\n\n- Piperacillin/Tazobactam: S\n\n- Imipenem: S \\<=1\n\n- Cefuroxim: R \\>=64\n\n- Gentamicin: R\n\n- Cotrimoxazole: R \\<=10\n\n- Ciprofloxacin: R \\<=0.5\n\n- Vancomycin: S 2\n\n- Linezolid: S 2\n\n- Tigecyclin: S \\<=0.12\n\n**Therapy and Progression:** After CT morphological exclusion of an\nabscess formation or retention, the wound drainage was removed under\nantibiotic coverage. Initially, empirical antibiotic therapy with\nCefuroxim was administered, followed by targeted treatment with oral\nUnacid based on resistance testing. The drainage insertion site healed\nprimarily. The bladder catheter was removed, after which urination was\nfree of residual urine. The patient has primary continence. We\ndischarged the patient to further outpatient treatment, with the patient\nreporting subjective well-being.\n\nMr. Harder showed gradual clinical improvement after initiating\nantibiotic therapy. His fever subsided, and lower abdominal tenderness\ndiminished. The IV fluids were discontinued, and he remained on oral\nantibiotics.\n\n**Urine Culture Results:** The urine culture results returned positive\nfor Escherichia coli (E. coli), a common uropathogen. The sensitivity\nprofile indicated susceptibility to ciprofloxacin.\n\n**Follow-Up:** Mr. Harder was closely monitored for the duration of his\nantibiotic course. He was advised to complete the full course of\nantibiotics and maintain adequate hydration. The urinary catheter was\nremoved on the fifth day of hospitalization after demonstrating improved\nurine output and resolution of symptoms. No further complications\nrelated to the catheter removal were observed.\n\n**Current Recommendations:**\n\n1. Please refer to the previous discharge letter for the procedure\n regarding prostate cancer.\n\n2. He was educated on the signs and symptoms of UTIs and instructed to\n seek prompt medical attention if symptoms recurred.\n\n**\\\n**\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nThank you for assigning Mr. Ben Harder, born on 08/02/1940 to the PET/CT\ncombination scanner examination on 12/11/2022.\n\n**Diagnoses:**\n\n- Initial diagnosis of prostate cancer in December 2015, confirmed by\n prostate biopsy.\n\n- Tumor detected in 11 out of 12 biopsy samples\n\n- Maximum Gleason score of 9\n\n- Preoperative PSA level: 5.42 ng/ml\n\n- In the initial PET/CT examination (preoperative) on 12/23/2015\n evidence of prostate cancer extending beyond the capsule in both\n prostatic lobes was found.\n\n- Infiltration of the left seminal vesicles and beginning infiltration\n of the right seminal vesicles\n\n- Multiple retroperitoneal lymph node metastases and bilateral pelvic\n lymph nodes.\n\n- Radical prostatectomy\n\n- Current PSA level: 1.23 ng/ml\n\n- Radiation therapy planned at our facility\n\n**Technique**: To expedite renal-urinary activity elimination, the\npatient was adequately hydrated. The examination was conducted using the\nPET/CT combination scanner BIOGRAPH 64 with CT parameters set at 120 kV\nand 1 mm slice thickness. PET emission data were acquired with 5 bed\npositions on a radiation therapy-compatible table for whole-body\nexamination in the caudocranial direction with transverse slices at 3.0\nmm intervals over the same axial range as the CT scan. Iterative\nreconstruction was performed. A whole-body scan was conducted 90 minutes\nafter the administration of 278 MBq Ga-68-PSMA (prostate-specific\nmembrane antigen). Transmissions-corrected and non-corrected PET scans,\nCT scans, fusion images, and the determination of the SUV value\n(standard uptake value, a measure of activity uptake per volume) were\nused for evaluation.\n\n**PET Findings:** The 3D whole-body images documented in 3 planes using\nPET and PET/CT technology showed the following changes compared to the\nprior examination on 12/23/2015:\n\n- Post-radical prostatectomy, there is diffuse activity accumulation\n in the region dorsal to the bladder, on the left side.\n\n- Regarding the known retroperitoneal lymph node metastases, the\n following changes were observed: New retrocrural nodule on the\n right. SUV 6.6, diameter: 6 mm.\n\n- Known interaortocaval lymph node, dorsally at the level of L3/4,\n showed increased metabolic activity from SUV 4.7 to 11.5. Slightly\n increased in size, measuring 7 to 8 mm. Additionally, two new\n metabolically active nodules cranially, up to the level of L2/3.\n\n- Slightly increased metabolic activity in the known right iliaca\n communis lymph node, located between the fifth lumbar vertebra and\n the psoas muscle, from 4.0 to 4.6, with the same size of 5 mm.\n\n- Progressive enlargement of the known confluent lymph nodes on the\n right parailiacal externa proximal side, now having a combined size\n of 10 x 26 mm (width x height), previously individual nodules of 10\n and 12 mm. SUV 18.2, previously max 11.5.\n\n- New paraaortic lymph nodes on the left, mostly small, SUV 11.2.\n\n- Newly added lymph nodes in both biiliac communal areas. Maximum size\n on the left is 15 mm, SUV 17.2.\n\n- New retrocrural lymph node on the right, measuring 6 mm, SUV 6.6.\n\n- Known lymph node on the right perirectal, slightly progressive from\n 8 to 10 mm. SUV 6.9, previously 6.4.\n\n- Known lymph node on the left iliaca externa not currently\n verifiable, possibly postoperative scarring.\n\n- Newly added focus in the bone at the level of the spinous\n process/dorsal arch of the fifth lumbar vertebra. In CT, a 7 mm\n focal sclerosis is noted. Normal activity accumulation in the soft\n tissues of the neck, axillae, and chest. Physiological accumulation\n in the parenchymal upper abdominal organs. Kidneys and urinary tract\n appear functionally normal. Whole-body CT following bolus-like\n peripheral venous machine injection of 100 ml of Optiray 350: No\n suspicious lymph nodes in the cervical, axillary, or mediastinal\n regions. Normal-sized thyroid gland. No pleuropulmonary infiltrates\n or round lesions. Scarred changes in the left lower lobe.\n Normal-sized liver without focal lesions. Spleen, pancreas, adrenal\n glands, and kidneys appear regular. No urinary obstruction..\n\n**Results**: In the postoperative PET/CT compared to the preoperative\nexamination on, there is now malignancy-typical PSMA receptor binding in\nthe former prostate lodge, indicating a local recurrence. Progression of\nretroperitoneal lymph node metastases, with further extension cranially,\nextending to the interaortocaval region up to the level of L2/3. Newly\nadded metastases on the left paraaortic and biiliac communal areas.\nProgression of known right iliaca externa lymph node metastases. The\nleft iliaca externa nodule is not verifiable, likely removed. New small\nretrocrural nodule on the right. New osteosclerotic metastasis in the\ndorsal arch of LWK 5. Minimal activity accumulation in the 8th rib on\nthe right lateral aspect. A developing metastasis cannot be conclusively\nruled out here. We kindly request information on the patient\\'s further\nclinical course (submission of medical reports, etc.).\n\n**Lab results**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Glucose (Plasma) 91 mg/dL 55-100 mg/dL\n Alkaline Phosphatase 93 U/L \\< 130 U/L\n Total Cholesterol 152 mg/dL \\< 200 mg/dL\n LDL-Cholesterol 89 mg/dL \\< 130 mg/dL\n HDL-Cholesterol 50 mg/dL 40-60 mg/dL\n Non-HDL Cholesterol 101.8 mg/dL \\< 200 mg/dL\n Triglycerides 64 mg/dL \\< 150 mg/dL\n White Blood Cells 4.1 K/uL 4.5-11 K/uL\n Red Blood Cells 4.68 M/uL 4.0-5.5 M/uL\n Hemoglobin 13.6 g/dL 12.5-17.2 g/dL\n Hematocrit 39.5% 37.0-49.0%\n MCH 29.1 pg 27.0-34.0 pg\n MCHC 34.4 g/dL 31.5-36.0 g/dL\n MCV 84.4 fL 80.0-101.0 fL\n RDW 13.0% 11.6-14.4%\n Platelets 238 K/uL 150-370 K/uL\n\n**\\\n**\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mr. Ben Harder, born on\n08/02/1940, who received inpatient treatment at our facility from\n06/23/2023 to 06/26/2023.\n\n**Diagnosis:**\n\nProstate Cancer pT3b pN1 R1 L0 V0 Gleason Score: 4 + 5 = 9 (Initial\ndiagnosis in December 2015)\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015. Currently, lymph node and bone metastasis\n\n**Other Diagnoses:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015.\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n (thora 11 and 12) with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT in 06/2023 scan indicated new extensive metastasis in\n the sacrum and diffuse lung metastases, accompanied by a PSA level\n of 1.35 ng/ml.\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n**Medications on Admission:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Candesartan (Atacand) 16 mg 1-0-1-0\n Aspirin 100 mg 1-0-0-0\n Chlorthalidone (Thalitone) 25 mg 1-0-0-0\n\n**Physical Examination:** The patient was in good general condition and\nhad normal orientation to all qualities. There were no edemas, dyspnea,\nfever, or cough.\n\n**Medical History:** Mr. Hader presents himself for the 1st cycle of RLT\nwith Ac-225-PSMA/Lu-177-I&T-PSMA for lymph node and bone metastatic\nprostate cancer on an inpatient basis. In the presence of progressive\nimaging findings under guideline-compliant therapy, the indication for\nRLT tandem therapy was confirmed according to the tumor conference on.\nUpon admission, the patient reports feeling well, denies any B-symptoms.\nThere is no fever or nausea, and the weight is currently stable. There\nhas been a tendency to fall for some time. The rest of the medical\nhistory is assumed to be known.\n\n**Neurological Consultation on 06/25/2023: **\n\nClinically neurological examination revealed a polyneuropathy syndrome\nof the lower extremities, predominantly on the right side, as well as a\nknown right-sided foot drop. In summary, we consider the falls to be\nmultifactorial due to foot weakness as well as polyneuropathy syndrome\nwith impaired proprioception as the cause of the balance disorder.\nRecommended further procedure: In the presence of a known PNP syndrome\nthat has occurred during chemotherapy, consider outpatient neurological\nevaluation and objectification by means of Electromyography and\npolyneuropathy laboratory tests.\n\n**Salivary Gland Scintigraphy on 06/26/2023**\n\n**Assessment**: Normal function of the submandibular and parotid glands\nbilaterally.\n\nPost-therapeutic imaging with Lu-177-PSMA imaging using\nSPECT/low-dose-CT\n\n**Assessment:** Consistent with the PET-CT, there is no tracer uptake in\nthe area of the prostate. Intensive accumulation of the therapeutic\nagent in the area of lymph node metastases, especially mediastinal.\nCorresponding to the PET/CT, there are clear focal tracer accumulations\nin the left upper lobe of the lung in the area of nodular or diffuse\ntissue condensations, possibly metastases or, secondarily,\npost-inflammatory. Intensive tracer uptake in the area of known bone\nmetastases from the previous examination. No newly appearing\ntracer-enhancing lesions. In addition, physiological accumulation in the\norgan systems involved in tracer metabolism and excretion. NB: Small\npleural effusions on both sides. Known pronounced peribronchial cuffs in\nthe upper lobes on both sides, possibly scarred, or indicative of\npulmonary venous congestion. Known atrophic kidney on the right.\n\n**Current Recommendations:**\n\n- Blood count checks and determination of kidney and liver parameters\n 1, 2, 4, and 8 weeks after therapy\n\n- Outpatient neurologic assessment for the evaluation of\n polyneuropathy\n\n- PSA determination 6-8 weeks after therapy\n\n- Appointment for a 2nd cycle of radioligand therapy\n (Ac-225-/Lu-177-PSMA)\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Neutrophils (%) 72.2 % 42.0-77.0 %\n Lymphocytes (%) 8.6 % 20.0-44.0 %\n Monocytes (%) 11.6 % 2.0-9.5 %\n Basophils (%) 1.4 % 0.0-1.8 %\n Eosinophils (%) 6.0 % 0.5-5.5 %\n Immature Granulocytes (%) 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 2.31 mEq/L 2.20-2.55 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n C-reactive Protein 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 µg/L \\< 4.40 µg/L\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 µg/L 1.32-8.92 µg/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 0.285 L/L 0.370-0.490 L/L\n RBC 3.3 /pL 4.0-5.6 /pL\n WBC 4.98 /nL 3.90-10.50 /nL\n Platelets 281 /nL 150-370 /nL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Neutrophils (Absolute) 3.59 /nL 1.50-7.70 /nL\n Immature Granulocytes (Absolute) 0.010 /nL \\< 0.050 /nL\n Lymphocytes (Absolute) 0.43 /nL 1.10-4.50 /nL\n Monocytes (Absolute) 0.58 /nL 0.10-0.90 /nL\n Eosinophils (Absolute) 0.30 /nL 0.02-0.50 /nL\n Basophils (Absolute) 0.07 /nL 0.00-0.20 /nL\n Reticulocytes 31.3 /nL 25.0-105.0 /nL\n Reticulocyte (%) 0.94 % 0.50-2.00 %\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to report on our mutual patient, Mr. Ben Harder, born on\n08/02/1940, who presented himself to our outpatient clinic on 1/8/2023.\n\n**Diagnoses:**\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9 (initial\n diagnosis in 11/2015)\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally on\n 11/16/2015\n\n- Currently, there are lymph node and bone metastases\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Initial PSA level was 4.8 ng/ml\n\n- History of Docetaxel therapy\n\n- History of Cabazitaxel therapy\n\n- History of 4 cycles of Lutetium-Radioligand therapy\n\n- Subsequently, radiation therapy was initiated for the lymph node\n metastasis but discontinued after 11 sessions due to dyspnea and G3\n esophagitis.\n\n- Arterial hypertension\n\n- Chronic renal insufficiency\n\n- Type 2 diabetes mellitus\n\n**Treatment and Progression:** The patient presents for a second opinion\non his prostate cancer, which has metastasized to the bones and lymph\nnodes and has become castration-resistant. He recently received\nLutetium-Radioligand therapy. Genetic sequencing from the tissue biopsy\ndid not reveal any significant gene mutations. The patient wishes to\nundergo further evaluation for the diagnosis of relevant genetic\nmutations. A previously punctured subdiaphragmatic lymph node metastasis\nhas not yet undergone genetic testing, which may be justified based on\nthe available data and publications in specific cases. A chemotherapy\nsession with Cabazitaxel is planned for the end of January in the\ntreating urological practice. In cases of DNA repair gene alterations, a\nplatinum combination could also be considered. Further possible\ndiagnostic and therapeutic steps were discussed with the patient. An\napplication for a repeat genetic sequencing will be submitted by our\ncolleagues from the genetics department.\n\n**Current Recommendations:**\n\n- Application for genetic sequencing for the punctured lymph node\n metastasis through the genetics department and DNA-med\n\n- Subsequent re-genetic sequencing of the subdiaphragmatic lymph node\n metastasis for relevant mutations\n\n- After receiving the results, a follow-up appointment can be\n scheduled in our uro-oncology outpatient clinic.\n\n.\n\n**\\\n**\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting to you regarding the inpatient stay of our patient Mr.\nBen Harder, born on 08/02/1940. He was under our care from 09/16/2023 to\n09/23/2023.\n\n**Diagnosis**: Prostate Cancer pT3b pN1 R1 L0 V0\n\n- Gleason Score: 4 + 5 = 9\n\n- Postoperative status following retropubic radical prostatectomy\n without nerve preservation and with pelvic lymphadenectomy.\n\n- Currently presenting with lymph node and bone metastases, mCRPC\n (metastatic castration-resistant prostate cancer)\n\n- Initial PSA level: 4.8 ng/ml\n\n**Previous Treatment and Course:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects in 01/2023.\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT scan indicated new extensive metastasis in the sacrum\n and diffuse lung metastases, accompanied by a PSA level of 1.35\n ng/ml.\n\n- Current PET-CT not available. Recommendations for further treatment\n options are as follows, based on externally described\n image-morphological progression in the recent CT:\n\n 1. Actinium-225-PSMA Therapy (Lu-177 Tandem Therapy), provided that\n all vital metastases are PSMA-positive (mandatory exclusion of\n post-renal urinary flow obstruction)\n\n 2. Alternatively, consider initiating therapy with Abiraterone +\n Prednisolone or a Cabazitaxel re-challenge (if there was a\n favorable response to the last 2 cycles of Cabazitaxel\n\n 3. Evaluation of pre-screening for CAR-T cell studies in oncology\n at CBF (contact will be made)\n\n**Other Diagnoses:**\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n- Type 2 Diabetes Mellitus\n\n**Current Presentation:** Mr. Ben Harder is presenting for his 2nd cycle\nof Radioligand Therapy (RLT) with Ac-225-PSMA/Lu-177-I&T-PSMA for lymph\nnode and bone metastatic prostate cancer. In light of progressive\nimage-morphological findings despite guideline-compliant treatment, the\nindication for RLT tandem therapy was determined in the tumor\nconference.\n\n**Medical History:** Mr. Harder reports that after the last treatment\ncycle, he experienced pronounced fatigue symptoms. He particularly\nstruggled with climbing stairs and walking longer distances. However, he\nmanaged to fully recover from these symptoms through targeted training.\nAdditionally, he developed pain in the area of the right ribcage\nfollowing the last treatment cycle. The pain occurs intermittently and\nis accompanied by increased salivation and nausea, sometimes leading to\nvomiting. Mr. Ben Harder also reports newly developed swallowing\ndifficulties. He feels that food gets stuck in his throat after\nswallowing.\n\n**Therapy and Progression:**\n\nIn the case of Mr. Ben Harder, due to metastatic prostate cancer with\nradiographic progression despite previous guideline-recommended therapy,\naccording to the recommendations, there was an indication for the 2nd\nradioligand therapy with Ac-225-PSMA/Lu-177-I&T-PSMA. The\npost-therapeutic imaging showed targeted accumulation of the therapeutic\nagent within the tumor. The therapy was administered due to elevated\nrenal retention parameters with reduced activity of Lu-177-PSMA. The\ncourse of therapy and the entire hospital stay were uncomplicated, so we\ncan now transition the patient to your outpatient care. We recommend\nclose laboratory monitoring (blood count, liver and kidney parameters)\nat 1, 2, 4, and 8 weeks, as well as a PSA determination 6-8 weeks after\ntherapy.\n\nIn the case of significant fatigue symptoms after the 1st cycle of\ntandem RLT, if there are blood count changes indicating a decrease in\nhemoglobin levels and recurrent fatigue symptoms, the administration of\nerythropoietin or the indication for blood product transfusion should be\nconsidered. Depending on the PSA value 6 weeks post-therapy and the\nfindings of the PSMA-PET/CT, the further course of action will be\ndetermined in the interdisciplinary Tumor Conference.\n\nIf the patient desires, they can seek a second opinion on further\ntherapeutic procedures in the specialized clinic of the Uro-Oncology\ncolleagues. In case of pronounced rib pain, if requested by the patient,\nthe possibility of undergoing radiation therapy can be evaluated. To do\nso, Mr. Harder can schedule an appointment at the Radio-Oncology clinic.\nPsycho-oncological counseling has been offered to the patient.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan Cilexetil (Atacan) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multi-Vitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Sodium Selenite 999 µg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B Complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Vitamin B1 200 mg 1x/Week\n Vitamin B6 25 mg 2-3x/Week\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------------- ---------------------\n Neutrophils % 80.3 % 42.0-77.0 %\n Lymphocytes % 6.7 % 20.0-44.0 %\n Monocytes % 8.9 % 2.0-9.5 %\n Basophils % 1.3 % 0.0-1.8 %\n Eosinophils % 2.4 % 0.5-5.5 %\n Immature Granulocytes % 0.4 % 0.0-1.0 %\n I:T Ratio 0.005 \n HFLC Absolute 0.0 /µL \n Sodium 140 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Calcium 9.36 mg/dL 8.8-10.2 mg/dL\n Chloride 102 mEq/L 98-107 mEq/L\n Creatinine 1.25 P+ mg/dL 0.70-1.20 mg/dL\n Estimated GFR 52 mL/min/1.73m\\^2 \n BUN (Urea) 44 mg/dL 17-48 mg/dL\n Uric Acid 3.8 mg/dL 3.6-8.2 mg/dL\n CRP 1.3 mg/L \\< 5.0 mg/L\n PSA 2.98 ng/mL \\< 4.4 ng/mL\n ALT (GPT) 22 U/L \\< 41 U/L\n AST (GOT) 49 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 19 U/L 8-61 U/L\n LDH 404 P+ U/L 135-250 U/L\n Testosterone \\<0.03 P- ng/mL 1.32-8.92 ng/mL\n TSH 1.14 mIU/L 0.27-4.20 mIU/L\n Complete Blood Count \n Differential Count \n Hemoglobin 10.6 g/dL 12.5-17.2 g/dL\n Hematocrit 30.5 % 37.0-49.0 %\n RBC 3.4 M/µL 4.0-5.6 M/µL\n WBC 5.49 K/µL 3.90-10.50 K/µL\n Platelets 279 K/µL 150-370 K/µL\n MCV 88.7 fL 80.0-101.0 fL\n MCH 30.8 pg 27.0-34.0 pg\n MCHC 34.8 g/dL 31.5-36.0 g/dL\n MPV 10.1 fL 7.0-12.0 fL\n RDW-CV 14.1 % 11.5-15.0 %\n Absolute Neutrophils 4.41 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.020 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.37 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.49 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.13 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 37.8 K/µL 25.0-105.0 K/µL\n Reticulocyte Percentage 1.10 % 0.50-2.00 %\n Reticulocyte Production Index 0.4 \n Ret-Hb 35.0 pg 28.5-34.5 pg\n Prothrombin Time 117 % \\> 78 %\n INR 0.94 \\< 1.25\n aPTT 30.2 sec 25.0-38.0 sec\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n\n\n\n\nHere is the query:\nRegarding Mr. Rudolph, what was the date of the cytological report?\n\nChoose the correct answer from the following options:\nA. 01/12/2019\nB. 01/16/2019\nC. 02/01/2019\nD. 03/05/2019\nE. 03/20/2019\n\n\nYour response:\n", "role": "user" }, { "content": "01/16/2019", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report to you about Mrs. Linda Mayer, born on 01/12/1948, who\npresented to our outpatient clinic on 07/13/19.\n\n**Diagnoses:**\n\n- BIRADS IV, recommended biopsy during breast diagnostics.\n\n- Left breast carcinoma: iT1b; iN0; MX; ER: 12/12; PR: 2/12; Her-2:\n neg; Ki67: 15%.\n\n**Other Diagnoses: **\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Pemphigus vulgaris under azathioprine therapy\n\n- Osteoporosis\n\n- Obesity with a BMI of 35\n\n- Undergoing immunosuppressive therapy with prednisolone\n\n**Family History:**\n\n- Sister deceased at age 39 from breast cancer.\n\n- Mother and grandmother (maternal and paternal) were diagnosed with\n breast cancer.\n\n**Medical History:** The CT thorax report indicates the presence of\ninflammatory foci, warranting further follow-up. The relevant data was\ndocumented and presented during the tumor conference. Subsequently, a\ntelephone conversation was conducted with the patient to discuss the\nnext steps.\n\n**Tumor board decision from 07/13/2019:**\n\n**Imaging: **\n\n1) MRI examination detected a unifocal lesion on the left external\n aspect, measuring approximately 2.4 cm in size.\n\n2) CT scan (thorax/abdomen 07/12/2019) revealed a previously known\n liver lesion, likely a hemangioma. No evidence of metastases was\n identified. Nonspecific, small foci were observed in the lungs,\n likely indicative of post-inflammatory changes.\n\n**Recommendations:**\n\n1. If no metastasis (M0): Fast-track BRCA testing is recommended.\n\n2. If BRCA testing returns negative: Proceed with a selective excision\n of the left breast after ultrasound-guided fine needle marking and\n sentinel lymph node biopsy on the left side. Additionally, perform\n Endopredict analysis on the surgical specimen.\n\n**Current Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ------------------------------- ------------ ----------- ---------------\n Aspirin 100mg Oral 1-0-0\n Simvastatin (Zocor) 40mg Oral 0-1-0\n Haloperidol (Haldol) 100mg Oral ½-0-½\n Zopiclone (Imovane) 7.5mg Oral 0-0-1\n Trazodone (Desyrel) 100mg Oral 0-0-½-\n Calcium Supplement (Caltrate) 500mg Oral 1-0-1\n Nystatin (Bio-Statin) As advised Oral 1-1-1-1\n Pantoprazole (Protonix) 40mg Oral 1-0-0\n Prednisolone (Prelone) 40mg Oral As advised\n Tramadol/Naloxone (Ultram) 50/4mg Oral 1-0-1\n Acyclovir (Zovirax) 800mg Oral 1-1-1\n\n**Mammography and Tomosynthesis from 07/8/2019:**\n\n[Findings]{.underline}**: **During the inspection and palpation, no\nsignificant findings were noted on either side. Some areas with higher\nmammographic density were observed, which slightly limited the\nassessment. However, during the initial examination, a small\narchitectural irregularity was identified on the outer left side. This\nirregularity appeared as a small, roundish compression measuring\napproximately 6mm and was visible only in the medio-lateral oblique\nimage, with a nipple distance of 8cm. Apart from this discovery, there\nwere no other suspicious focal findings on either side. No clustered or\nirregular microcalcifications were detected. Additionally, a long-term,\nunchanged observation noted some asymmetry with denser breast tissue\npresent on both sides, particularly on the outer aspects. Sonographic\nevaluation posed challenges due to the mixed echogenic glandular tissue.\nAs a possible corresponding feature to the questionable architectural\nirregularity on the outer left side, a blurred, echo-poor area with a\nvertical alignment measuring about 7x5mm was identified. Importantly, no\nother suspicious focal findings were observed, and there was no evidence\nof enlarged lymph nodes in the axilla on both sides.\n\n[Assessment]{.underline}**:** The observed finding on the left side\npresents an uncertain nature, categorized as BIRADS IVb. In contrast,\nthe finding on the right side appears benign, categorized as BIRADS II.\nTo gain a more conclusive understanding of the left-sided finding, we\nrecommend a histological assessment through a sonographically guided\nhigh-speed punch biopsy. An appointment has been scheduled with the\npatient to proceed with this biopsy and obtain a definitive\ndiagnosis.Formularbeginn\n\nFormularende**Current Recommendations:**\\\nA fast-track decision will be made regarding tumor genetics, and the\npatient will be notified of the appointment via telephone. The patient\nshould bring the pathology blocks from Fairview Clinic on the day of\nblood collection for genetic testing, along with a referral for an\nEndopredict test. A multidisciplinary team meeting will be convened\nafter the Endopredict test and genetic testing results are available. If\nthere is persistence or worsening of symptoms, we strongly advise the\npatient to seek immediate re-evaluation. Additionally, outside of\nregular office hours, the patient can seek assistance at the emergency\ncare unit in case of emergency.\n\n**MRI from 07/11/2019:**\n\n[Technique:]{.underline} Breast MRI (3T scanner) with dedicated mammary\nsurface coil: \n\n[Findings:]{.underline} The overall contrast enhancement was observed\nbilaterally to evaluate the Grade II findings. There was low to moderate\nsmall-spotted contrast enhancement with slightly limited assessability.\nThe contrast dynamics revealed a patchy, confluent, blurred, and\nelongated contrast enhancement, corresponding to the primary lesion,\nwhich measured approximately 2.4 cm on the lower left exterior. Single\nspicules were noted, and the lesion appeared hypointense in T1w imaging.\nNo suspicious focal findings with contrast enhancement were detected on\nthe right side. Small axillary lymph nodes were observed on the left\nside, but they did not appear suspicious based on MR morphology.\nAdditionally, there were no suspicious lymph nodes on the right side.\n\n[Assessment:]{.underline} An unifocal primary lesion measuring\napproximately 2.4 cm in diameter was identified on the lower left\nexterior. It exhibited patchy confluent enhancement and architectural\ndisturbance, with single spicules. No evidence of suspicious lymph nodes\nwas found. The left side is categorized as BIRADS 6, indicating a high\nsuspicion of malignancy, while the right side is categorized as BIRADS\n2, indicating a benign finding.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide you with an update on the medical condition of\nMrs. Linda Mayer, born on 01/12/1948, who attended our outpatient clinic\non 08/02/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast (17mm)\n\n- Histological grade G3, estrogen receptor (ER) and progesterone\n receptor (PR) negative.\n\n- Postmenopausal for the past eight years.\n\n- Previous surgical history includes an appendectomy.\n\n- Allergies: Hay fever\n\n \n\n**Current Presentation**: The patient sought consultation following a\nconfirmed diagnosis of DCIS (Ductal Carcinoma In Situ) in the right\nbreast, which was determined through a vacuum-assisted biopsy.\n\n**Physical Examination**: Upon physical examination, there is evidence\nof a post-intervention hematoma located in the upper right quadrant of\nthe right breast. However, the clip from the biopsy is not clearly\nvisible. A sonographic examination of the right axilla reveals no\nabnormalities.\n\n**Current Recommendations:**\n\n- Imaging studies have been conducted.\n\n- A case presentation is scheduled for our mammary conference\n tomorrow.\n\n- Subsequently, planning for surgery will commence, including the\n evaluation of sentinel lymph nodes following a right mastectomy and\n axillary lymph node dissection.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient care at our facility on 08/29/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast, measuring 17mm in size, classified as Grade 3, and\n testing negative for estrogen receptors (ER) and progesterone\n receptors (PR).\n\n- Mrs. Mayer has been postmenopausal for eight years.\n\n- Notable allergy: Hay fever\n\n**Tumor Board Decision:** Mammography imaging revealed a clip associated\nwith a focal finding in the right breast adjacent to calcifications.\n\n[Recommendation]{.underline}: Proceed with sentinel lymph node\nevaluation after right mastectomy, including clip localization on the\nright side.\n\n**Current Presentation**: During the patient\\'s recent outpatient visit,\nan extensive pre-operative consultation was conducted. This discussion\ncovered the indications for the surgery, details of the surgical\nprocess, potential alternative options, as well as general and specific\nrisks associated with the procedure. These risks included the\npossibility of an aesthetically suboptimal outcome and the chance of\nencountering an R1 situation. The patient did not have any further\nquestions and provided written consent for the procedure.\n\n**Physical Examination:** Both breasts appear normal upon inspection and\npalpation. The right axilla shows no abnormalities.\n\n**Medical History:** Mrs. Linda Mayer presented to our clinic with a\nvacuum biopsy-confirmed DCIS of the right breast for therapeutic\nintervention. The decision for surgery was reached following a\ncomprehensive review by our interdisciplinary breast board. After an\nextensive discussion of the procedure\\'s scope, associated risks, and\nalternative options, the patient provided informed consent for the\nproposed surgery.\n\n**Preoperative Procedure:** Sonographic and mammographic fine needle\nmarking of the remaining findings and the clip in the right breast.\n\n**Surgical Report:** Team time-out conducted with colleagues of\nanesthesia. Patient positioned in the supine position. Surgical site\ndisinfection and sterile draping. Marking of the incision site.\n\nA semicircular incision was made laterally on the right breast.\nVisualization and dissection along the marking wire towards the marked\nfinding. Excision of the marked findings, with a safety margin of\napproximately 1-2 cm. The excised specimen measured approximately 4 x 5\nx 3 cm. Markings using standard protocol (green thread cranially, blue\nthread ventrally). The excised specimen was sent for preparation\nradiography. Hemostasis was meticulously ensured. Insertion of a 10Ch\nBlake drain into the segmental cavity, followed by suturing.\nVerification of a blood-dry wound cavity. Preparation radiography\nincluded the marked area and the marking wires. The excised material was\ntransferred to our pathology colleagues for histological examination.\nSubdermal and intracutaneous sutures with Monocryl 3/0 in a continuous\nmanner. Application of Steristrips and dressing. Instruments, swabs, and\ncloths were accounted for per the nurse\\'s checklist. The patient was\ncorrectly positioned throughout the operation. The anesthesiologic\ncourse was without significant problems. A thorax compression bandage\nwas applied in the operating room as a preventive measure against\nbleeding.\n\n**Postoperative Procedure:** Pain management, thrombosis prophylaxis,\napplication of a pressure dressing, drainage under suction.\n\n**Examinations:** **Digital Mammography performed on 08/29/2019**\n\n[Clinical indication]{.underline}: DCIS right\n\n[Question]{.underline}: Please send specimen + Mx-FNM\n\n**Findings**: Sonographically guided wire marking of the maximum\nmicrocalcification group measuring about 12 mm. Local hematoma cavity\nand inset clip marking directly cranial to the finding. Stitch direction\nfrom lateral to medial. The wire is positioned with the tip caudal to\nthe clip in close proximity to the microcalcification. Additional\nmarking of the focal localization on the skin. Documentation of the wire\ncourse in two planes.\n\n- Telephone discussion of findings with the surgeon.\n\n- Preparation radiography and preparation sonography are recommended.\n\n- Marking wire and suspicious focal findings centrally included in the\n preparation.\n\n- Intraoperative report of findings has been conveyed to the surgeon.\n\n**Current Recommendations:**\n\n- Scheduled for inpatient admission on ward 22 tomorrow.\n\n- Right breast mastectomy with sentinel lymph node evaluation.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to update you on the clinical course of Mrs. Linda Mayer,\nborn on 01/12/1948, who was under our inpatient care from 08/30/2019 to\n09/12/2019.\n\n**Diagnosis:** Vacuum-assisted biopsy confirmed Ductal Carcinoma In Situ\n(DCIS) in the right breast, measuring 17mm, Grade 3, ER/PR negative.\n\n**Tumor Board Decision (07/13/2019):**\n\n[Imaging:]{.underline} Clip identified in focal lesion in the right\nbreast, adjacent to calcifications.\n\n[Recommendation]{.underline}**:** Spin Echo following fine-needle\nlocalization with mammography-guided control of the clip in the right\nbreast.\n\n[Subsequent Recommendation (08/27/2019):]{.underline} Radiation therapy\nto the right breast. Regular follow-up is advised.\n\n**Medical History:** Ms. Linda Mayer presented to our facility on\n08/30/2019 for the aforementioned surgical procedure. After a\ncomprehensive discussion regarding the surgical plan, potential risks,\nand possible complications, the patient consented to proceed. The\nsurgery was executed without complications on 09/01/2019. The\npostoperative course was unremarkable, allowing for Ms. Mayer\\'s\ndischarge on 09/12/2019 in stable condition and with no signs of wound\nirritation.\n\n**Histopathological Findings (09/01/2019):**\n\nThe resected segment from the right breast showed a maximum necrotic\nzone of 1.6 cm with foreign body reaction, chronic resorptive\ninflammation, fibrosis, and residual hemorrhage. These findings\nprimarily correspond to the pre-biopsy site. Surrounding this were areas\nof DCIS with solid and cribriform growth patterns and comedonecrosis,\nWHO Grade 3, Nuclear Grade 3, with a reconstructed extent of 3.5 cm.\nResection margins were as follows: ventral 0.15 cm, caudal 0.2 cm,\ndorsal 0.4 cm, with remaining margins exceeding 0.5 cm. TNM\nClassification (8th Edition, 2017): pTis (DCIS), R0, G3. Additional\nimmunohistochemical studies are underway to determine hormone receptor\nstatus; a supplementary report will follow.\n\n**Postoperative Plan:**\n\nThe patient was educated on standard postoperative care and the\nimportance of immediate re-evaluation for any persistent or worsening\nsymptoms. Radiation therapy to the right breast is planned, along with\nregular follow-up appointments.\n\nShould you have any questions or require further clarification, we are\nreadily available. For urgent concerns outside of regular office hours,\nemergency care is available at the Emergency Department.\n\n**Internal Histopathological Findings Report**\n\n**Clinical Data:** DCIS in the right breast (17 mm), Grade 3, ER/PR\nnegative.\n\n**Macroscopic Examination:**\n\nThe resected mammary segment from the right breast, marked with dual\nthreads and containing a fine-needle marker inserted ventro-laterally,\nmeasures 4.5 x 5.5 x 3 cm (HxWxD) and weighs 35 grams. The specimen was\nsectioned from medial to lateral into 14 lamellae. The cut surface\npredominantly shows yellowish, lobulated mammary parenchyma with sparse\nstriated whitish glandular components. A DCIS-suspected area, up to 2.1\ncm in size, is evident caudally and centro-ventrally (from lamellae\n4-10), displaying both reddish-hemorrhagic and whitish-nodular\nindurations. Minimal distances from the suspicious area to the resection\nmargins are as follows: cranial 2 cm, caudal 0.2 cm, dorsal 0.2 cm,\nventral 0.1 cm, medial 1.6 cm, lateral 2.5 cm. The suspect area was\ncompletely embedded. Ink markings: green/cranial, yellow/caudal,\nblue/ventral, black/dorsal.\n\n**Microscopic Examination:**\n\nHistological sections of the mammary parenchyma reveal fibro-lipomatous\nstroma and glandular lobules with a two-layered epithelial lining. In\nlamellae 3-6 and 11, solid and cribriform epithelial proliferations are\nevident. Cells are cuboidal with variably enlarged, predominantly\nmoderately pleomorphic, round to oval nuclei. Comedo-like necroses are\noccasionally observed in secondary lumina. Microscopic distances to the\ndeposition margins are consistent with the macroscopic findings. The\nsurrounding stroma in lamellae 6-9 shows extensive geographic adipose\ntissue necrosis, multinucleated foreign body-type giant cells, foamy\ncell macrophages, collagen fiber proliferation, and fresh hemorrhages.\n\n**Supplemental Immunohistochemical Findings\n(09/04/2019):** **Microscopy:** In the meantime, the material was\nfurther processed as announced.\n\nHere, the previously described intraductal epithelial growths, each with\nnegative staining reaction for the estrogen and progesterone receptor\n(with regular external and internal control reaction).\n\n \n\n**Critical Findings:**\n\nResected mammary segment with paracentral, max. 1.6 cm necrotic zone\nwith foreign body reaction, chronic resorptive. Chronic resorptive\ninflammation, fibrosis, and hemorrhage remnants (primarily corresponding\nto the pre-biopsy site), and surrounding portions of ductal carcinoma in\nsitu. Ductal carcinoma in situ, solid and rib-shaped growth type with\ncomedonecrosis, WHO grade 3, nuclear grade 3. The resection was locally\ncomplete with the following Safety margins: ventral 0.15 cm, caudal 0.2\ncm, dorsal 0.4 cm, and the remaining sedimentation margins more than 0.5\ncm.\n\nTNM classification (8th edition 2017): pTis (DCIS), R0, G3.\n\n[Hormone receptor status:]{.underline}\n\n- Estrogen receptor: negative (0%).\n\n- Progesterone receptor: negative (0%).\n\n \n\n \n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient treatment on 27/09/2019.\n\n**Diagnoses**: Left breast carcinoma; iT1c; iN0; MX; ER:12/12; PR:2/12;\nHer-2: neg; Ki67:15%, BRCA 2 mutation.\n\n**Other Diagnoses**:\n\n- Hailey-Hailey disease - currently regressing under prednisolone.\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 due to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage (Abrasio) in 2004\n\n- Hysterectomy in 2005\n\n**Allergies**: Hay fever\n\n**Imaging**:\n\n- CT revealed a cystic lesion in the liver, not suspicious for\n metastasis. Granulomatous, post-inflammatory changes in the lung.\n\n- An MRI of the left breast showed a unifocal lesion on the outer left\n side with a 2.4 cm extension.\n\n**Histology: **Gene score of 6.5, indicating a high-risk profile (pT2 or\npN1) if BRCA negative.\n\n**Recommendation**: If BRCA negative, SE left mamma after ultrasound-FNM\nwith correlation in Mx and SLNB on the left.\n\n**Current Presentation**: Mrs. Linda Mayer presented for pre-operative\nevaluation for left mastectomy. BRCA testing confirmed a BRCA2 mutation,\nwarranting bilateral subcutaneous mastectomy and SLNB on the left.\nReconstruction with implants and mesh is planned, along with a breast\nlift as requested by the patient.\n\n**Macroscopy:**\n\n**Left Subcutaneous Mastectomy (Blue/Ventral, Green/Cranial):**\n\n- Specimen Size: 17 x 15 x 6 cm (Height x Width x Depth), Weight: 410\n g\n\n- Description: Dual filament-labeled subcutaneous mastectomy specimen\n\n- Specimen Workup: 27 lamellae from lateral to medial\n\n- Tumor-Suspect Area (Lamellae 17-21): Max. 1.6 cm, white dermal,\n partly blurred\n\n- Margins from Tumor Area: Ventral 0.1 cm, Caudal 1 cm, Dorsal 1.2 cm,\n Cranial \\> 5 cm, Lateral \\> 5 cm, Medial \\> 2 cm\n\n- Remaining Mammary Parenchyma: Predominantly yellowish lipomatous\n with focal nodular appearance\n\n- Ink Markings: Cranial/Green, Caudal/Yellow, Ventral/Blue,\n Dorsal/Black\n\n - A: Lamella 17 - Covers dorsal and caudal\n\n - B: Lamella 18 - Covers ventral\n\n - C: Lamella 19 - Covers ventral\n\n - D: Blade 21 - Covers ventral\n\n - E: Lamella 20 - Reference cranial\n\n - F: Lamella 16 - Immediately laterally following mammary\n parenchyma\n\n - G: Blade 22 - Reference immediately medial following mammary\n tissue\n\n - H: Lamella 12 - Central section\n\n - I: Lamella 8 - Documented section top/outside\n\n - J: Lamella 3 - Vestigial section below/outside\n\n - K: Lamella 21 - White-nodular imposing area\n\n - L: Lamella 8 - Further section below/outside with nodular area\n\n - M: Lateral border lamella perpendicularly\n\n - N: Medial border lamella perpendicular (Exemplary)\n\n**Second Sentinel Lymph Node on the Left:**\n\n- Specimen: Maximum of 6 cm of fat tissue resectate with 1 to 2 cm of\n lymph nodes and smaller nodular indurations.\n\n- A, B: One lymph node each divided\n\n- C: Further nodular indurations\n\n**Palpable Lymph Nodes Level I:**\n\n- Specimen: One max. 4.5 cm large fat resectate with nodular\n indurations up to 1.5 cm in size\n\n- A: One nodular induration divided\n\n- B: Further nodular indurated portions\n\n**Right Subcutaneous Mastectomy:**\n\n- Specimen: Double thread-labeled 450 g subcutaneous mastectomy\n specimen\n\n- Assumed Suture Markings: Blue (Ventral) and Green (Cranial)\n\n- Dorsal Fascia Intact\n\n- [Specimen Preparation:]{.underline} 16 lamellae from medial to\n lateral\n\n- Predominantly yellowish lobulated with streaky, beige, impinging\n strands of tissue\n\n- Isolated hemorrhages in the parenchyma\n\n- Ink Markings: Green = Cranial, Yellow = Caudal, Blue = Ventral,\n Black = Dorsal\n\n<!-- -->\n\n- A: Medial border lamella perpendicular (Exemplary)\n\n- B: Lamella 5 with reference ventrally (below inside)\n\n- C: Lamella 8 with reference ventrally (below inside)\n\n- D: Lamella 6 with ventral and dorsal reference (upper inside)\n\n- E: Blade 8 with ventral and dorsal cover (top inside)\n\n- F: Blade 11 with cover dorsal and caudal (bottom outside)\n\n- G: Blade 13 with dorsal cover (bottom outside)\n\n- H: Blade 10 with ventral and dorsal cover (top outside)\n\n- I: Lamella 14 with reference cranial and dorsal and bleeding in\n (upper outer)\n\n- J: Lateral border lamella perpendicular (Exemplary)\n\n**Microscopy:**\n\n1\\) In the tumor-suspicious area, a blurred large fibrosis zone with\nstar-shaped extensions is visible. Intercalated are single-cell and\nstranded epithelial cells with a high nuclear-cytoplasmic ratio. The\nnuclei are monomorphic with finely dispersed chromatin, at most, very\nisolated mitoses. Adjacent distended glandular ducts with a discohesive\ncell proliferate with the same cytomorphology. Sporadically, preexistent\nglandular ducts are sheared disc-like by the infiltrative tumor cells.\nSamples from the nodular area of lamella 21 show areas of cell-poor\nhyaline sclerosis with partly ectatically dilated glandular ducts.\n\n2\\) Second lymph node with partial infiltrates of the neoplasia described\nabove. The cells here are relatively densely packed. Somewhat increased\nmitoses. In the lymph nodes, iron deposition is also in the sinus\nhistiocytes.\n\n3\\) Lymph nodes with partly sparse iron deposition. No epithelial foreign\ninfiltrates.\n\n4\\) Regular mammary gland parenchyma. No tumor infiltrates. Part of the\nglandular ducts are slightly cystically dilated.\n\n**Preliminary Critical Findings Report: **\n\nLeft breast carcinoma measuring max 1.6 cm diagnosed as moderately\ndifferentiated invasive lobular carcinoma, B.R.E. score 6 (3+2+1, G2).\nPresence of tumor-associated and peritumoral lobular carcinoma in situ.\nResection status indicates locally complete excision of both invasive\nand non-invasive carcinoma; minimal margins as follows: ventral \\<0.1\ncm, caudal 0.2 cm, dorsal 0.8 cm, remaining margins ≥0.5 cm. Nodal\nstatus reveals max 0.25 cm metastasis in 1/5 nodes, 0/2 additional\nnodes, without extracapsular spread. Right mammary gland from\nsubcutaneous mastectomy shows tumor-free parenchyma.\n\n**TNM classification (8th ed. 2017):** pT1c, pTis (LCIS), pN1a, G2, L0,\nV0, Pn0, R0. Investigations to determine tumor biology were initiated.\nAddendum follows.\n\n**Supplementary findings on 10/07/2019**\n\nEditing: immunohistochemistry:** **\n\nEstrogen receptor, Progesterone receptor, Her2neu, MIB-1 (block 1D).\n\n**Critical Findings Report:** Breast carcinoma on the left with a 1.6 cm\ninvasive lobular carcinoma, moderately differentiated, with a B.R.E.\nscore of 6 (3+2+1, G2). Additionally, tumor-associated and peritumoral\nlobular carcinoma in situ are noted. Resection status confirms locally\ncomplete excision of both invasive and non-invasive carcinomas; minimal\nresection margins are ventral \\<0.1 cm, caudal (LCIS) 0.2 cm, dorsal 0.8\ncm, and all other margins ≥0.5 cm. Nodal assessment reveals a single\nmetastasis with a maximum dimension of 0.25 cm among 7 lymph nodes,\nspecifically found in 1/5 nodes, with no additional metastasis in 0/2\nnodes and no extracapsular extension. Contralateral right mammary gland\nfrom subcutaneous mastectomy is tumor-free.\n\nTumor biology of the invasive carcinoma demonstrates strong positive\nestrogen receptor expression in 100% of tumor cells, strong positive\nprogesterone receptor expression in 1% of tumor cells, negative HER2/neu\nstatus (Score 1+), and a Ki67 (MIB-1) proliferation index of 25%.\n\n**TNM classification (8th Edition 2017):** pT1c, pTis (LCIS), pN1a (1/7\nECE-, sn), G2, L0, V0, Pn0, R0.\n\n**Surgery Report (Vac Change + Irrigation)**: Indication for VAC change.\nAfter a detailed explanation of the procedure, its risks, and\nalternatives, the patient agrees to the proposed procedure.\n\nThe course of surgery: Proper positioning in a supine position. Removal\nof the VAC sponge. A foul odor appears from the wound cavity. Careful\ndisinfection of the surgical area. Sterile draping. Detailed inspection\nof the wound conditions. Wound debridement with removal of fibrin\ncoatings and freshening of the wound. Resection of necrotic material in\nplaces with sharp spoon. Followed by extensive Irrigation of the entire\nwound bed and wound edges using 1 l Polyhexanide solution. Renewed VAC\nsponge application according to standard.\n\n**Postoperative procedure**: Pain medication, thrombosis prophylaxis,\ncontinuation of antibiotic therapy. In the case of abundant\nStaphylococcus aureus and isolated Pseudomosas in the smear and still\nclinical suspected infection, extension of antibiotic treatment to\nMeropenem.\n\n**Surgery Report: Implant Placement**\n\n**Type of Surgery:** Implant placement and wound closure.\n\n**Report:** After infection and VAC therapy, clean smears and planning\nof reinsertion. Informed consent. Intraoperative consults: Anesthesia.\n\n**Course of Surgery:** Team time out. Removal VAC sponge. Disinfection\nand covering. Irrigation of the wound cavity with Serasept. Blust\nirrigation. Fixation cranially and laterally with 4 fixation sutures\nwith Vircryl 2-0. Choice of trial implant. Temporary insertion. Control\nin sitting and lying positions. Choice of the implant. Repeated\ndisinfection. Change of gloves. Insertion of the implant into the\npocket. Careful hemostasis. Insertion of a Blake drain into the wound\ncavity. Suturing of the drainage. Subcutaneous sutures with Monocryl\n3-0.\n\n**Type of Surgery:** Prophylactic open Laparoscopy, extensive\nadhesiolysis\n\n**Type of Anesthesia:** ITN\n\n**Report:** Patient presented for prophylactic right adnexectomy in the\ncourse of hysterectomy and left adnexectomy due to genetic burden.\nIntraoperatively, secondary wound closure was to be performed in the\ncase of a right mammary wound weeping more than one year\npostoperatively. The patient agreed to the planned procedure in writing\nafter receiving detailed information about the extent, the risks, and\nthe alternatives.\n\n**Course of the Operation:** Team time out with anesthesia colleagues.\nFlat lithotomy positioning, disinfection, and sterile draping. Placement\nof permanent transurethral catheter. Subumbilical incision and\ndissection onto the fascia. Opening of the fascia and suturing of the\nsame. Exposure of the peritoneum and opening of the same. Insertion of\nthe 10-mm optic trocar. Insertion of three additional trocars into the\nlower abdomen (left and center right, each 5mm; right 10mm). The\nfollowing situation is seen: when the camera is inserted from the\numbilical region, an extensive adhesion is seen. Only by changing the\ncamera to the right lower bay is extensive adhesiolysis possible. The\nomentum is fused with the peritoneum and the serosa of the uterus. Upper\nabdomen as far as visible inconspicuous.\n\nAfter hysterectomy and adnexectomy on the left side, adnexa on the right\nside atrophic and inconspicuous. The peritoneum is smooth as far as can\nbe seen.\n\nVisualization of the right adnexa and the suspensory ligament of ovary.\n\nCoagulation of the suspensory ligament of ovary ligament after\nvisualization of the ureter on the same side. Stepwise dissection of the\nadnexa from the pelvic wall.\n\nRecovery via endobag. Hemostasis. Inspection of the situs.\n\nRemoval of instrumentation under vision and draining of\npneumoperitoneum.\n\nClosure of the abdominal fascia at the umbilicus and right lower\nabdomen. Suturing of the skin with Monocryl 3/0. Compression bandage at\neach trocar insertion site. Inspection of the right mamma. In the area\nof the surgical scar laterally/externally, 2-3 small epithelium-lined\npore-like openings are visible; here, on pressure, discharge of rather\nviscous/sebaceous, non-odorous, or purulent fluid. No dehiscence is\nvisible, suspected. fistula ducts to the implant cavity. After\nconsultation with the mamma surgeon, a two-stage procedure was planned\nfor the treatment of the fistula tracts. Correct positioning and\ninconspicuous anesthesiological course. Instrumentation, swabs, and\ncloths complete according to the operating room nurse. Postoperative\nprocedures include analgesia, mobilization, thrombosis prophylaxis, and\nwaiting for histology.\n\n**Internal Histopathological Report** \n\n[Clinical information/question]{.underline}: Fistula formation mammary\nright. Dignity?\n\n[Macroscopy]{.underline}**:** Skin spindle from scar mammary right: fix.\na 2.4 cm long, stranded skin-subcutaneous excidate. Lamellation and\ncomplete embedding.\n\n[Processing]{.underline}**:** 1 block, HE\n\n[Microscopy]{.underline}**:** Histologic skin/subcutaneous\ncross-sections with overlay by a multilayered keratinizing squamous\nepithelium. The dermis with few inset regular skin adnexal structures,\nsparse to moderately dense mononuclear-dominated inflammatory\ninfiltrates, and proliferation of cell-poor, fiber-rich collagenous\nconnective tissue.\n\n**Critical Findings Report:** \n\nSkin spindle on scar mamma right: skin/subcutaneous resectate with\nfibrosis and chronic inflammation. To ensure that all findings are\nrecorded, the material will be further processed. A follow-up report\nwill follow.\n\n[Microscopy]{.underline}**:** In the meantime, the material was further\nprocessed as announced. The van Gieson stain showed extensive\nproliferation of collagenous and, in some places elastic fibers. Also in\nthe additional immunohistochemical staining against no evidence of\natypical epithelial infiltrates.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n CRP 7.8 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 11.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 3.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to provide an update on Mrs. Linda Mayer, born on\n01/12/1948, who received inpatient care at our facility from 01/01/2021\nto 01/14/2021.\n\n**Diagnosis:** Hailey-Hailey disease.\n\n- Upon admission, the patient was under treatment with Acitretin 25mg.\n\n**Other Diagnoses**:\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 die to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage in 2004\n\n- Hysterectomy in 2005\n\n**Medical History:** Mrs. Linda Mayer was referred to our hospital for\nthe management of Hailey-Hailey disease after assessment in our\noutpatient clinic. She reported a worsening of painful skin erosions on\nher neck and inner thighs over a span of approximately 3 weeks.\nItchiness was not reported. Prior attempts at treatment, including the\ntopical use of Fucicort, Prednisolone with Octenidine, and Polidocanol\ngel, had provided limited relief. She denied any other physical\ncomplaints, dyspnea, B symptoms, infections, or irregularities in stool\nand micturition.\n\nHer history revealed the initial onset of Hailey-Hailey disease,\ninitially presenting as itching followed by skin erosions, which\nsubsequently healed with scarring. The diagnosis was established at the\nFairview Clinic. Previous therapeutic interventions included systemic\ncortisone shock therapy, as-needed application of Fucicort ointment, and\naxillary laser therapy.\n\n**Family History:**\n\n- Father: Hailey-Hailey Disease (M. Hailey-Hailey)\n\n- Mother and Sister: Breast carcinoma\n\n**Psychosocial History:** Socially, Ms. Linda Mayer is described as a\nretiree, having previously worked as a nurse.\n\n**Physical Examination on Admission:**\n\nHeight: 16 cm, Body Weight: 80.0 kg, BMI: 29.7\n\n**Physical Examination Findings:**\n\nGenerally stable condition with increased nutritional status. Her\nconsciousness was unremarkable, and cranial mobility was free. Ocular\nmobility was regular, with prompt pupillary reflexes to accommodation\nand light. She exhibited a normal heart rate, and cardiac and pulmonary\nexaminations were unremarkable. No heart murmurs were detected. Renal\nbed and spine were not palpable. Further internal and orienting\nneurological examinations revealed no pathological findings.\n\n**Skin Findings on Admission:** Sharp erosions, approximately 10x10 cm\nin size, with a livid-erythematous base, partly crusty, were observed on\nthe neck and proximal inner thighs.\n\nIn the axillary regions on both sides, there were marginal,\nlivid-erythematous, well-demarcated plaques interspersed with scarring\nstrands, more pronounced on the right side.\n\nSkin type II.\n\nMucous membranes appeared normal. Dermographism was noted to be ruber.\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------ ------------ -------------------------------\n Prednisolone (Deltasone) 5 mg 1.5-0-0-0-0-0\n Aspirin (Bayer) 100 mg 0-1-0-0-0-0\n Simvastatin (Zocor) 40 mg 0-0-0-0-1\n Pantoprazole (Protonix) 45.1 mg 1-0-0-0-0\n Acitretin (Soriatane) 25 mg 1-0-0-0-0\n Tetrabenazine (Xenazine) 111 mg 0.25-0.25-0.25-0.25-0.25-0.25\n Letrozole (Femara) 2.5 mg 0-0-1-0\n Risedronate Sodium (Actonel) 35 mg 1-0-0-0-0\n Acetaminophen (Tylenol) 500 mg 0-1-0-1\n Naloxone (Narcan) 8.8 mg 1-0-1-0\n Eszopiclone (Lunesta) 7.5 mg 0-0-1-0\n\n**Other Findings:** MRSA Smears:\n\n- Nasal Smear: Normal flora, no MRSA.\n\n- Throat Swab: Normal flora, no MRSA.\n\n- Non-lesional Skin Smear: Normal flora.\n\n- Lesional Skin Swab: Abundant Pseudomonas aeruginosa, abundant\n Klebsiella oxytoca, and abundant Serratia sp., sensitive to\n piperacillin-tazobactam.\n\n**Therapy and Progression:** Mrs. Linda Mayer was admitted on 01/01/2021\nas an inpatient for a refractory exacerbation of previously diagnosed\nHailey-Hailey disease. On admission, both bacteriological and\nmycological smears were conducted, which indicated abundant levels of\nPseudomonas aeruginosa, Klebsiella oxytoca, and Serratia sp. Lab tests\nshowed a CRP level of 2.83 mg/dL and a leukocyte count of 8.8 G/L.\n\nInitial topical therapy consisted of Zinc oxide ointment, Clotrimazole\npaste, and Triamcinolone Acetonide shake lotion. Treatment was modified\non 01/04/2021 to include Clotrimazole (Lotrimin) paste in the mornings\nand methylprednisolone emulsion in the evenings. Starting on 01/08,\neosin aqueous solution was introduced for application on the thighs,\nserving antiseptic and drying purposes. A hydrophilic prednicarbate\ncream at 0.25% concentration, combined with octenidine at 0.1%, was\napplied to the neck and thighs twice daily, also starting on 01/08. For\nshowering, octenidine-based wash lotion was utilized. Additionally, Mrs.\nLinda Mayer received an emulsifying ointment as part of her treatment.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are providing an update on our patient Mrs. Linda Mayer, born on\n01/12/1948, who presented to our outpatient clinic on 09/22/2021.\n\n**Diagnoses:** M. Hailey-Hailey\n\n**Medical History:**\n\n- Diagnosis of M. Hailey-Hailey at the Fairview Clinic\n\n<!-- -->\n\n- Treatment involved systemic steroid shock therapy, laser therapy,\n and the initiation of Acitretin in October 2021, with no observed\n improvement.\n\n<!-- -->\n\n- A dermabrasion procedure was scheduled on 03/18/2021, during a\n previous inpatient admission.\n\n- Acitretin 25mg has been administered daily, with favorable outcomes\n noted when using Triamcinolone/Triclosan or Prednisolone +\n Octenidine.\n\n- A history of mastectomy with Vacuum-Assisted Closure (VAC) has\n resulted in breast erosion.\n\n**Skin Findings:**\n\n- Erythematous and partially mottled lesions have been identified in\n the axillary and inguinal regions, with some scarring observed in\n the axillary area.\n\n- On 04/28/2021, somewhat erosive plaques were noted in the inguinal\n regions.\n\n- As of 05/05/2021 discrete erosions are currently present on both\n forearms.\n\n**Current Recommendations:**\n\n- Inpatient admission is scheduled for September 2021.\n\n- The prescribed treatment plan includes topical prednicarbate\n (Dermatop) 0.25% with Octenidine 0.1%, per NRF 11.145, in a 50g\n container, to be applied once daily for 1-2 weeks.\n\n- Hydrocortisone 5% in a suitable base, 200g, is to be applied daily.\n\n- The regimen also includes prednicarbate (Dermatop) combined with\n Octenidine.\n\n- Acitretin will be continued temporarily.\n\n- A follow-up appointment in the outpatient clinic is scheduled for\n three months from now.\n\n- Discontinuation of Acitretin.\n\n- It is recommended to avoid the use of compresses on the erosions to\n prevent constant trauma.\n\n- Topical therapy with petrolatum-based wound ointment and sterile\n compresses.\n\n\n\n\nHere is the query:\nWhich laboratory parameter was elevated beyond the reference range upon Mrs. Linda Mayer's discharge in September 2019?\n\nChoose the correct answer from the following options:\nA. Total Bilirubin\nB. Sodium\nC. CRP\nD. Potassium\nE. Creatinine\n\n\nYour response:\n", "role": "user" }, { "content": "CRP", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report to you about Mrs. Linda Mayer, born on 01/12/1948, who\npresented to our outpatient clinic on 07/13/19.\n\n**Diagnoses:**\n\n- BIRADS IV, recommended biopsy during breast diagnostics.\n\n- Left breast carcinoma: iT1b; iN0; MX; ER: 12/12; PR: 2/12; Her-2:\n neg; Ki67: 15%.\n\n**Other Diagnoses: **\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Pemphigus vulgaris under azathioprine therapy\n\n- Osteoporosis\n\n- Obesity with a BMI of 35\n\n- Undergoing immunosuppressive therapy with prednisolone\n\n**Family History:**\n\n- Sister deceased at age 39 from breast cancer.\n\n- Mother and grandmother (maternal and paternal) were diagnosed with\n breast cancer.\n\n**Medical History:** The CT thorax report indicates the presence of\ninflammatory foci, warranting further follow-up. The relevant data was\ndocumented and presented during the tumor conference. Subsequently, a\ntelephone conversation was conducted with the patient to discuss the\nnext steps.\n\n**Tumor board decision from 07/13/2019:**\n\n**Imaging: **\n\n1) MRI examination detected a unifocal lesion on the left external\n aspect, measuring approximately 2.4 cm in size.\n\n2) CT scan (thorax/abdomen 07/12/2019) revealed a previously known\n liver lesion, likely a hemangioma. No evidence of metastases was\n identified. Nonspecific, small foci were observed in the lungs,\n likely indicative of post-inflammatory changes.\n\n**Recommendations:**\n\n1. If no metastasis (M0): Fast-track BRCA testing is recommended.\n\n2. If BRCA testing returns negative: Proceed with a selective excision\n of the left breast after ultrasound-guided fine needle marking and\n sentinel lymph node biopsy on the left side. Additionally, perform\n Endopredict analysis on the surgical specimen.\n\n**Current Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ------------------------------- ------------ ----------- ---------------\n Aspirin 100mg Oral 1-0-0\n Simvastatin (Zocor) 40mg Oral 0-1-0\n Haloperidol (Haldol) 100mg Oral ½-0-½\n Zopiclone (Imovane) 7.5mg Oral 0-0-1\n Trazodone (Desyrel) 100mg Oral 0-0-½-\n Calcium Supplement (Caltrate) 500mg Oral 1-0-1\n Nystatin (Bio-Statin) As advised Oral 1-1-1-1\n Pantoprazole (Protonix) 40mg Oral 1-0-0\n Prednisolone (Prelone) 40mg Oral As advised\n Tramadol/Naloxone (Ultram) 50/4mg Oral 1-0-1\n Acyclovir (Zovirax) 800mg Oral 1-1-1\n\n**Mammography and Tomosynthesis from 07/8/2019:**\n\n[Findings]{.underline}**: **During the inspection and palpation, no\nsignificant findings were noted on either side. Some areas with higher\nmammographic density were observed, which slightly limited the\nassessment. However, during the initial examination, a small\narchitectural irregularity was identified on the outer left side. This\nirregularity appeared as a small, roundish compression measuring\napproximately 6mm and was visible only in the medio-lateral oblique\nimage, with a nipple distance of 8cm. Apart from this discovery, there\nwere no other suspicious focal findings on either side. No clustered or\nirregular microcalcifications were detected. Additionally, a long-term,\nunchanged observation noted some asymmetry with denser breast tissue\npresent on both sides, particularly on the outer aspects. Sonographic\nevaluation posed challenges due to the mixed echogenic glandular tissue.\nAs a possible corresponding feature to the questionable architectural\nirregularity on the outer left side, a blurred, echo-poor area with a\nvertical alignment measuring about 7x5mm was identified. Importantly, no\nother suspicious focal findings were observed, and there was no evidence\nof enlarged lymph nodes in the axilla on both sides.\n\n[Assessment]{.underline}**:** The observed finding on the left side\npresents an uncertain nature, categorized as BIRADS IVb. In contrast,\nthe finding on the right side appears benign, categorized as BIRADS II.\nTo gain a more conclusive understanding of the left-sided finding, we\nrecommend a histological assessment through a sonographically guided\nhigh-speed punch biopsy. An appointment has been scheduled with the\npatient to proceed with this biopsy and obtain a definitive\ndiagnosis.Formularbeginn\n\nFormularende**Current Recommendations:**\\\nA fast-track decision will be made regarding tumor genetics, and the\npatient will be notified of the appointment via telephone. The patient\nshould bring the pathology blocks from Fairview Clinic on the day of\nblood collection for genetic testing, along with a referral for an\nEndopredict test. A multidisciplinary team meeting will be convened\nafter the Endopredict test and genetic testing results are available. If\nthere is persistence or worsening of symptoms, we strongly advise the\npatient to seek immediate re-evaluation. Additionally, outside of\nregular office hours, the patient can seek assistance at the emergency\ncare unit in case of emergency.\n\n**MRI from 07/11/2019:**\n\n[Technique:]{.underline} Breast MRI (3T scanner) with dedicated mammary\nsurface coil: \n\n[Findings:]{.underline} The overall contrast enhancement was observed\nbilaterally to evaluate the Grade II findings. There was low to moderate\nsmall-spotted contrast enhancement with slightly limited assessability.\nThe contrast dynamics revealed a patchy, confluent, blurred, and\nelongated contrast enhancement, corresponding to the primary lesion,\nwhich measured approximately 2.4 cm on the lower left exterior. Single\nspicules were noted, and the lesion appeared hypointense in T1w imaging.\nNo suspicious focal findings with contrast enhancement were detected on\nthe right side. Small axillary lymph nodes were observed on the left\nside, but they did not appear suspicious based on MR morphology.\nAdditionally, there were no suspicious lymph nodes on the right side.\n\n[Assessment:]{.underline} An unifocal primary lesion measuring\napproximately 2.4 cm in diameter was identified on the lower left\nexterior. It exhibited patchy confluent enhancement and architectural\ndisturbance, with single spicules. No evidence of suspicious lymph nodes\nwas found. The left side is categorized as BIRADS 6, indicating a high\nsuspicion of malignancy, while the right side is categorized as BIRADS\n2, indicating a benign finding.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide you with an update on the medical condition of\nMrs. Linda Mayer, born on 01/12/1948, who attended our outpatient clinic\non 08/02/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast (17mm)\n\n- Histological grade G3, estrogen receptor (ER) and progesterone\n receptor (PR) negative.\n\n- Postmenopausal for the past eight years.\n\n- Previous surgical history includes an appendectomy.\n\n- Allergies: Hay fever\n\n \n\n**Current Presentation**: The patient sought consultation following a\nconfirmed diagnosis of DCIS (Ductal Carcinoma In Situ) in the right\nbreast, which was determined through a vacuum-assisted biopsy.\n\n**Physical Examination**: Upon physical examination, there is evidence\nof a post-intervention hematoma located in the upper right quadrant of\nthe right breast. However, the clip from the biopsy is not clearly\nvisible. A sonographic examination of the right axilla reveals no\nabnormalities.\n\n**Current Recommendations:**\n\n- Imaging studies have been conducted.\n\n- A case presentation is scheduled for our mammary conference\n tomorrow.\n\n- Subsequently, planning for surgery will commence, including the\n evaluation of sentinel lymph nodes following a right mastectomy and\n axillary lymph node dissection.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient care at our facility on 08/29/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast, measuring 17mm in size, classified as Grade 3, and\n testing negative for estrogen receptors (ER) and progesterone\n receptors (PR).\n\n- Mrs. Mayer has been postmenopausal for eight years.\n\n- Notable allergy: Hay fever\n\n**Tumor Board Decision:** Mammography imaging revealed a clip associated\nwith a focal finding in the right breast adjacent to calcifications.\n\n[Recommendation]{.underline}: Proceed with sentinel lymph node\nevaluation after right mastectomy, including clip localization on the\nright side.\n\n**Current Presentation**: During the patient\\'s recent outpatient visit,\nan extensive pre-operative consultation was conducted. This discussion\ncovered the indications for the surgery, details of the surgical\nprocess, potential alternative options, as well as general and specific\nrisks associated with the procedure. These risks included the\npossibility of an aesthetically suboptimal outcome and the chance of\nencountering an R1 situation. The patient did not have any further\nquestions and provided written consent for the procedure.\n\n**Physical Examination:** Both breasts appear normal upon inspection and\npalpation. The right axilla shows no abnormalities.\n\n**Medical History:** Mrs. Linda Mayer presented to our clinic with a\nvacuum biopsy-confirmed DCIS of the right breast for therapeutic\nintervention. The decision for surgery was reached following a\ncomprehensive review by our interdisciplinary breast board. After an\nextensive discussion of the procedure\\'s scope, associated risks, and\nalternative options, the patient provided informed consent for the\nproposed surgery.\n\n**Preoperative Procedure:** Sonographic and mammographic fine needle\nmarking of the remaining findings and the clip in the right breast.\n\n**Surgical Report:** Team time-out conducted with colleagues of\nanesthesia. Patient positioned in the supine position. Surgical site\ndisinfection and sterile draping. Marking of the incision site.\n\nA semicircular incision was made laterally on the right breast.\nVisualization and dissection along the marking wire towards the marked\nfinding. Excision of the marked findings, with a safety margin of\napproximately 1-2 cm. The excised specimen measured approximately 4 x 5\nx 3 cm. Markings using standard protocol (green thread cranially, blue\nthread ventrally). The excised specimen was sent for preparation\nradiography. Hemostasis was meticulously ensured. Insertion of a 10Ch\nBlake drain into the segmental cavity, followed by suturing.\nVerification of a blood-dry wound cavity. Preparation radiography\nincluded the marked area and the marking wires. The excised material was\ntransferred to our pathology colleagues for histological examination.\nSubdermal and intracutaneous sutures with Monocryl 3/0 in a continuous\nmanner. Application of Steristrips and dressing. Instruments, swabs, and\ncloths were accounted for per the nurse\\'s checklist. The patient was\ncorrectly positioned throughout the operation. The anesthesiologic\ncourse was without significant problems. A thorax compression bandage\nwas applied in the operating room as a preventive measure against\nbleeding.\n\n**Postoperative Procedure:** Pain management, thrombosis prophylaxis,\napplication of a pressure dressing, drainage under suction.\n\n**Examinations:** **Digital Mammography performed on 08/29/2019**\n\n[Clinical indication]{.underline}: DCIS right\n\n[Question]{.underline}: Please send specimen + Mx-FNM\n\n**Findings**: Sonographically guided wire marking of the maximum\nmicrocalcification group measuring about 12 mm. Local hematoma cavity\nand inset clip marking directly cranial to the finding. Stitch direction\nfrom lateral to medial. The wire is positioned with the tip caudal to\nthe clip in close proximity to the microcalcification. Additional\nmarking of the focal localization on the skin. Documentation of the wire\ncourse in two planes.\n\n- Telephone discussion of findings with the surgeon.\n\n- Preparation radiography and preparation sonography are recommended.\n\n- Marking wire and suspicious focal findings centrally included in the\n preparation.\n\n- Intraoperative report of findings has been conveyed to the surgeon.\n\n**Current Recommendations:**\n\n- Scheduled for inpatient admission on ward 22 tomorrow.\n\n- Right breast mastectomy with sentinel lymph node evaluation.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to update you on the clinical course of Mrs. Linda Mayer,\nborn on 01/12/1948, who was under our inpatient care from 08/30/2019 to\n09/12/2019.\n\n**Diagnosis:** Vacuum-assisted biopsy confirmed Ductal Carcinoma In Situ\n(DCIS) in the right breast, measuring 17mm, Grade 3, ER/PR negative.\n\n**Tumor Board Decision (07/13/2019):**\n\n[Imaging:]{.underline} Clip identified in focal lesion in the right\nbreast, adjacent to calcifications.\n\n[Recommendation]{.underline}**:** Spin Echo following fine-needle\nlocalization with mammography-guided control of the clip in the right\nbreast.\n\n[Subsequent Recommendation (08/27/2019):]{.underline} Radiation therapy\nto the right breast. Regular follow-up is advised.\n\n**Medical History:** Ms. Linda Mayer presented to our facility on\n08/30/2019 for the aforementioned surgical procedure. After a\ncomprehensive discussion regarding the surgical plan, potential risks,\nand possible complications, the patient consented to proceed. The\nsurgery was executed without complications on 09/01/2019. The\npostoperative course was unremarkable, allowing for Ms. Mayer\\'s\ndischarge on 09/12/2019 in stable condition and with no signs of wound\nirritation.\n\n**Histopathological Findings (09/01/2019):**\n\nThe resected segment from the right breast showed a maximum necrotic\nzone of 1.6 cm with foreign body reaction, chronic resorptive\ninflammation, fibrosis, and residual hemorrhage. These findings\nprimarily correspond to the pre-biopsy site. Surrounding this were areas\nof DCIS with solid and cribriform growth patterns and comedonecrosis,\nWHO Grade 3, Nuclear Grade 3, with a reconstructed extent of 3.5 cm.\nResection margins were as follows: ventral 0.15 cm, caudal 0.2 cm,\ndorsal 0.4 cm, with remaining margins exceeding 0.5 cm. TNM\nClassification (8th Edition, 2017): pTis (DCIS), R0, G3. Additional\nimmunohistochemical studies are underway to determine hormone receptor\nstatus; a supplementary report will follow.\n\n**Postoperative Plan:**\n\nThe patient was educated on standard postoperative care and the\nimportance of immediate re-evaluation for any persistent or worsening\nsymptoms. Radiation therapy to the right breast is planned, along with\nregular follow-up appointments.\n\nShould you have any questions or require further clarification, we are\nreadily available. For urgent concerns outside of regular office hours,\nemergency care is available at the Emergency Department.\n\n**Internal Histopathological Findings Report**\n\n**Clinical Data:** DCIS in the right breast (17 mm), Grade 3, ER/PR\nnegative.\n\n**Macroscopic Examination:**\n\nThe resected mammary segment from the right breast, marked with dual\nthreads and containing a fine-needle marker inserted ventro-laterally,\nmeasures 4.5 x 5.5 x 3 cm (HxWxD) and weighs 35 grams. The specimen was\nsectioned from medial to lateral into 14 lamellae. The cut surface\npredominantly shows yellowish, lobulated mammary parenchyma with sparse\nstriated whitish glandular components. A DCIS-suspected area, up to 2.1\ncm in size, is evident caudally and centro-ventrally (from lamellae\n4-10), displaying both reddish-hemorrhagic and whitish-nodular\nindurations. Minimal distances from the suspicious area to the resection\nmargins are as follows: cranial 2 cm, caudal 0.2 cm, dorsal 0.2 cm,\nventral 0.1 cm, medial 1.6 cm, lateral 2.5 cm. The suspect area was\ncompletely embedded. Ink markings: green/cranial, yellow/caudal,\nblue/ventral, black/dorsal.\n\n**Microscopic Examination:**\n\nHistological sections of the mammary parenchyma reveal fibro-lipomatous\nstroma and glandular lobules with a two-layered epithelial lining. In\nlamellae 3-6 and 11, solid and cribriform epithelial proliferations are\nevident. Cells are cuboidal with variably enlarged, predominantly\nmoderately pleomorphic, round to oval nuclei. Comedo-like necroses are\noccasionally observed in secondary lumina. Microscopic distances to the\ndeposition margins are consistent with the macroscopic findings. The\nsurrounding stroma in lamellae 6-9 shows extensive geographic adipose\ntissue necrosis, multinucleated foreign body-type giant cells, foamy\ncell macrophages, collagen fiber proliferation, and fresh hemorrhages.\n\n**Supplemental Immunohistochemical Findings\n(09/04/2019):** **Microscopy:** In the meantime, the material was\nfurther processed as announced.\n\nHere, the previously described intraductal epithelial growths, each with\nnegative staining reaction for the estrogen and progesterone receptor\n(with regular external and internal control reaction).\n\n \n\n**Critical Findings:**\n\nResected mammary segment with paracentral, max. 1.6 cm necrotic zone\nwith foreign body reaction, chronic resorptive. Chronic resorptive\ninflammation, fibrosis, and hemorrhage remnants (primarily corresponding\nto the pre-biopsy site), and surrounding portions of ductal carcinoma in\nsitu. Ductal carcinoma in situ, solid and rib-shaped growth type with\ncomedonecrosis, WHO grade 3, nuclear grade 3. The resection was locally\ncomplete with the following Safety margins: ventral 0.15 cm, caudal 0.2\ncm, dorsal 0.4 cm, and the remaining sedimentation margins more than 0.5\ncm.\n\nTNM classification (8th edition 2017): pTis (DCIS), R0, G3.\n\n[Hormone receptor status:]{.underline}\n\n- Estrogen receptor: negative (0%).\n\n- Progesterone receptor: negative (0%).\n\n \n\n \n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient treatment on 27/09/2019.\n\n**Diagnoses**: Left breast carcinoma; iT1c; iN0; MX; ER:12/12; PR:2/12;\nHer-2: neg; Ki67:15%, BRCA 2 mutation.\n\n**Other Diagnoses**:\n\n- Hailey-Hailey disease - currently regressing under prednisolone.\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 due to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage (Abrasio) in 2004\n\n- Hysterectomy in 2005\n\n**Allergies**: Hay fever\n\n**Imaging**:\n\n- CT revealed a cystic lesion in the liver, not suspicious for\n metastasis. Granulomatous, post-inflammatory changes in the lung.\n\n- An MRI of the left breast showed a unifocal lesion on the outer left\n side with a 2.4 cm extension.\n\n**Histology: **Gene score of 6.5, indicating a high-risk profile (pT2 or\npN1) if BRCA negative.\n\n**Recommendation**: If BRCA negative, SE left mamma after ultrasound-FNM\nwith correlation in Mx and SLNB on the left.\n\n**Current Presentation**: Mrs. Linda Mayer presented for pre-operative\nevaluation for left mastectomy. BRCA testing confirmed a BRCA2 mutation,\nwarranting bilateral subcutaneous mastectomy and SLNB on the left.\nReconstruction with implants and mesh is planned, along with a breast\nlift as requested by the patient.\n\n**Macroscopy:**\n\n**Left Subcutaneous Mastectomy (Blue/Ventral, Green/Cranial):**\n\n- Specimen Size: 17 x 15 x 6 cm (Height x Width x Depth), Weight: 410\n g\n\n- Description: Dual filament-labeled subcutaneous mastectomy specimen\n\n- Specimen Workup: 27 lamellae from lateral to medial\n\n- Tumor-Suspect Area (Lamellae 17-21): Max. 1.6 cm, white dermal,\n partly blurred\n\n- Margins from Tumor Area: Ventral 0.1 cm, Caudal 1 cm, Dorsal 1.2 cm,\n Cranial \\> 5 cm, Lateral \\> 5 cm, Medial \\> 2 cm\n\n- Remaining Mammary Parenchyma: Predominantly yellowish lipomatous\n with focal nodular appearance\n\n- Ink Markings: Cranial/Green, Caudal/Yellow, Ventral/Blue,\n Dorsal/Black\n\n - A: Lamella 17 - Covers dorsal and caudal\n\n - B: Lamella 18 - Covers ventral\n\n - C: Lamella 19 - Covers ventral\n\n - D: Blade 21 - Covers ventral\n\n - E: Lamella 20 - Reference cranial\n\n - F: Lamella 16 - Immediately laterally following mammary\n parenchyma\n\n - G: Blade 22 - Reference immediately medial following mammary\n tissue\n\n - H: Lamella 12 - Central section\n\n - I: Lamella 8 - Documented section top/outside\n\n - J: Lamella 3 - Vestigial section below/outside\n\n - K: Lamella 21 - White-nodular imposing area\n\n - L: Lamella 8 - Further section below/outside with nodular area\n\n - M: Lateral border lamella perpendicularly\n\n - N: Medial border lamella perpendicular (Exemplary)\n\n**Second Sentinel Lymph Node on the Left:**\n\n- Specimen: Maximum of 6 cm of fat tissue resectate with 1 to 2 cm of\n lymph nodes and smaller nodular indurations.\n\n- A, B: One lymph node each divided\n\n- C: Further nodular indurations\n\n**Palpable Lymph Nodes Level I:**\n\n- Specimen: One max. 4.5 cm large fat resectate with nodular\n indurations up to 1.5 cm in size\n\n- A: One nodular induration divided\n\n- B: Further nodular indurated portions\n\n**Right Subcutaneous Mastectomy:**\n\n- Specimen: Double thread-labeled 450 g subcutaneous mastectomy\n specimen\n\n- Assumed Suture Markings: Blue (Ventral) and Green (Cranial)\n\n- Dorsal Fascia Intact\n\n- [Specimen Preparation:]{.underline} 16 lamellae from medial to\n lateral\n\n- Predominantly yellowish lobulated with streaky, beige, impinging\n strands of tissue\n\n- Isolated hemorrhages in the parenchyma\n\n- Ink Markings: Green = Cranial, Yellow = Caudal, Blue = Ventral,\n Black = Dorsal\n\n<!-- -->\n\n- A: Medial border lamella perpendicular (Exemplary)\n\n- B: Lamella 5 with reference ventrally (below inside)\n\n- C: Lamella 8 with reference ventrally (below inside)\n\n- D: Lamella 6 with ventral and dorsal reference (upper inside)\n\n- E: Blade 8 with ventral and dorsal cover (top inside)\n\n- F: Blade 11 with cover dorsal and caudal (bottom outside)\n\n- G: Blade 13 with dorsal cover (bottom outside)\n\n- H: Blade 10 with ventral and dorsal cover (top outside)\n\n- I: Lamella 14 with reference cranial and dorsal and bleeding in\n (upper outer)\n\n- J: Lateral border lamella perpendicular (Exemplary)\n\n**Microscopy:**\n\n1\\) In the tumor-suspicious area, a blurred large fibrosis zone with\nstar-shaped extensions is visible. Intercalated are single-cell and\nstranded epithelial cells with a high nuclear-cytoplasmic ratio. The\nnuclei are monomorphic with finely dispersed chromatin, at most, very\nisolated mitoses. Adjacent distended glandular ducts with a discohesive\ncell proliferate with the same cytomorphology. Sporadically, preexistent\nglandular ducts are sheared disc-like by the infiltrative tumor cells.\nSamples from the nodular area of lamella 21 show areas of cell-poor\nhyaline sclerosis with partly ectatically dilated glandular ducts.\n\n2\\) Second lymph node with partial infiltrates of the neoplasia described\nabove. The cells here are relatively densely packed. Somewhat increased\nmitoses. In the lymph nodes, iron deposition is also in the sinus\nhistiocytes.\n\n3\\) Lymph nodes with partly sparse iron deposition. No epithelial foreign\ninfiltrates.\n\n4\\) Regular mammary gland parenchyma. No tumor infiltrates. Part of the\nglandular ducts are slightly cystically dilated.\n\n**Preliminary Critical Findings Report: **\n\nLeft breast carcinoma measuring max 1.6 cm diagnosed as moderately\ndifferentiated invasive lobular carcinoma, B.R.E. score 6 (3+2+1, G2).\nPresence of tumor-associated and peritumoral lobular carcinoma in situ.\nResection status indicates locally complete excision of both invasive\nand non-invasive carcinoma; minimal margins as follows: ventral \\<0.1\ncm, caudal 0.2 cm, dorsal 0.8 cm, remaining margins ≥0.5 cm. Nodal\nstatus reveals max 0.25 cm metastasis in 1/5 nodes, 0/2 additional\nnodes, without extracapsular spread. Right mammary gland from\nsubcutaneous mastectomy shows tumor-free parenchyma.\n\n**TNM classification (8th ed. 2017):** pT1c, pTis (LCIS), pN1a, G2, L0,\nV0, Pn0, R0. Investigations to determine tumor biology were initiated.\nAddendum follows.\n\n**Supplementary findings on 10/07/2019**\n\nEditing: immunohistochemistry:** **\n\nEstrogen receptor, Progesterone receptor, Her2neu, MIB-1 (block 1D).\n\n**Critical Findings Report:** Breast carcinoma on the left with a 1.6 cm\ninvasive lobular carcinoma, moderately differentiated, with a B.R.E.\nscore of 6 (3+2+1, G2). Additionally, tumor-associated and peritumoral\nlobular carcinoma in situ are noted. Resection status confirms locally\ncomplete excision of both invasive and non-invasive carcinomas; minimal\nresection margins are ventral \\<0.1 cm, caudal (LCIS) 0.2 cm, dorsal 0.8\ncm, and all other margins ≥0.5 cm. Nodal assessment reveals a single\nmetastasis with a maximum dimension of 0.25 cm among 7 lymph nodes,\nspecifically found in 1/5 nodes, with no additional metastasis in 0/2\nnodes and no extracapsular extension. Contralateral right mammary gland\nfrom subcutaneous mastectomy is tumor-free.\n\nTumor biology of the invasive carcinoma demonstrates strong positive\nestrogen receptor expression in 100% of tumor cells, strong positive\nprogesterone receptor expression in 1% of tumor cells, negative HER2/neu\nstatus (Score 1+), and a Ki67 (MIB-1) proliferation index of 25%.\n\n**TNM classification (8th Edition 2017):** pT1c, pTis (LCIS), pN1a (1/7\nECE-, sn), G2, L0, V0, Pn0, R0.\n\n**Surgery Report (Vac Change + Irrigation)**: Indication for VAC change.\nAfter a detailed explanation of the procedure, its risks, and\nalternatives, the patient agrees to the proposed procedure.\n\nThe course of surgery: Proper positioning in a supine position. Removal\nof the VAC sponge. A foul odor appears from the wound cavity. Careful\ndisinfection of the surgical area. Sterile draping. Detailed inspection\nof the wound conditions. Wound debridement with removal of fibrin\ncoatings and freshening of the wound. Resection of necrotic material in\nplaces with sharp spoon. Followed by extensive Irrigation of the entire\nwound bed and wound edges using 1 l Polyhexanide solution. Renewed VAC\nsponge application according to standard.\n\n**Postoperative procedure**: Pain medication, thrombosis prophylaxis,\ncontinuation of antibiotic therapy. In the case of abundant\nStaphylococcus aureus and isolated Pseudomosas in the smear and still\nclinical suspected infection, extension of antibiotic treatment to\nMeropenem.\n\n**Surgery Report: Implant Placement**\n\n**Type of Surgery:** Implant placement and wound closure.\n\n**Report:** After infection and VAC therapy, clean smears and planning\nof reinsertion. Informed consent. Intraoperative consults: Anesthesia.\n\n**Course of Surgery:** Team time out. Removal VAC sponge. Disinfection\nand covering. Irrigation of the wound cavity with Serasept. Blust\nirrigation. Fixation cranially and laterally with 4 fixation sutures\nwith Vircryl 2-0. Choice of trial implant. Temporary insertion. Control\nin sitting and lying positions. Choice of the implant. Repeated\ndisinfection. Change of gloves. Insertion of the implant into the\npocket. Careful hemostasis. Insertion of a Blake drain into the wound\ncavity. Suturing of the drainage. Subcutaneous sutures with Monocryl\n3-0.\n\n**Type of Surgery:** Prophylactic open Laparoscopy, extensive\nadhesiolysis\n\n**Type of Anesthesia:** ITN\n\n**Report:** Patient presented for prophylactic right adnexectomy in the\ncourse of hysterectomy and left adnexectomy due to genetic burden.\nIntraoperatively, secondary wound closure was to be performed in the\ncase of a right mammary wound weeping more than one year\npostoperatively. The patient agreed to the planned procedure in writing\nafter receiving detailed information about the extent, the risks, and\nthe alternatives.\n\n**Course of the Operation:** Team time out with anesthesia colleagues.\nFlat lithotomy positioning, disinfection, and sterile draping. Placement\nof permanent transurethral catheter. Subumbilical incision and\ndissection onto the fascia. Opening of the fascia and suturing of the\nsame. Exposure of the peritoneum and opening of the same. Insertion of\nthe 10-mm optic trocar. Insertion of three additional trocars into the\nlower abdomen (left and center right, each 5mm; right 10mm). The\nfollowing situation is seen: when the camera is inserted from the\numbilical region, an extensive adhesion is seen. Only by changing the\ncamera to the right lower bay is extensive adhesiolysis possible. The\nomentum is fused with the peritoneum and the serosa of the uterus. Upper\nabdomen as far as visible inconspicuous.\n\nAfter hysterectomy and adnexectomy on the left side, adnexa on the right\nside atrophic and inconspicuous. The peritoneum is smooth as far as can\nbe seen.\n\nVisualization of the right adnexa and the suspensory ligament of ovary.\n\nCoagulation of the suspensory ligament of ovary ligament after\nvisualization of the ureter on the same side. Stepwise dissection of the\nadnexa from the pelvic wall.\n\nRecovery via endobag. Hemostasis. Inspection of the situs.\n\nRemoval of instrumentation under vision and draining of\npneumoperitoneum.\n\nClosure of the abdominal fascia at the umbilicus and right lower\nabdomen. Suturing of the skin with Monocryl 3/0. Compression bandage at\neach trocar insertion site. Inspection of the right mamma. In the area\nof the surgical scar laterally/externally, 2-3 small epithelium-lined\npore-like openings are visible; here, on pressure, discharge of rather\nviscous/sebaceous, non-odorous, or purulent fluid. No dehiscence is\nvisible, suspected. fistula ducts to the implant cavity. After\nconsultation with the mamma surgeon, a two-stage procedure was planned\nfor the treatment of the fistula tracts. Correct positioning and\ninconspicuous anesthesiological course. Instrumentation, swabs, and\ncloths complete according to the operating room nurse. Postoperative\nprocedures include analgesia, mobilization, thrombosis prophylaxis, and\nwaiting for histology.\n\n**Internal Histopathological Report** \n\n[Clinical information/question]{.underline}: Fistula formation mammary\nright. Dignity?\n\n[Macroscopy]{.underline}**:** Skin spindle from scar mammary right: fix.\na 2.4 cm long, stranded skin-subcutaneous excidate. Lamellation and\ncomplete embedding.\n\n[Processing]{.underline}**:** 1 block, HE\n\n[Microscopy]{.underline}**:** Histologic skin/subcutaneous\ncross-sections with overlay by a multilayered keratinizing squamous\nepithelium. The dermis with few inset regular skin adnexal structures,\nsparse to moderately dense mononuclear-dominated inflammatory\ninfiltrates, and proliferation of cell-poor, fiber-rich collagenous\nconnective tissue.\n\n**Critical Findings Report:** \n\nSkin spindle on scar mamma right: skin/subcutaneous resectate with\nfibrosis and chronic inflammation. To ensure that all findings are\nrecorded, the material will be further processed. A follow-up report\nwill follow.\n\n[Microscopy]{.underline}**:** In the meantime, the material was further\nprocessed as announced. The van Gieson stain showed extensive\nproliferation of collagenous and, in some places elastic fibers. Also in\nthe additional immunohistochemical staining against no evidence of\natypical epithelial infiltrates.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n CRP 7.8 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 11.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 3.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to provide an update on Mrs. Linda Mayer, born on\n01/12/1948, who received inpatient care at our facility from 01/01/2021\nto 01/14/2021.\n\n**Diagnosis:** Hailey-Hailey disease.\n\n- Upon admission, the patient was under treatment with Acitretin 25mg.\n\n**Other Diagnoses**:\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 die to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage in 2004\n\n- Hysterectomy in 2005\n\n**Medical History:** Mrs. Linda Mayer was referred to our hospital for\nthe management of Hailey-Hailey disease after assessment in our\noutpatient clinic. She reported a worsening of painful skin erosions on\nher neck and inner thighs over a span of approximately 3 weeks.\nItchiness was not reported. Prior attempts at treatment, including the\ntopical use of Fucicort, Prednisolone with Octenidine, and Polidocanol\ngel, had provided limited relief. She denied any other physical\ncomplaints, dyspnea, B symptoms, infections, or irregularities in stool\nand micturition.\n\nHer history revealed the initial onset of Hailey-Hailey disease,\ninitially presenting as itching followed by skin erosions, which\nsubsequently healed with scarring. The diagnosis was established at the\nFairview Clinic. Previous therapeutic interventions included systemic\ncortisone shock therapy, as-needed application of Fucicort ointment, and\naxillary laser therapy.\n\n**Family History:**\n\n- Father: Hailey-Hailey Disease (M. Hailey-Hailey)\n\n- Mother and Sister: Breast carcinoma\n\n**Psychosocial History:** Socially, Ms. Linda Mayer is described as a\nretiree, having previously worked as a nurse.\n\n**Physical Examination on Admission:**\n\nHeight: 16 cm, Body Weight: 80.0 kg, BMI: 29.7\n\n**Physical Examination Findings:**\n\nGenerally stable condition with increased nutritional status. Her\nconsciousness was unremarkable, and cranial mobility was free. Ocular\nmobility was regular, with prompt pupillary reflexes to accommodation\nand light. She exhibited a normal heart rate, and cardiac and pulmonary\nexaminations were unremarkable. No heart murmurs were detected. Renal\nbed and spine were not palpable. Further internal and orienting\nneurological examinations revealed no pathological findings.\n\n**Skin Findings on Admission:** Sharp erosions, approximately 10x10 cm\nin size, with a livid-erythematous base, partly crusty, were observed on\nthe neck and proximal inner thighs.\n\nIn the axillary regions on both sides, there were marginal,\nlivid-erythematous, well-demarcated plaques interspersed with scarring\nstrands, more pronounced on the right side.\n\nSkin type II.\n\nMucous membranes appeared normal. Dermographism was noted to be ruber.\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------ ------------ -------------------------------\n Prednisolone (Deltasone) 5 mg 1.5-0-0-0-0-0\n Aspirin (Bayer) 100 mg 0-1-0-0-0-0\n Simvastatin (Zocor) 40 mg 0-0-0-0-1\n Pantoprazole (Protonix) 45.1 mg 1-0-0-0-0\n Acitretin (Soriatane) 25 mg 1-0-0-0-0\n Tetrabenazine (Xenazine) 111 mg 0.25-0.25-0.25-0.25-0.25-0.25\n Letrozole (Femara) 2.5 mg 0-0-1-0\n Risedronate Sodium (Actonel) 35 mg 1-0-0-0-0\n Acetaminophen (Tylenol) 500 mg 0-1-0-1\n Naloxone (Narcan) 8.8 mg 1-0-1-0\n Eszopiclone (Lunesta) 7.5 mg 0-0-1-0\n\n**Other Findings:** MRSA Smears:\n\n- Nasal Smear: Normal flora, no MRSA.\n\n- Throat Swab: Normal flora, no MRSA.\n\n- Non-lesional Skin Smear: Normal flora.\n\n- Lesional Skin Swab: Abundant Pseudomonas aeruginosa, abundant\n Klebsiella oxytoca, and abundant Serratia sp., sensitive to\n piperacillin-tazobactam.\n\n**Therapy and Progression:** Mrs. Linda Mayer was admitted on 01/01/2021\nas an inpatient for a refractory exacerbation of previously diagnosed\nHailey-Hailey disease. On admission, both bacteriological and\nmycological smears were conducted, which indicated abundant levels of\nPseudomonas aeruginosa, Klebsiella oxytoca, and Serratia sp. Lab tests\nshowed a CRP level of 2.83 mg/dL and a leukocyte count of 8.8 G/L.\n\nInitial topical therapy consisted of Zinc oxide ointment, Clotrimazole\npaste, and Triamcinolone Acetonide shake lotion. Treatment was modified\non 01/04/2021 to include Clotrimazole (Lotrimin) paste in the mornings\nand methylprednisolone emulsion in the evenings. Starting on 01/08,\neosin aqueous solution was introduced for application on the thighs,\nserving antiseptic and drying purposes. A hydrophilic prednicarbate\ncream at 0.25% concentration, combined with octenidine at 0.1%, was\napplied to the neck and thighs twice daily, also starting on 01/08. For\nshowering, octenidine-based wash lotion was utilized. Additionally, Mrs.\nLinda Mayer received an emulsifying ointment as part of her treatment.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are providing an update on our patient Mrs. Linda Mayer, born on\n01/12/1948, who presented to our outpatient clinic on 09/22/2021.\n\n**Diagnoses:** M. Hailey-Hailey\n\n**Medical History:**\n\n- Diagnosis of M. Hailey-Hailey at the Fairview Clinic\n\n<!-- -->\n\n- Treatment involved systemic steroid shock therapy, laser therapy,\n and the initiation of Acitretin in October 2021, with no observed\n improvement.\n\n<!-- -->\n\n- A dermabrasion procedure was scheduled on 03/18/2021, during a\n previous inpatient admission.\n\n- Acitretin 25mg has been administered daily, with favorable outcomes\n noted when using Triamcinolone/Triclosan or Prednisolone +\n Octenidine.\n\n- A history of mastectomy with Vacuum-Assisted Closure (VAC) has\n resulted in breast erosion.\n\n**Skin Findings:**\n\n- Erythematous and partially mottled lesions have been identified in\n the axillary and inguinal regions, with some scarring observed in\n the axillary area.\n\n- On 04/28/2021, somewhat erosive plaques were noted in the inguinal\n regions.\n\n- As of 05/05/2021 discrete erosions are currently present on both\n forearms.\n\n**Current Recommendations:**\n\n- Inpatient admission is scheduled for September 2021.\n\n- The prescribed treatment plan includes topical prednicarbate\n (Dermatop) 0.25% with Octenidine 0.1%, per NRF 11.145, in a 50g\n container, to be applied once daily for 1-2 weeks.\n\n- Hydrocortisone 5% in a suitable base, 200g, is to be applied daily.\n\n- The regimen also includes prednicarbate (Dermatop) combined with\n Octenidine.\n\n- Acitretin will be continued temporarily.\n\n- A follow-up appointment in the outpatient clinic is scheduled for\n three months from now.\n\n- Discontinuation of Acitretin.\n\n- It is recommended to avoid the use of compresses on the erosions to\n prevent constant trauma.\n\n- Topical therapy with petrolatum-based wound ointment and sterile\n compresses.\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/18/2018 to\n03/01/2018.\n\n**Diagnoses: **\n\n- Malignant melanoma of the left scapula, TD 16 mm, exophytic\n ulcerating, invasion stage - III, R0\n\n- **Mutation analysis:** BRAF status: mutated. PD-L1 status: PD-L1\n tumor proportion score (TPS): \\<1%. Immune cell infiltrate (IC): 2%\n of tumor area. PD-L1 combined-positive score (CPS): 2.\n\n- **History:** Ms. Done was admitted to the hospital with high grade\n suspicion of malignant melanoma of the back. The patient reported a\n skin lesion that had been present for approximately 4 weeks. The\n lesion had grown rapidly during this time and appeared to be oozing\n and bleeding. She presented to our outpatient clinic, where she was\n advised to undergo surgical excision in case of suspected\n malignancy.\n\n- Questions about B-symptoms, AP complaints, stool or urine\n abnormalities were negated.\n\n- System Therapy (Adjuvant Treatment for Stage III Melanoma): 1\n\n02/22/18: 1st dose pembrolizumab 200mg\n\n03/15/18: 2nd dose Pembrolizumab 200mg\n\n04/05/18: 3rd dose Pembrolizumab 200mg\n\n04/26/18: 4th dose Pembrolizumab 200mg\n\n05/17/18: 5th dose Pembrolizumab 200mg\n\n06/07/18: 6th dose Pembrolizumab 200mg\n\n06/28/18: 7th dose Pembrolizumab 200mg\n\n07/19/18: 8th dose Pembrolizumab 200mg\n\n08/09/18: 9th dose Pembrolizumab 200mg i.v.\n\n**Physical examination findings:** 52-year-old female patient in normal\ngeneral condition, nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement normal. Pupils are equal and\nreactive to light and accommodation. Regular, normocardial heart rate\nduring recording. Cor and pulmo auscultatory and percutaneously\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall, liver\nand spleen not enlarged, no pain to palpation, no resistance to\npalpation, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged cervical, submandibular, supra- and infraclavicular, axillary\nand inguinal lymph nodes palpable. inguinal lymph nodes palpable.\nFurther internal and orienting neurological examination neurological\nexamination remained without pathological findings.\n\n**Skin findings:** In the area of the left scapula, a table tennis-ball\nsized area with a slightly fissured, oozing, pink-black pigmented\nsurface. On the cranial side an irregularly black-brown pigmented macula\nof about 3.2x1.2 cm is visible.\n\n**PET/CT with 203 MBq (F-18)-Fluorodeoxyglucose from 02/18/2018: **\n\nWeight: 66 kg, blood glucose: 118 mg/dL. 20 mg furosemide; acquisition\nstart 91 min after tracer injection; 821 mm scan length á () mm/s in\nflow technique (neck to proximal thigh); oral and i.v. contrast (1.5\nmL/kg, i.v., max. 120 mL). Quantitative analysis of\nattenuation-corrected image data using SUV calculation.\n\n**Findings:**\n\nCT: In case of known contrast agent allergy, premedication was performed\nwith one ampoule each of H1 and H2 antihistamine. The contrast-enhanced\nexamination proceeded without complications during the course.\n\nNeck: Symmetrical visualization of the soft tissues of the neck. No\nevidence of pathologically enlarged cervical lymph nodes. Struma nodosa\nwith several hypodense nodes on the right side up to max. approx. 1 cm.\n\nThorax: Cutaneous/subcutaneous irregular-shaped lesion caudal to the\nright scapula. Limited assessability in the lung window with motion\nartifacts and shallow inspiration depth. As far as assessable, no\nevidence of larger suspicious intrapulmonary pulmonary round foci. No\ninfiltrate. No pleural effusion. No evidence of pathologically enlarged\nlymph nodes mediastinal, hilar and axillary bilaterally.\n\nAbdomen/pelvis: Normal contrast of liver parenchyma without evidence of\nsuspicious focal liver lesions. Portal vein and hepatic veins perfused\nregularly. Gallbladder without irritation. Spleen with accessory spleen,\npancreas and adrenal glands bds. regular. Kidneys perfused at the same\nside. No urinary retention. Nephrolithiasis on the right side.\nVisualization of the parenchymatous upper abdominal organs. No evidence\nof pathologically enlarged coeliacal, mesenteric, retroperitoneal,\niliac, and inguinal lymph nodes. Inhomogeneously contrasted enlarged\nprostate. Urinary bladder wall, as far as assessable with low filling\ncircumferentially wall thickened.\n\nSkeleton: no evidence of suspicious osteodestructive lesions. Osteopenia\nwith degenerative skeletal changes.\n\nPET:\n\nIncreased tracer enhancement of the suspicious lesion caudal to left\nscapula, indicative of a melanoma (SUVmax 67). Focal intense tracer\nenhancement in the right thyroid lobe (SUVmax approximately 7.9).\nElongated intense tracer enhancement in the lower abdomen ventrally\nmedian without clear correlate, most consistent with contamination.\nOtherwise, unremarkable activity distribution in the study area.\n\nAssessment:\n\nNo evidence of metabolically active metastases in the study area.\n\n**Operation report from** **02/22/2018**:\n\nProcedure: Excision of malignant melanoma on the left upper back.\n\nPreoperative Diagnosis: Malignant melanoma, left upper back.\n\nPostoperative Diagnosis: Malignant melanoma, left upper back.\n\nAnesthesia: Local anesthesia using 70 mL tumescent solution comprising\n0.21% Lidocaine/Ropivacaine with epinephrine.\n\nProcedure Details: The surgical area was prepped using Betadine. The\narea was draped in a sterile fashion. Excision of the exophytic tumor\nwas performed, measuring 51 x 20 x 15 mm. A safety margin of 10 mm was\nmaintained in depth, with the excision extending slightly into the\nsubcutaneous tissue but not beyond the fascia. This resulted in a total\ndefect size of 75 x 45 mm. The defect could not be closed with a simple\nprimary suture. Perforator vessels were coagulated, and the defect was\nbridged using skin flaps. Additional resection of Burow triangles was\ndone according to aesthetic units. The wound was closed using an\nintracutaneous suture technique. A continuous overhand blocked suture\nwas used with 3-0 Vicryl. The patient was advised that the visible\nsuture material could be removed between postoperative days 14 and 16. A\ndressing was applied, followed by a pressure dressing to minimize\nswelling and promote healing. Comments: The patient tolerated the\nprocedure well and was provided postoperative care instructions.\n\nPlan: Follow up in clinic for suture removal and wound assessment\nbetween postoperative days 14 and 16.\n\n**Histology Dermatohistology:** **02/23/2018.**\n\n**Gross Examination:** A roughly oval excision specimen measuring 48 x\n36 x 14 mm. The specimen is serially sectioned into lamellar stages A\nthrough H (8 cassettes).\n\n**Microscopic Examination:**\n\nStage A: Displays a benign epidermis and dermis without evidence of\nmelanocytic tumor cells.\n\nStage B: Features an irregularly thickened epidermis. At the center of\nthe section, melanocytic tumor cells are observed at the dermoepidermal\njunction (positive for MelanA stain). Additionally, abundant\nmelanophages and pigment deposits are noted. The lateral safety margin\nmeasures at least 8 mm.\n\nStage C: Resembles stage B. Atypical melanocytic tumor cells are present\nat the dermoepidermal junction. Upper dermis displays fibrosis,\ninflammation, and numerous melanophages (confirmed by positive MelanA\nstaining). The lateral safety margin is at least 6 mm.\n\nStage D: Central region shows melanocytic tumor cells in both the\nepidermis and upper dermis. There is significant inflammation,\nmelanophages, and pigment deposition (confirmed by MelanA staining).\n\nThe maximum lateral safety margin here is approximately 8 mm. A small\nlymph node in the subcutaneous fat tissue is also seen, infiltrated by\nmelanocytic tumor cells.\n\nThe tumor shows stages E, F, G and H: Exophytic, bovist-like growing\nulcerated hemorrhagic tumor consisting of completely pleomorphic tumor\ncells. These cells vary in morphology, appearing both nested and\nspindle-shaped, with clear cytoplasm and conspicuous nucleoli. Notable\npigment production is observed, as are numerous atypical mitoses.\nControl staining in stage F with MelanA is completely positive. The\nsections are entirely excised.\n\n**Diagnosis:** Exophytic, ulcerated malignant melanoma with a tumor\nthickness of at least 15 mm. The tumor invasion is categorized as stage\nIII.\n\n**Medication upon discharge: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ----------------------------------------- --------------- -------------- ------------------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Oral Once daily in the morning\n Enoxaparin (Lovenox) 0.2 mL Subcutaneous In the evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Oral Morning and evening\n Leuprorelin (Lupron Depot) 3.75 mg Depot Subcutaneous Every 4 weeks\n Fentanyl Transdermal System (Duragesic) 12 μg/hr Transdermal Changed every 3 days\n Pantoprazole (Protonix) 40 mg Oral Once daily in the morning\n Sevelamer (Renagel) 800 mg Oral Once daily in the morning\n Multivitamin One tablet Oral Once daily in the morning\n Torsemide (Demadex) 200 mg Oral Once daily in the morning\n Cholecalciferol (Dekristol) 20,000 IU Oral Once weekly\n Sodium Bicarbonate (Bicanorm) One tablet Oral Once daily in the morning\n Calcitriol (Rocaltrol) 0.25 μg Oral Once daily in the morning\n Valacyclovir (Valtrex) 500 mg Oral Half-tablet daily in the morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Oral Mornings on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Oral In the morning on day 1 and day 2 following daratumumab administration\n\n\n\n### text_1\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 10/23/2020 to\n11/01/2020.\n\n- Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\n according to UICC.\n\n- Therapies to date:\n\n- Resection of primary tumor (malignant melanoma) on the left upper\n back (02/2018)\n\n- 01/20 Microsurgical resection right frontal tumor\n\n- 02/20 Excision of empyema\n\n- 02-03/20: Radiation therapy\n\n- 05/02/20: Start of immunotherapy with Nivolumab & 05/26/20: Start of\n combination immunotherapy 60 mg nivolumab, 200 mg ipilimumab (-\\>\n drug exanthema)\n\n**Physical examination findings: **\n\nOn admission, the patient was awake and adequately oriented. Height:\n166cm, weight: 56kg. Nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement regular. Pupils equal, pupillary\nreflex responsive to accommodation and light. Regular, normocardial\nheart rate on admission. Heart and lung: auscultatory and percutaneous\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall Liver\nand spleen are not enlarged, no tenderness, no rebound palpable.\nResistences palpable, loud bowel sounds. No enlarged No enlarged\ncervical, submandibular, supra- and infraclavicular lymph nodes\npalpable. **Skin findings:** Pronounced xerosis cutis, raised skin\nfolds, some with erythema and fine lamellar scale and fine lamellar\nscale, especially on the arms and face. **Microbiology:** Nasal swab:\nnormal flora, no MRSA. Throat swab: Normal flora, no MRSA Virology:\n10/23/2020: No detection of SARS-CoV-2 by PCR in the submitted material.\n\n**Therapy and Progression:**\n\n**Summary:** The patient presented with exsiccation eczema on the arms,\nlegs, and face.\n\n**Treatment Details:** Topical Treatment for Eczema: Applied Desonide\nCream once daily to the affected areas. For maintenance, applied Eucerin\nCream daily to the body and a moisturizing ointment like Cetaphil to the\nface.\n\n**Antipruritic Treatment:** Prescribed Benadryl tablets, to be taken as\nneeded.\n\n**Oncology Consultation:** The patient was educated by our oncologist,\nDr. Ex, regarding adjuvant therapy options. The potential benefits and\nrisks of a combination immunotherapy with Nivolumab and Ipilimumab were\ndiscussed. The patient had already started Nivolumab 200 mg therapy on\n05/26/2020.\n\n**Incident on 10/28/2020**: The patient had an unattended fall,\nresulting in a hematoma on the left forehead. An emergency CT scan\nshowed no new fractures or acute hemorrhage but confirmed the presence\nof previously known cystic metastasis.\n\n**Operation report (01/02/2020): **\n\n**Diagnosis:** Hemorrhaged right frontal metastasis from previously\ndiagnosed malignant melanoma (ID 2018)\n\n**Procedure:** Microsurgical resection of right frontal mass with\nintraoperative neuromonitoring (MEPs stable) and neuronavigation via a\nleft frontolateral craniotomy.\n\nTime: 10:34 am Closure Time: 1:04 pm. Total Duration: 2 hours 30 minutes\n\n**Preoperative Evaluation:** Imaging identified a hemorrhage in the\nright frontal lobe. Given the patient\\'s history of malignant melanoma,\na hemorrhagic melanoma metastasis was suspected. No other intracranial\nmetastases were detected. The patient and their family were informed of\nthe surgical benefits and risks. After ample time for consideration and\nquestions, written informed consent was obtained.\n\n**Procedure Details:** The patient was positioned supine and intubated.\nThe head was secured in a Mayfield clamp and rotated 60° to the right.\nThe navigation dataset was reviewed. Using the navigation system, a left\nfrontotemporal craniotomy was planned. An arcuate incision line was\ndrawn. The surgical area was shaved, cleaned, and sterilized.\nProphylactic antibiotics and mannitol were administered. A time-out was\nconducted preoperatively. The skin was incised, and Raney clips were\ninserted. The left temporal muscle was split. Using the navigation\nsystem for guidance, a left frontolateral craniotomy was performed. The\nbone flap was carefully removed and preserved in an antibiotic solution\nfor later reimplantation. The dura mater was opened, and the operating\nmicroscope was introduced. Upon inspection, the tumor was evident.\n\n**MRI brain report (01/04/2020): **\n\n**Clinical Information:** Postoperative assessment following\nmicrosurgical resection of a left frontal hemorrhaged metastasis from\npreviously diagnosed malignant melanoma.\n\n**Technique:** Multiplanar, multisequence MRI of the brain, including\nT1-weighted, T2-weighted, FLAIR, diffusion-weighted imaging (DWI), and\npost-contrast T1-weighted sequences.\n\n**Findings:** There is evidence of a right frontotemporal craniotomy\nwith associated post-surgical changes in the right frontal region.\nTitanium plates and screws are noted securing the bone flap, causing\nminimal artifact. The previous tumor site in the right frontal lobe\nshows post-surgical changes with a well-circumscribed cavity. There is\nno evidence of residual enhancing tumor within this cavity on\npost-contrast sequences, suggesting complete resection. Surrounding this\ncavity, there\\'s mild edema, consistent with expected post-operative\nchanges. No other intracranial metastases. The ventricles are of normal\nsize and symmetric. There is no evidence of hydrocephalus. No midline\nshift or mass effect is observed. There are scattered foci of\nsusceptibility artifact in the surgical bed on gradient echo sequences,\nconsistent with expected postoperative blood products. Major\nintracranial vessels appear patent with no evidence of vascular\nocclusion or significant stenosis. The remaining brain parenchyma\nappears normal in signal intensity and morphology on all sequences. No\nother significant abnormalities are identified.\n\n**Impression:** Post-surgical changes in the left frontal lobe\nconsistent with recent tumor resection. There is no evidence of residual\ntumor in the surgical bed. Expected postoperative edema and blood\nproducts adjacent to the resection site. No new metastatic foci\nidentified. No evidence of complications such as hydrocephalus, midline\nshift, or vascular abnormalities.\n\n**Operation report (02/04/2020): **\n\n**Diagnosis:** Subfascial, epidural, and subdural empyema following\nresection of right frontal metastasis for malignant melanoma.\n\n**Procedure:** Empyema removal (subfascial, epidural, subdural) S\nIncision Time: 15:23 Closure Time: 04:01 PM Total Duration: 2 hours 31\nminutes\n\n**Preoperative Evaluation:** The patient had a prior surgical resection\nof a right frontal metastasis due to known malignant melanoma. On a\nrecent outpatient visit, a cerebrospinal fluid (CSF) cushion was\nidentified and punctured, revealing the presence of pathogens. Imaging\nindicated deep and subcutaneous abscesses, necessitating revision\nsurgery. The patient was adequately informed about the procedure,\nunderstood the associated risks, and provided written consent.\n\n**Procedure Details:** The patient was positioned supine with the head\nrotated approximately 60° in a Mayfield clamp. The surgical area was\nwashed and sterilized, focusing on the pre-existing access point. A team\ntime-out was conducted. Perioperative antibiotics were withheld until\nall samples for microbiology were obtained. The skin was incised,\nrevealing multiple layers of muscle. These were carefully dissected,\nleading to the identification and evacuation of the subcutaneous\nepifascial abscess. Infected muscle tissue and abscess walls were\nresected. The skull flap appeared loosened. A miniplate was removed, and\nupon further inspection, the dura mater appeared strained. It was\nincised and revealed turbid fluid, indicating a deep abscess. The dura\nmater was mobilized, though adherence to the cortex was observed around\nthe resection cavity, suggesting possible tumor regrowth. Affected areas\nwere carefully resected. After thorough irrigation, a drainage system\nwas inserted into the resection cavity. A duraplasty was performed,\nfollowed by the reimplantation of the bone flap using a miniplate. The\npatient was also included in a bone flap study and was randomized for\nflap reimplantation. After further irrigation, the wound was\nmeticulously closed, and a subfascial drain was inserted. The final\nclosure was completed with single button sutures. Under the guidance of\nthe operating microscope, the tumor was meticulously dissected from the\nsurrounding healthy tissue. Special care was taken to minimize damage to\nthe surrounding brain structures. The intraoperative neuromonitoring\nindicated stable MEPs throughout, suggesting that motor pathways\nremained undisturbed during the procedure. Throughout the resection,\nperiodic hemostasis was achieved using bipolar electrocautery to control\nbleeding. Following the complete resection of the tumor, the surgical\ncavity was irrigated with sterile saline to remove any residual debris.\nThe integrity of the surrounding brain tissue was assessed, and no\nimmediate complications were observed. The dura mater was sutured,\nensuring a watertight closure. A synthetic dural graft was used to\nreinforce the suture line. The preserved bone flap was reimplanted and\nsecured in place using titanium plates and screws. The temporal muscle\nand soft tissues were reapproximated and sutured in layers. The skin was\nclosed using a combination of absorbable sutures for the subcutaneous\nlayer and non-absorbable sutures for the skin. Sterile dressings were\napplied to the incision site. Postoperative Assessment: The procedure\nwas completed without complications. Immediate postoperative\nneurological examination revealed no new deficits. The patient was\ntransferred to the recovery room in stable condition, awaiting\nextubation by the anesthesiology team.\n\n**Recommendations:** Close monitoring in the neurological intensive care\nunit (NICU) is advised for the first 24 hours. Postoperative imaging,\ntypically an MRI, should be scheduled within the next 48 hours to assess\nthe extent of tumor resection and to rule out any postoperative\ncomplications.\n\n**Summary:** Mrs. Done\\'s recent hospital course was complicated by the\ndetection and subsequent excision of a hemorrhagic metastasis from a\nknown history of malignant melanoma. She continues to be on targeted\ntherapy with close monitoring. No new metastasis or recurrence has been\ndetected as of the last evaluation. The interdisciplinary approach\ninvolving the neurosurgery and oncology teams has been pivotal in her\nmanagement. Given the aggressive nature of melanoma, regular\nsurveillance and immediate action upon detection of new\nlesions/metastasis are paramount for her prognosis.\n\n**02-03/20: Radiation therapy **\n\nDiagnosis: Metastatic malignant melanoma with a focus on the right\nfrontal metastasis. Technique: Stereotactic radiosurgery (SRS) using a\nlinear accelerator (LINAC). Fractionation: Given the aggressive nature\nof malignant melanoma, a hypofractionated regimen was adopted. The\npatient underwent five sessions, each delivering a dose of 6 Gy for a\ncumulative total dose of 30 Gy.\n\nTreatment Planning: A simulation CT scan with a 1mm slice thickness was\nperformed in the treatment position, with a thermoplastic mask for\nimmobilization. The treatment planning system utilized the simulation\nCT, along with MRI for better tumor delineation. The target volume and\ncritical structures like the eyes, optic nerves, chiasm, and brainstem\nwere contoured. The radiation plan was optimized to ensure maximal dose\nto the target while sparing the critical structures.\n\nProcedure: At each session, patient positioning was verified using\ncone-beam CT (CBCT) to ensure precise targeting. Real-time monitoring\nwas employed to account for any intrafraction motion.\n\nSide Effects: The patient tolerated the treatment well. She reported\ntransient fatigue and mild scalp irritation, which resolved with\nconservative measures. No acute radiation-induced neurotoxicity was\nobserved.\n\n**Patient History Update: Mrs. Jane Done (DOB: 01/01/1966)**\n\n**General Status (10/03/2020):**\n\nMrs. Done presented in stable condition with stable vital signs.\nNeurologically, she\\'s intact with no new focal deficits. The surgical\nscars in the frontal region from previous operations are not fully\nhealed and there is some dehiscence and swelling, indicative of\ninfection. This wound complication can be traced back to her previous\nhistory of an empyema which required surgical intervention.\n\n**Dermatological Assessment:**\n\nThe previous exsiccation eczema, prominent on her arms, legs, and face,\nhas improved markedly. The treatment regimen involving consistent\nmoisturization and targeted topical therapies seems effective.\nImportantly, there were no new suspicious skin lesions or nodules noted\nduring her most recent full-body skin check.\n\n**Oncology Status:**\n\nMrs. Done remains on her immunotherapy regimen, specifically the\ncombination of Nivolumab and Ipilimumab. Her response has been positive,\nwith no new metastatic sites identified in the latest assessments. She\nhas displayed commendable compliance with this regimen and regular\nfollow-up evaluations.\n\n**Recent MRI Brain (09/30/2020):**\n\nHer latest multiplanar, multisequence MRI revealed post-surgical\nalterations in the right frontal lobe, consistent with previous\nobservations. Encouragingly, there was no sign of any residual or\nrecurrent tumor activity. Moreover, the MRI did not show any new\nintracranial metastatic sites or other significant abnormalities.\n\n**Thoracic CT Scan (10/01/2020): **\n\nTechnique: Post complication-free bolus i.v. administration of Imeron\n400, a multiline spiral CT was performed through the thorax during the\nvenous contrast phase, supplemented with thin-section, coronary, and\nsagittal secondary reconstructions.\n\nFindings: Multiple roundish subsolid nodules found bipulmonary, notably\na 4mm nodule in the right upper lobe. Blurred subpleural condensations\nin the left upper lobe. Another blurred bronchus-associated\nconsolidation was observed in the left upper lobe and pleurally in the\nleft dorsal lower lobe. No evidence of pathologically enlarged lymph\nnodes in the hilar, mediastinal, or axillary regions. Unchanged\npresentation of the left adrenal gland from the preliminary examination.\nThickened imprinting of the gastric wall noted. Ventrally emphasized\nspondylophytic attachments observed in the thoracic spine. No\nosteodestructive processes detected.\n\n**Impression:** Presence of multiple subsolid pulmonary nodules;\nrecommended follow-up in 4-6 weeks for potential (post-) inflammatory or\nmalignant genesis. No evidence of pathologically enlarged lymph nodes.\n\n**Abdomen/Pelvis CT Scan (10/01/2023): **\n\nTechnique: A low dose CT scan was taken of the abdomen and pelvis.\n\n**Findings:** Regular visualization of the acquired basal lung sections.\nOrthotopic kidneys without urinary stasis. No evidence of urinary\ncalculi. Suspected uterine fibroids attached to the uterus wall.\nEnlarged right ovary with minor calcifications. Assessment: Absence of\nurinary calculi. Possible uterine fibroids and an enlarged right ovary,\nsuggesting a specialized gynecological examination.\n\n**PICC Line Installation (10/02/2020)**\n\n**Diagnosis:**\n\nHome antibiotics required for wound healing disorder following discharge\ndue to an empyema.\n\n**Type of Surgery:**\n\nInstallation of a PICC line in the left basilic vein.\n\n**Anesthesia:**\n\nLocal anesthesia\n\n**Procedure Details:**\n\nThe patient was presented for long-term antibiotic treatment due to a\nwound healing disturbance post the discharge of an epidural abscess. The\nprimary aim was to apply a PICC-line catheter for the antibiotic\nregimen. A written informed consent was duly obtained prior to the\nprocedure.\n\nThe standard procedure began with the washing off and draping of the\npatient. A preoperative sonography of the arm veins was conducted. Based\non the sonographic results, it was decided to insert the catheter via\nthe left basilica vein.\n\nUnder venous congestion and following local anesthesia with 2mL Mecain,\na 2mm skin incision was made. The sonographically guided puncture was\nperformed successfully. Post this, the peel-away sheath was inserted.\nWith the wire in place, the catheter was advanced with its tip\npositioned approximately 2cm below the carina. The wire was subsequently\nremoved. Following this, the catheter was aspirated and flushed with\nNaCl to ensure its patency. A sterile fixation was then applied, and the\nwound was dressed.\n\n**Notes:**\n\nNo complications were observed during the procedure. The patient was\nadvised on the care and maintenance of the PICC line. Regular follow-ups\nare recommended to monitor the wound healing and the effectiveness of\nthe antibiotic treatment.\n\nThe patient was discharged with instructions and is scheduled for a\nfollow-up in two weeks.\n\n**Additional Therapeutic Engagements:**\n\nFor her overall well-being and to counter the side effects of her\ntreatment journey, Mrs. Done has been actively involved in physical\ntherapy sessions. These sessions focus on enhancing her strength and\nbalance, especially given the previous incident of an unattended fall.\nTo address the inevitable psychological strains of her diagnosis, she\nhas also been attending counseling sessions.\n\n**Current Recommendations:**\n\n-Continue the ongoing immunotherapy without changes.\n\n-Dermatological check-ups every month are advised for early detection of\nany potential skin abnormalities.\n\n-Regular neurological evaluations are crucial to ensure no emergence of\nnew deficits.\n\n-Imaging should be scheduled every six months for proactive monitoring.\n\n-Her physical therapy regimen should be ongoing to maintain and improve\nmobility.\n\n-Continue counseling to support her emotional and psychological\nwell-being.\n\n**Summary and Notes:**\n\nMrs. Done\\'s resilience and adherence to her treatments are commendable.\nHer progress is a testament to the integrated care approach she has been\nreceiving. Maintaining a proactive surveillance stance will be essential\nfor her long-term prognosis and quality of life.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe wish to provide an update regarding our mutual patient, Mrs. Jane\nDone, born on 01.01.1966. She was admitted to our clinic from 11/23/2020\nto 12/01/2020.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done presented for a follow-up visit on 11/23/2020. Over the past\nfew months, she reported fatigue and intermittent bouts of nausea. Of\nsignificant concern were newly identified skin changes located on her\nright arm.\n\n**Clinical Findings:**\n\nSkin: Multiple macules and patches on the right arm, the largest\nmeasuring about 1.5cm in diameter, hyperpigmented with irregular\nborders.\n\n**US: **\n\nUltrasound imaging of the right arm revealed no deep extension or\ninvasion of underlying structures. This preliminary assessment was\ncrucial, suggesting that if malignancy is present, it might be in early\nstages.\n\n**Histology: **\n\nHistological examination: Gross Description: The sample consists of\nmultiple tan-pink soft tissue fragments, aggregating to 1.8 cm in the\ngreatest dimension.\n\nMicroscopic description: Sections show a proliferation of atypical\nmelanocytes arranged in nests and as single units at the dermoepidermal\njunction. Some of these cells infiltrate the papillary dermis.\n\nImmunohistochemistry: The atypical cells are positive for HMB-45 and\nS-100. Melan A is focally positive. Ki-67 proliferation index is about\n10%.\n\nFinal Diagnosis: Dysplastic nevus with severe atypia; margins appear\nclear. Further excision is recommended to ensure complete removal and to\nrule out invasive melanoma.\n\n**Lab results: **\n\nComplete Blood Count (CBC):\n\nHemoglobin: 12.3 g/dL (Normal range: 12-16 g/dL)\n\nWhite Blood Cell Count: 6,200 cells/µL (Normal range: 4,000-11,000\ncells/µL)\n\nPlatelet Count: 290,000 cells/µL (Normal range: 150,000-450,000\ncells/µL)\n\nDifferential:\n\nNeutrophils 65%, Lymphocytes 25%, Monocytes 8%, Eosinophils 2%. B.\n\nLiver Function Tests (LFTs):\n\nALT (Alanine Aminotransferase): 40 U/L (Normal range: 7-56 U/L)\n\nAST (Aspartate Aminotransferase): 38 U/L (Normal range: 10-40 U/L)\n\nALP (Alkaline Phosphatase): 90 U/L (Normal range: 44-147 U/L)\n\nTotal Bilirubin: 1.0 mg/dL (Normal range: 0.1-1.2 mg/dL)\n\nAlbumin: 4.2 g/dL (Normal range: 3.4-5.4 g/dL)\n\nAssessment/Recommendations:\n\nGiven her history and the suspicious nature of the new skin changes, we\nhave decided to send the biopsy for urgent histological assessment.\n\nFurthermore, considering her reported symptoms, we have conducted a\nthorough internal check-up, including blood tests and liver function\ntests, to rule out any systemic side effects of the immunotherapy.\n\nWe recommend continuous monitoring of Mrs. Done's condition and kindly\nrequest your valuable input in managing her case optimally. A\nmultidisciplinary approach, given her complicated medical history, will\nbe most beneficial for the patient.\n\nPlease find attached the detailed examination and investigative reports\nfor your reference.\n\nWith kind regards,\n\n\n\n### text_3\n**Dear colleague, **\n\nWe wish to provide a comprehensive update regarding our mutual patient,\nMrs. Jane Done, born on 01.01.1966. She has had a history of various\nmedical conditions and treatments, which we believe is essential to\ndiscuss for her optimal management and was admitted to our clinical from\n01/01/2021 to 01/28/2021.\n\n**Previous Diagnoses and Therapies:**\n\nMetastatic malignant melanoma (presumed ID 2018); M1, stage IV according\nto UICC. Resection of primary tumor (malignant melanoma) on the left\nupper back (02/2018)\n\n01/20 Microsurgical resection right frontal tumor\n\n02/20 Excision of empyema\n\n02-03/20: Radiation therapy\n\n05/02/20: Start of immunotherapy with Nivolumab\n\n05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\nImaging 01/02/2021: PET/CT: Cervical lymph node metastasis;\n\ncMRI: no evidence of metastases. Contrast-enhancing meninges.\n\n**Virology: **\n\nUpon Admission: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load\nof 7,000 Geq/mL and a Ct value of 32.\n\nAt Discharge: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load of\n2,350 Geq/mL and a Ct value of 32.\n\n**Microbiology: **\n\nMRSA Screening Upon Admission: Nasal Swab: Normal flora detected; MRSA\nnot present. Throat Swab: Normal flora detected; MRSA not present.\n\nProcedures:\n\n\\- Presentation to neurology for CSF puncture (e.g., exclude\nmeningeosis)\n\n\\- Panel sequencing complement\n\n\\- Surgery/therapy: Neck dissection followed by adjuvant therapy with\npembrolizumab.\n\nClinical examination:\n\nExamination findings: Patient in normal general and nutritional\ncondition, consciousness unremarkable. Cranial mobility free, ocular\nmobility normal. Pupils are isocor, pupillary reflex prompt to\naccommodation and light. Regular, normocardial heart rate on admission.\nNo typical heart murmurs. Abdomen: abdominal wall soft, liver and spleen\nnot enlarged, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged in the axillary or inguinal region palpable.\n\nPET-CT from 01/02/2021:\n\nIntense metabolically active lymph node metastases, otherwise no\nevidence of vital tumor tissue in the study area.\n\n**PET CT report from 01/02/2021: **\n\nProcedure: PET/CT with 246 MBq (F-18)-fluorodeoxyglucose and a 60-minute\nuptake period.\n\nFindings: CT Findings: Neck: Right Level II: Three lymph nodes, largest\nmeasuring 2.1 x 1.8 cm with central necrosis. Right Level III: Two lymph\nnodes, largest measuring 1.5 x 1.2 cm. Left Level II: One lymph node\nmeasuring 1.3 x 1.1 cm. Left Level IV: Two lymph nodes, largest\nmeasuring 1.7 x 1.4 cm. Retropharyngeal space: One lymph node measuring\n1.0 x 0.9 cm.\n\nPET Findings: Neck: Right Level II: Increased FDG uptake with SUVmax of\n7.8, consistent with metastatic disease. Right Level III: Increased FDG\nuptake with SUVmax of 6.5. Left Level II: Increased FDG uptake with\nSUVmax of 6.0. Left Level IV: Increased FDG uptake with SUVmax of 7.2.\nRetropharyngeal space: Increased FDG uptake with SUVmax of 6.1.\nImpression: Cervical Lymph Nodes: Multiple pathologically enlarged\ncervical lymph nodes in bilateral level II, right level III, left level\nIV, and retropharyngeal space with increased FDG uptake, highly\nsuggestive of metastatic involvement from the known primary melanoma.\n\n**Surgery report 01/05/2021: **\n\nThe surgery commenced with a collaborative discussion with the\nanesthesia team and a standard team time-out was executed. The patient\nwas properly positioned, and the surgical site was aseptically draped.\nThe facial neuromonitoring system was set up and verified. Local\nanesthesia was then administered at the site of the skin incision, which\nwas located near the previous scar. This incision followed the anterior\nborder of the sternocleidomastoid muscle in a curved pattern. Upon\nincising the subcutaneous tissue, the external jugular vein became\nvisible and was selectively ligated. The encountered tissue appeared\nnotably fibrotic and scarred. A skin incision extended from the mastoid\nregion down nearly to the clavicle. The platysma muscle was subsequently\ncut. Due to the presence of a lymph node mass, the auricularis magnus\nnerve had to be severed. The sternocleidomastoid muscle and the\nposterior belly of the digastric muscle were then exposed. Multiple\ndarkened lymph node metastases were identified, both beneath the skin\nand within the sternocleidomastoid muscle. In subsequent steps, efforts\nwere made to distinguish the internal jugular vein from the surrounding\nscarred tissue. A lymph node mass, which exhibited characteristics\nhighly suggestive of metastasis (given its darkened color), was removed.\nThe accessory nerve was identified and preserved. Further dissection was\ndone posteriorly to the sternocleidomastoid muscle, in the direction of\nlevel V. An expansive mass of lymph nodes was excised in this region.\nThe trapezoid branch of the accessory nerve was visualized, and its\nfunction was monitored and preserved with the aid of neuromonitoring.\nThe removed lymph node mass, some excised tissue, and portions of the\nsternocleidomastoid muscle with embedded lymph nodes were sent for\nhistological analysis. During the procedure, care was taken to avoid\ndamaging major neck vessels and nerves. Concluding the procedure, 8 and\n10 French Redon drains were placed, the wound was closed in layers, and\nthen covered with a spray-on bandage, steristrips, and a pressure\ndressing. The surgical site appeared bloodless at the conclusion of the\nsurgery.\n\n**Macroscopy:**\n\n**Macroscopic Description:**\n\nDimensions: 6.8 x 0.7 x 0.4 cm spindle-shaped, non-oriented skin and\nsubcutaneous tissue resection. Central area shows an irritation-free,\nfine scar measuring up to 6.3 x 4.8 cm. The cut surface appears\nconsistently off-white.\n\nInk markings: soft tissue margin of specimen = green. A: central\nlamellae B: spindle tips perpendicular\n\nAnterior Margin of Upper Third of Sternocleidomastoid Muscle:\nDimensions: Four combined tissue samples totaling 4.7 x 3.8 x 1.1 cm.\n\nAppearance: Tan, fibrous soft tissues with multiple uniformly dark\nnodules on the cut surface, each measuring up to 1.1 cm.\n\nA, B: one nodule each halved C, D: other nodular sections E: remaining\ntan fibrous sections Anterior Margin of Lower Third of\nSternocleidomastoid Muscle: Largest measurement: 3.4 cm.\n\nAppearance: Grayish-brown with some fibrous regions and homogeneously\ndark-brown nodes up to 1.5 cm in size on the cut surface. A, B: one node\neach halved C: other nodes D: brown-fibrous sections Region V Occipital:\nLargest measurement: Two samples, each up to 3.8 cm.\n\nAppearance: Mixture of grayish-tan and light brown fibrous soft tissue\nwith nodes up to 2.2 cm, uniformly dark brown.\n\nA, B: one node halved C, D: another node halved each Processing: 16\nparaffin blocks, HE stained.\n\nMicroscopic Description: Dermis and subcutaneous resection shows\nscarring with fibrosis. Epidermis is regular, without any atypical\ncells. No evidence of melanoma or carcinoma. 2./3.\n\nMultiple nodular tumor clusters present in the soft tissue and skeletal\nmuscles, lacking lymph node structure. Tumor cells are polygonal, with\nsome spindle-shaped cells having moderately large, irregular nuclei and\nnoticeable nucleoli. Cytoplasm appears slightly granular with a light\nbrownish pigment.\n\nSeven lymph nodes (measuring up to 3.6 cm) indicate metastasis from the\npreviously mentioned tumor, with extracapsular spread. Four other lymph\nnodes are free from the tumor.\n\n**Critical Findings:** Multiple nodular soft tissue metastases, with the\nlargest measuring 1.3 cm, indicative of melanoma present in both soft\ntissue and muscle. Resection margins are mostly free of tumor, with the\nclosest approach being less than 0.15 cm (points 2 and 3). Seven lymph\nnodes (up to 3.6 cm in size) show metastasis from the melanoma, with\nextracapsular spread. Four lymph nodes are tumor-free (7 out of 11\nnodes, ECE positive) (point 4). Dermis and subcutaneous excision shows\nscarring fibrosis (point 1).\n\nFor the optimal management of Mrs. Done, close monitoring and a\nmultidisciplinary approach will be essential. Thank you for your\ncontinued collaboration in ensuring the best care for our mutual\npatient.\n\n**Lab values upon discharge: **\n\n **Parameter** **Result** **Reference Range** **Interpretation**\n -------------------------------- -------------- ---------------------------------------- ---------------------\n **Complete Blood Count (CBC)** \n Hemoglobin (Hb) 12.4 g/dL 12.0 - 16.0 g/dL Within normal range\n White Blood Cell (WBC) 9.2 x10\\^9/L 4.0 - 10.0 x10\\^9/L Within normal range\n Platelets 250 x10\\^9/L 150 - 400 x10\\^9/L Within normal range\n **Liver Function Tests (LFT)** \n AST 28 U/L 10 - 35 U/L Within normal range\n ALT 32 U/L 10 - 40 U/L Within normal range\n Total Bilirubin 0.8 mg/dL 0.2 - 1.2 mg/dL Within normal range\n **Kidney Function Test** \n Serum Creatinine 0.9 mg/dL 0.5 - 1.2 mg/dL Within normal range\n Blood Urea Nitrogen (BUN) 15 mg/dL 7 - 20 mg/dL Within normal range\n **Electrolytes** \n Sodium 138 mEq/L 135 - 145 mEq/L Within normal range\n Potassium 4.2 mEq/L 3.5 - 5.0 mEq/L Within normal range\n Chloride 101 mEq/L 95 - 105 mEq/L Within normal range\n **Thyroid Function Tests** \n TSH 3.1 mU/L 0.5 - 5.0 mU/L Within normal range\n Free T4 1.4 ng/dL 0.9 - 2.4 ng/dL Within normal range\n **Lipid Profile** \n Total Cholesterol 190 mg/dL \\< 200 mg/dL Desirable\n LDL Cholesterol 100 mg/dL \\< 100 mg/dL Optimal\n HDL Cholesterol 55 mg/dL \\> 40 mg/dL (Men), \\> 50 mg/dL (Women) Normal\n Triglycerides 110 mg/dL \\< 150 mg/dL Normal\n\n**Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ---------------- ------------ ----------- -----------------------------\n Pembrolizumab 200mg IV Every 3 weeks\n Nivolumab 60mg IV As per oncologist\\'s advice\n Ipilimumab 200mg IV As per oncologist\\'s advice\n Paracetamol 500mg Oral Every 4-6 hours as needed\n Omeprazole 20mg Oral Once daily\n\n\n\n### text_4\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/14/2022 to\n03/01/2022.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done showed multiple metastases in her CT examination. On physical\nexamination, Mrs. Done appears well-nourished and in no acute distress.\nHer vital signs are stable. Cardiovascular examination reveals regular\nheart sounds with no murmurs. Respiratory examination shows clear breath\nsounds bilaterally. Abdominal examination reveals no palpable masses or\norganomegaly. Neurological examination is within normal limits.\n\n**Radiology/Nuclear Medicine**\n\n**CT thorax/abdomen/pelvis + Contrast from 02/10/2022**\n\n**Technique:** Multi-phase, multi-slice computed tomography of the\nthorax, abdomen, and pelvis was performed following the intravenous\nadministration of contrast material. Coronal and sagittal\nreconstructions were obtained.\n\n**Thorax:** In the thoracic region, the lungs are notable for multiple\nnodular opacities across both lung fields, consistent with metastatic\ndeposits. The most sizable lesion is seen in the right upper lobe,\napproximately 1.5 cm in diameter. No associated cavitation or pleural\neffusion is detected. A concerning 2 cm mass abutting the lateral wall\nof the left ventricle is noted, raising the suspicion for cardiac\nmetastasis. The mediastinum also exhibits lymphadenopathy with a\ndominant node in the prevascular space, measuring 2.2 cm. Further, there\nare lytic lesions involving the sternum and right 4th rib, consistent\nwith osseous metastatic disease.\n\n**Abdomen/pelvis**: Liver shows multiple hypodense lesions throughout\nboth lobes, indicative of metastatic spread. The dominant lesion in the\nright lobe measures 3 cm. The kidneys, however, are unremarkable without\ndiscernible metastatic deposits. Retroperitoneal lymphadenopathy is also\npresent, highlighted by a node anterior to the aorta of 1.8 cm. In\naddition, there is a 2.5 cm mass identified within the left psoas\nmuscle, consistent with muscular metastasis. Both the left acetabulum\nand the right iliac wing manifest with lytic lesions, suggestive of\nmetastatic involvement. There is also enlargement of the bilateral\ninternal iliac lymph nodes, with the left side\\'s node measuring up to\n1.6 cm. Bladder, prostate, and rectum with no discernible pathology.\n\n**Impression**: Multiple pulmonary nodules consistent with pulmonary\nmetastases. Cardiac lesion suggestive of metastatic involvement.\nEvidence of skeletal metastases in the thorax and pelvis. Hepatic and\nmuscular metastases, indicative of disseminated disease. Lymphadenopathy\nin the mediastinal, retroperitoneal, and pelvic regions.\n\n**PET-CT scan from 02/11/2022**\n\n**Clinical Indication:** Follow-up evaluation of a known case of\nMetastatic Melanoma, Stage IV, M1c with notable findings from a CT scan\ndated 12/01/2014.\n\n**Technique:** Whole-body PET-CT scan was conducted after intravenous\nadministration of 18F-FDG. The patient fasted for 6 hours prior to the\nscan, and blood glucose levels were confirmed to be within the\nacceptable range. Both CT and PET images were acquired, and images were\nco-registered for optimal evaluation. Standard uptake values (SUVs) were\ncalculated for areas of interest.\n\n**Findings: **\n\n**Thorax:** Both lungs depict several hypermetabolic foci, corroborating\nthe CT findings of multiple nodules. The largest lesion in the right\nupper lobe demonstrates an SUVmax of 8.2, indicative of active metabolic\ndisease. The cardiac mass adjacent to the left ventricle, measuring\napproximately 2 cm, also reveals increased 18F-FDG uptake with an SUVmax\nof 9.5, strengthening the suspicion of cardiac metastasis. Enlarged\nmediastinal lymph nodes, particularly the node in the prevascular space,\nshows marked hypermetabolism with an SUVmax of 7.4. Notably, the lytic\nskeletal lesions identified on the CT in the sternum and right 4th rib\nalso display increased metabolic activity, consistent with metastatic\nbone disease.\n\n**Abdomen/Pelvis:** Hepatic lesions are congruent with the findings of\nthe preceding CT, showing heightened metabolic activity. The most\nprominent lesion in the right lobe exhibits an SUVmax of 8.8.\nRetroperitoneal lymph nodes are metabolically active, with the anterior\naortic node demonstrating an SUVmax of 6.9. The 2.5 cm left psoas muscle\nmass also reveals increased uptake with an SUVmax of 7.3, suggesting\nactive muscular metastasis. In the pelvic region, the lytic lesions\nidentified in the left acetabulum and right iliac wing on the CT confirm\ntheir malignant nature with notable metabolic activity. Bilateral\ninternal iliac lymph nodes show hypermetabolism with the left node\\'s\nSUVmax reaching 7.1. Other pelvic organs, including the bladder,\nprostate, and rectum, did not show any significant 18F-FDG uptake, in\nline with the unremarkable CT findings.\n\n**Impression:** The PET-CT findings are consistent with active\nmetastatic disease. There is evidence of hypermetabolic pulmonary\nnodules, a likely cardiac metastasis, hepatic and muscular metastases,\nand metabolically active skeletal lesions in both the thorax and pelvis.\nAdditionally, there is hypermetabolism in the lymph nodes across\nmultiple regions. These findings align closely with the previously\ndiagnosed metastatic melanoma, Stage IV, M1c**. **\n\n**Discussion**\n\nMrs. Done has been diagnosed with recurrent metastatic melanoma with\nlymph node involvement. This poses significant implications for her\nprognosis, emphasizing the need for urgent and comprehensive\nintervention.\n\nHer molecular profile has revealed the presence of the BRAF V600E\nmutation.\n\nOur recommended therapeutic combination includes Vemurafenib and\nCobimetinib, both of which are aimed at disrupting the aberrant BRAF-MEK\nsignaling cascade. Complementing this, we suggest the administration of\nPembrolizumab.\n\nMrs. Done is scheduled for six cycles of this treatment regimen. We will\nmonitor her laboratory parameters, such as blood counts, electrolytes,\nand hepatic and renal profiles, bi-weekly. It is imperative to note that\nany fevers surpassing 38.3°C warrant immediate medical attention.\n\nComprehensive patient education module has been designed to enable Mrs.\nDone to identify and manage any potential side effects efficiently.\n\nWe will ensure rigorous monitoring of her blood pressure and lipid\nmetrics, with the possibility of introducing alternative medications if\nclinical scenarios demand.\n\nWe deeply value your collaboration in Mrs. Done\\'s healthcare journey.\nOur team remains at your disposal for any queries or clarifications.\n\n\n\n\n\nHere is the query:\nWhich of the following medications was given to the Mrs. Done for eczema treatment during the hospital stay from 10/23/2020 to 11/01/2020?\n\nChoose the correct answer from the following options:\nA. Paracetamol\nB. Pembrolizumab\nC. Desonide Cream\nD. Levothyroxine\nE. Calcium Supplement\n\n\nYour response:\n", "role": "user" }, { "content": "Desonide Cream", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/18/2018 to\n03/01/2018.\n\n**Diagnoses: **\n\n- Malignant melanoma of the left scapula, TD 16 mm, exophytic\n ulcerating, invasion stage - III, R0\n\n- **Mutation analysis:** BRAF status: mutated. PD-L1 status: PD-L1\n tumor proportion score (TPS): \\<1%. Immune cell infiltrate (IC): 2%\n of tumor area. PD-L1 combined-positive score (CPS): 2.\n\n- **History:** Ms. Done was admitted to the hospital with high grade\n suspicion of malignant melanoma of the back. The patient reported a\n skin lesion that had been present for approximately 4 weeks. The\n lesion had grown rapidly during this time and appeared to be oozing\n and bleeding. She presented to our outpatient clinic, where she was\n advised to undergo surgical excision in case of suspected\n malignancy.\n\n- Questions about B-symptoms, AP complaints, stool or urine\n abnormalities were negated.\n\n- System Therapy (Adjuvant Treatment for Stage III Melanoma): 1\n\n02/22/18: 1st dose pembrolizumab 200mg\n\n03/15/18: 2nd dose Pembrolizumab 200mg\n\n04/05/18: 3rd dose Pembrolizumab 200mg\n\n04/26/18: 4th dose Pembrolizumab 200mg\n\n05/17/18: 5th dose Pembrolizumab 200mg\n\n06/07/18: 6th dose Pembrolizumab 200mg\n\n06/28/18: 7th dose Pembrolizumab 200mg\n\n07/19/18: 8th dose Pembrolizumab 200mg\n\n08/09/18: 9th dose Pembrolizumab 200mg i.v.\n\n**Physical examination findings:** 52-year-old female patient in normal\ngeneral condition, nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement normal. Pupils are equal and\nreactive to light and accommodation. Regular, normocardial heart rate\nduring recording. Cor and pulmo auscultatory and percutaneously\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall, liver\nand spleen not enlarged, no pain to palpation, no resistance to\npalpation, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged cervical, submandibular, supra- and infraclavicular, axillary\nand inguinal lymph nodes palpable. inguinal lymph nodes palpable.\nFurther internal and orienting neurological examination neurological\nexamination remained without pathological findings.\n\n**Skin findings:** In the area of the left scapula, a table tennis-ball\nsized area with a slightly fissured, oozing, pink-black pigmented\nsurface. On the cranial side an irregularly black-brown pigmented macula\nof about 3.2x1.2 cm is visible.\n\n**PET/CT with 203 MBq (F-18)-Fluorodeoxyglucose from 02/18/2018: **\n\nWeight: 66 kg, blood glucose: 118 mg/dL. 20 mg furosemide; acquisition\nstart 91 min after tracer injection; 821 mm scan length á () mm/s in\nflow technique (neck to proximal thigh); oral and i.v. contrast (1.5\nmL/kg, i.v., max. 120 mL). Quantitative analysis of\nattenuation-corrected image data using SUV calculation.\n\n**Findings:**\n\nCT: In case of known contrast agent allergy, premedication was performed\nwith one ampoule each of H1 and H2 antihistamine. The contrast-enhanced\nexamination proceeded without complications during the course.\n\nNeck: Symmetrical visualization of the soft tissues of the neck. No\nevidence of pathologically enlarged cervical lymph nodes. Struma nodosa\nwith several hypodense nodes on the right side up to max. approx. 1 cm.\n\nThorax: Cutaneous/subcutaneous irregular-shaped lesion caudal to the\nright scapula. Limited assessability in the lung window with motion\nartifacts and shallow inspiration depth. As far as assessable, no\nevidence of larger suspicious intrapulmonary pulmonary round foci. No\ninfiltrate. No pleural effusion. No evidence of pathologically enlarged\nlymph nodes mediastinal, hilar and axillary bilaterally.\n\nAbdomen/pelvis: Normal contrast of liver parenchyma without evidence of\nsuspicious focal liver lesions. Portal vein and hepatic veins perfused\nregularly. Gallbladder without irritation. Spleen with accessory spleen,\npancreas and adrenal glands bds. regular. Kidneys perfused at the same\nside. No urinary retention. Nephrolithiasis on the right side.\nVisualization of the parenchymatous upper abdominal organs. No evidence\nof pathologically enlarged coeliacal, mesenteric, retroperitoneal,\niliac, and inguinal lymph nodes. Inhomogeneously contrasted enlarged\nprostate. Urinary bladder wall, as far as assessable with low filling\ncircumferentially wall thickened.\n\nSkeleton: no evidence of suspicious osteodestructive lesions. Osteopenia\nwith degenerative skeletal changes.\n\nPET:\n\nIncreased tracer enhancement of the suspicious lesion caudal to left\nscapula, indicative of a melanoma (SUVmax 67). Focal intense tracer\nenhancement in the right thyroid lobe (SUVmax approximately 7.9).\nElongated intense tracer enhancement in the lower abdomen ventrally\nmedian without clear correlate, most consistent with contamination.\nOtherwise, unremarkable activity distribution in the study area.\n\nAssessment:\n\nNo evidence of metabolically active metastases in the study area.\n\n**Operation report from** **02/22/2018**:\n\nProcedure: Excision of malignant melanoma on the left upper back.\n\nPreoperative Diagnosis: Malignant melanoma, left upper back.\n\nPostoperative Diagnosis: Malignant melanoma, left upper back.\n\nAnesthesia: Local anesthesia using 70 mL tumescent solution comprising\n0.21% Lidocaine/Ropivacaine with epinephrine.\n\nProcedure Details: The surgical area was prepped using Betadine. The\narea was draped in a sterile fashion. Excision of the exophytic tumor\nwas performed, measuring 51 x 20 x 15 mm. A safety margin of 10 mm was\nmaintained in depth, with the excision extending slightly into the\nsubcutaneous tissue but not beyond the fascia. This resulted in a total\ndefect size of 75 x 45 mm. The defect could not be closed with a simple\nprimary suture. Perforator vessels were coagulated, and the defect was\nbridged using skin flaps. Additional resection of Burow triangles was\ndone according to aesthetic units. The wound was closed using an\nintracutaneous suture technique. A continuous overhand blocked suture\nwas used with 3-0 Vicryl. The patient was advised that the visible\nsuture material could be removed between postoperative days 14 and 16. A\ndressing was applied, followed by a pressure dressing to minimize\nswelling and promote healing. Comments: The patient tolerated the\nprocedure well and was provided postoperative care instructions.\n\nPlan: Follow up in clinic for suture removal and wound assessment\nbetween postoperative days 14 and 16.\n\n**Histology Dermatohistology:** **02/23/2018.**\n\n**Gross Examination:** A roughly oval excision specimen measuring 48 x\n36 x 14 mm. The specimen is serially sectioned into lamellar stages A\nthrough H (8 cassettes).\n\n**Microscopic Examination:**\n\nStage A: Displays a benign epidermis and dermis without evidence of\nmelanocytic tumor cells.\n\nStage B: Features an irregularly thickened epidermis. At the center of\nthe section, melanocytic tumor cells are observed at the dermoepidermal\njunction (positive for MelanA stain). Additionally, abundant\nmelanophages and pigment deposits are noted. The lateral safety margin\nmeasures at least 8 mm.\n\nStage C: Resembles stage B. Atypical melanocytic tumor cells are present\nat the dermoepidermal junction. Upper dermis displays fibrosis,\ninflammation, and numerous melanophages (confirmed by positive MelanA\nstaining). The lateral safety margin is at least 6 mm.\n\nStage D: Central region shows melanocytic tumor cells in both the\nepidermis and upper dermis. There is significant inflammation,\nmelanophages, and pigment deposition (confirmed by MelanA staining).\n\nThe maximum lateral safety margin here is approximately 8 mm. A small\nlymph node in the subcutaneous fat tissue is also seen, infiltrated by\nmelanocytic tumor cells.\n\nThe tumor shows stages E, F, G and H: Exophytic, bovist-like growing\nulcerated hemorrhagic tumor consisting of completely pleomorphic tumor\ncells. These cells vary in morphology, appearing both nested and\nspindle-shaped, with clear cytoplasm and conspicuous nucleoli. Notable\npigment production is observed, as are numerous atypical mitoses.\nControl staining in stage F with MelanA is completely positive. The\nsections are entirely excised.\n\n**Diagnosis:** Exophytic, ulcerated malignant melanoma with a tumor\nthickness of at least 15 mm. The tumor invasion is categorized as stage\nIII.\n\n**Medication upon discharge: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ----------------------------------------- --------------- -------------- ------------------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Oral Once daily in the morning\n Enoxaparin (Lovenox) 0.2 mL Subcutaneous In the evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Oral Morning and evening\n Leuprorelin (Lupron Depot) 3.75 mg Depot Subcutaneous Every 4 weeks\n Fentanyl Transdermal System (Duragesic) 12 μg/hr Transdermal Changed every 3 days\n Pantoprazole (Protonix) 40 mg Oral Once daily in the morning\n Sevelamer (Renagel) 800 mg Oral Once daily in the morning\n Multivitamin One tablet Oral Once daily in the morning\n Torsemide (Demadex) 200 mg Oral Once daily in the morning\n Cholecalciferol (Dekristol) 20,000 IU Oral Once weekly\n Sodium Bicarbonate (Bicanorm) One tablet Oral Once daily in the morning\n Calcitriol (Rocaltrol) 0.25 μg Oral Once daily in the morning\n Valacyclovir (Valtrex) 500 mg Oral Half-tablet daily in the morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Oral Mornings on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Oral In the morning on day 1 and day 2 following daratumumab administration\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 10/23/2020 to\n11/01/2020.\n\n- Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\n according to UICC.\n\n- Therapies to date:\n\n- Resection of primary tumor (malignant melanoma) on the left upper\n back (02/2018)\n\n- 01/20 Microsurgical resection right frontal tumor\n\n- 02/20 Excision of empyema\n\n- 02-03/20: Radiation therapy\n\n- 05/02/20: Start of immunotherapy with Nivolumab & 05/26/20: Start of\n combination immunotherapy 60 mg nivolumab, 200 mg ipilimumab (-\\>\n drug exanthema)\n\n**Physical examination findings: **\n\nOn admission, the patient was awake and adequately oriented. Height:\n166cm, weight: 56kg. Nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement regular. Pupils equal, pupillary\nreflex responsive to accommodation and light. Regular, normocardial\nheart rate on admission. Heart and lung: auscultatory and percutaneous\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall Liver\nand spleen are not enlarged, no tenderness, no rebound palpable.\nResistences palpable, loud bowel sounds. No enlarged No enlarged\ncervical, submandibular, supra- and infraclavicular lymph nodes\npalpable. **Skin findings:** Pronounced xerosis cutis, raised skin\nfolds, some with erythema and fine lamellar scale and fine lamellar\nscale, especially on the arms and face. **Microbiology:** Nasal swab:\nnormal flora, no MRSA. Throat swab: Normal flora, no MRSA Virology:\n10/23/2020: No detection of SARS-CoV-2 by PCR in the submitted material.\n\n**Therapy and Progression:**\n\n**Summary:** The patient presented with exsiccation eczema on the arms,\nlegs, and face.\n\n**Treatment Details:** Topical Treatment for Eczema: Applied Desonide\nCream once daily to the affected areas. For maintenance, applied Eucerin\nCream daily to the body and a moisturizing ointment like Cetaphil to the\nface.\n\n**Antipruritic Treatment:** Prescribed Benadryl tablets, to be taken as\nneeded.\n\n**Oncology Consultation:** The patient was educated by our oncologist,\nDr. Ex, regarding adjuvant therapy options. The potential benefits and\nrisks of a combination immunotherapy with Nivolumab and Ipilimumab were\ndiscussed. The patient had already started Nivolumab 200 mg therapy on\n05/26/2020.\n\n**Incident on 10/28/2020**: The patient had an unattended fall,\nresulting in a hematoma on the left forehead. An emergency CT scan\nshowed no new fractures or acute hemorrhage but confirmed the presence\nof previously known cystic metastasis.\n\n**Operation report (01/02/2020): **\n\n**Diagnosis:** Hemorrhaged right frontal metastasis from previously\ndiagnosed malignant melanoma (ID 2018)\n\n**Procedure:** Microsurgical resection of right frontal mass with\nintraoperative neuromonitoring (MEPs stable) and neuronavigation via a\nleft frontolateral craniotomy.\n\nTime: 10:34 am Closure Time: 1:04 pm. Total Duration: 2 hours 30 minutes\n\n**Preoperative Evaluation:** Imaging identified a hemorrhage in the\nright frontal lobe. Given the patient\\'s history of malignant melanoma,\na hemorrhagic melanoma metastasis was suspected. No other intracranial\nmetastases were detected. The patient and their family were informed of\nthe surgical benefits and risks. After ample time for consideration and\nquestions, written informed consent was obtained.\n\n**Procedure Details:** The patient was positioned supine and intubated.\nThe head was secured in a Mayfield clamp and rotated 60° to the right.\nThe navigation dataset was reviewed. Using the navigation system, a left\nfrontotemporal craniotomy was planned. An arcuate incision line was\ndrawn. The surgical area was shaved, cleaned, and sterilized.\nProphylactic antibiotics and mannitol were administered. A time-out was\nconducted preoperatively. The skin was incised, and Raney clips were\ninserted. The left temporal muscle was split. Using the navigation\nsystem for guidance, a left frontolateral craniotomy was performed. The\nbone flap was carefully removed and preserved in an antibiotic solution\nfor later reimplantation. The dura mater was opened, and the operating\nmicroscope was introduced. Upon inspection, the tumor was evident.\n\n**MRI brain report (01/04/2020): **\n\n**Clinical Information:** Postoperative assessment following\nmicrosurgical resection of a left frontal hemorrhaged metastasis from\npreviously diagnosed malignant melanoma.\n\n**Technique:** Multiplanar, multisequence MRI of the brain, including\nT1-weighted, T2-weighted, FLAIR, diffusion-weighted imaging (DWI), and\npost-contrast T1-weighted sequences.\n\n**Findings:** There is evidence of a right frontotemporal craniotomy\nwith associated post-surgical changes in the right frontal region.\nTitanium plates and screws are noted securing the bone flap, causing\nminimal artifact. The previous tumor site in the right frontal lobe\nshows post-surgical changes with a well-circumscribed cavity. There is\nno evidence of residual enhancing tumor within this cavity on\npost-contrast sequences, suggesting complete resection. Surrounding this\ncavity, there\\'s mild edema, consistent with expected post-operative\nchanges. No other intracranial metastases. The ventricles are of normal\nsize and symmetric. There is no evidence of hydrocephalus. No midline\nshift or mass effect is observed. There are scattered foci of\nsusceptibility artifact in the surgical bed on gradient echo sequences,\nconsistent with expected postoperative blood products. Major\nintracranial vessels appear patent with no evidence of vascular\nocclusion or significant stenosis. The remaining brain parenchyma\nappears normal in signal intensity and morphology on all sequences. No\nother significant abnormalities are identified.\n\n**Impression:** Post-surgical changes in the left frontal lobe\nconsistent with recent tumor resection. There is no evidence of residual\ntumor in the surgical bed. Expected postoperative edema and blood\nproducts adjacent to the resection site. No new metastatic foci\nidentified. No evidence of complications such as hydrocephalus, midline\nshift, or vascular abnormalities.\n\n**Operation report (02/04/2020): **\n\n**Diagnosis:** Subfascial, epidural, and subdural empyema following\nresection of right frontal metastasis for malignant melanoma.\n\n**Procedure:** Empyema removal (subfascial, epidural, subdural) S\nIncision Time: 15:23 Closure Time: 04:01 PM Total Duration: 2 hours 31\nminutes\n\n**Preoperative Evaluation:** The patient had a prior surgical resection\nof a right frontal metastasis due to known malignant melanoma. On a\nrecent outpatient visit, a cerebrospinal fluid (CSF) cushion was\nidentified and punctured, revealing the presence of pathogens. Imaging\nindicated deep and subcutaneous abscesses, necessitating revision\nsurgery. The patient was adequately informed about the procedure,\nunderstood the associated risks, and provided written consent.\n\n**Procedure Details:** The patient was positioned supine with the head\nrotated approximately 60° in a Mayfield clamp. The surgical area was\nwashed and sterilized, focusing on the pre-existing access point. A team\ntime-out was conducted. Perioperative antibiotics were withheld until\nall samples for microbiology were obtained. The skin was incised,\nrevealing multiple layers of muscle. These were carefully dissected,\nleading to the identification and evacuation of the subcutaneous\nepifascial abscess. Infected muscle tissue and abscess walls were\nresected. The skull flap appeared loosened. A miniplate was removed, and\nupon further inspection, the dura mater appeared strained. It was\nincised and revealed turbid fluid, indicating a deep abscess. The dura\nmater was mobilized, though adherence to the cortex was observed around\nthe resection cavity, suggesting possible tumor regrowth. Affected areas\nwere carefully resected. After thorough irrigation, a drainage system\nwas inserted into the resection cavity. A duraplasty was performed,\nfollowed by the reimplantation of the bone flap using a miniplate. The\npatient was also included in a bone flap study and was randomized for\nflap reimplantation. After further irrigation, the wound was\nmeticulously closed, and a subfascial drain was inserted. The final\nclosure was completed with single button sutures. Under the guidance of\nthe operating microscope, the tumor was meticulously dissected from the\nsurrounding healthy tissue. Special care was taken to minimize damage to\nthe surrounding brain structures. The intraoperative neuromonitoring\nindicated stable MEPs throughout, suggesting that motor pathways\nremained undisturbed during the procedure. Throughout the resection,\nperiodic hemostasis was achieved using bipolar electrocautery to control\nbleeding. Following the complete resection of the tumor, the surgical\ncavity was irrigated with sterile saline to remove any residual debris.\nThe integrity of the surrounding brain tissue was assessed, and no\nimmediate complications were observed. The dura mater was sutured,\nensuring a watertight closure. A synthetic dural graft was used to\nreinforce the suture line. The preserved bone flap was reimplanted and\nsecured in place using titanium plates and screws. The temporal muscle\nand soft tissues were reapproximated and sutured in layers. The skin was\nclosed using a combination of absorbable sutures for the subcutaneous\nlayer and non-absorbable sutures for the skin. Sterile dressings were\napplied to the incision site. Postoperative Assessment: The procedure\nwas completed without complications. Immediate postoperative\nneurological examination revealed no new deficits. The patient was\ntransferred to the recovery room in stable condition, awaiting\nextubation by the anesthesiology team.\n\n**Recommendations:** Close monitoring in the neurological intensive care\nunit (NICU) is advised for the first 24 hours. Postoperative imaging,\ntypically an MRI, should be scheduled within the next 48 hours to assess\nthe extent of tumor resection and to rule out any postoperative\ncomplications.\n\n**Summary:** Mrs. Done\\'s recent hospital course was complicated by the\ndetection and subsequent excision of a hemorrhagic metastasis from a\nknown history of malignant melanoma. She continues to be on targeted\ntherapy with close monitoring. No new metastasis or recurrence has been\ndetected as of the last evaluation. The interdisciplinary approach\ninvolving the neurosurgery and oncology teams has been pivotal in her\nmanagement. Given the aggressive nature of melanoma, regular\nsurveillance and immediate action upon detection of new\nlesions/metastasis are paramount for her prognosis.\n\n**02-03/20: Radiation therapy **\n\nDiagnosis: Metastatic malignant melanoma with a focus on the right\nfrontal metastasis. Technique: Stereotactic radiosurgery (SRS) using a\nlinear accelerator (LINAC). Fractionation: Given the aggressive nature\nof malignant melanoma, a hypofractionated regimen was adopted. The\npatient underwent five sessions, each delivering a dose of 6 Gy for a\ncumulative total dose of 30 Gy.\n\nTreatment Planning: A simulation CT scan with a 1mm slice thickness was\nperformed in the treatment position, with a thermoplastic mask for\nimmobilization. The treatment planning system utilized the simulation\nCT, along with MRI for better tumor delineation. The target volume and\ncritical structures like the eyes, optic nerves, chiasm, and brainstem\nwere contoured. The radiation plan was optimized to ensure maximal dose\nto the target while sparing the critical structures.\n\nProcedure: At each session, patient positioning was verified using\ncone-beam CT (CBCT) to ensure precise targeting. Real-time monitoring\nwas employed to account for any intrafraction motion.\n\nSide Effects: The patient tolerated the treatment well. She reported\ntransient fatigue and mild scalp irritation, which resolved with\nconservative measures. No acute radiation-induced neurotoxicity was\nobserved.\n\n**Patient History Update: Mrs. Jane Done (DOB: 01/01/1966)**\n\n**General Status (10/03/2020):**\n\nMrs. Done presented in stable condition with stable vital signs.\nNeurologically, she\\'s intact with no new focal deficits. The surgical\nscars in the frontal region from previous operations are not fully\nhealed and there is some dehiscence and swelling, indicative of\ninfection. This wound complication can be traced back to her previous\nhistory of an empyema which required surgical intervention.\n\n**Dermatological Assessment:**\n\nThe previous exsiccation eczema, prominent on her arms, legs, and face,\nhas improved markedly. The treatment regimen involving consistent\nmoisturization and targeted topical therapies seems effective.\nImportantly, there were no new suspicious skin lesions or nodules noted\nduring her most recent full-body skin check.\n\n**Oncology Status:**\n\nMrs. Done remains on her immunotherapy regimen, specifically the\ncombination of Nivolumab and Ipilimumab. Her response has been positive,\nwith no new metastatic sites identified in the latest assessments. She\nhas displayed commendable compliance with this regimen and regular\nfollow-up evaluations.\n\n**Recent MRI Brain (09/30/2020):**\n\nHer latest multiplanar, multisequence MRI revealed post-surgical\nalterations in the right frontal lobe, consistent with previous\nobservations. Encouragingly, there was no sign of any residual or\nrecurrent tumor activity. Moreover, the MRI did not show any new\nintracranial metastatic sites or other significant abnormalities.\n\n**Thoracic CT Scan (10/01/2020): **\n\nTechnique: Post complication-free bolus i.v. administration of Imeron\n400, a multiline spiral CT was performed through the thorax during the\nvenous contrast phase, supplemented with thin-section, coronary, and\nsagittal secondary reconstructions.\n\nFindings: Multiple roundish subsolid nodules found bipulmonary, notably\na 4mm nodule in the right upper lobe. Blurred subpleural condensations\nin the left upper lobe. Another blurred bronchus-associated\nconsolidation was observed in the left upper lobe and pleurally in the\nleft dorsal lower lobe. No evidence of pathologically enlarged lymph\nnodes in the hilar, mediastinal, or axillary regions. Unchanged\npresentation of the left adrenal gland from the preliminary examination.\nThickened imprinting of the gastric wall noted. Ventrally emphasized\nspondylophytic attachments observed in the thoracic spine. No\nosteodestructive processes detected.\n\n**Impression:** Presence of multiple subsolid pulmonary nodules;\nrecommended follow-up in 4-6 weeks for potential (post-) inflammatory or\nmalignant genesis. No evidence of pathologically enlarged lymph nodes.\n\n**Abdomen/Pelvis CT Scan (10/01/2023): **\n\nTechnique: A low dose CT scan was taken of the abdomen and pelvis.\n\n**Findings:** Regular visualization of the acquired basal lung sections.\nOrthotopic kidneys without urinary stasis. No evidence of urinary\ncalculi. Suspected uterine fibroids attached to the uterus wall.\nEnlarged right ovary with minor calcifications. Assessment: Absence of\nurinary calculi. Possible uterine fibroids and an enlarged right ovary,\nsuggesting a specialized gynecological examination.\n\n**PICC Line Installation (10/02/2020)**\n\n**Diagnosis:**\n\nHome antibiotics required for wound healing disorder following discharge\ndue to an empyema.\n\n**Type of Surgery:**\n\nInstallation of a PICC line in the left basilic vein.\n\n**Anesthesia:**\n\nLocal anesthesia\n\n**Procedure Details:**\n\nThe patient was presented for long-term antibiotic treatment due to a\nwound healing disturbance post the discharge of an epidural abscess. The\nprimary aim was to apply a PICC-line catheter for the antibiotic\nregimen. A written informed consent was duly obtained prior to the\nprocedure.\n\nThe standard procedure began with the washing off and draping of the\npatient. A preoperative sonography of the arm veins was conducted. Based\non the sonographic results, it was decided to insert the catheter via\nthe left basilica vein.\n\nUnder venous congestion and following local anesthesia with 2mL Mecain,\na 2mm skin incision was made. The sonographically guided puncture was\nperformed successfully. Post this, the peel-away sheath was inserted.\nWith the wire in place, the catheter was advanced with its tip\npositioned approximately 2cm below the carina. The wire was subsequently\nremoved. Following this, the catheter was aspirated and flushed with\nNaCl to ensure its patency. A sterile fixation was then applied, and the\nwound was dressed.\n\n**Notes:**\n\nNo complications were observed during the procedure. The patient was\nadvised on the care and maintenance of the PICC line. Regular follow-ups\nare recommended to monitor the wound healing and the effectiveness of\nthe antibiotic treatment.\n\nThe patient was discharged with instructions and is scheduled for a\nfollow-up in two weeks.\n\n**Additional Therapeutic Engagements:**\n\nFor her overall well-being and to counter the side effects of her\ntreatment journey, Mrs. Done has been actively involved in physical\ntherapy sessions. These sessions focus on enhancing her strength and\nbalance, especially given the previous incident of an unattended fall.\nTo address the inevitable psychological strains of her diagnosis, she\nhas also been attending counseling sessions.\n\n**Current Recommendations:**\n\n-Continue the ongoing immunotherapy without changes.\n\n-Dermatological check-ups every month are advised for early detection of\nany potential skin abnormalities.\n\n-Regular neurological evaluations are crucial to ensure no emergence of\nnew deficits.\n\n-Imaging should be scheduled every six months for proactive monitoring.\n\n-Her physical therapy regimen should be ongoing to maintain and improve\nmobility.\n\n-Continue counseling to support her emotional and psychological\nwell-being.\n\n**Summary and Notes:**\n\nMrs. Done\\'s resilience and adherence to her treatments are commendable.\nHer progress is a testament to the integrated care approach she has been\nreceiving. Maintaining a proactive surveillance stance will be essential\nfor her long-term prognosis and quality of life.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding our mutual patient, Mrs. Jane\nDone, born on 01.01.1966. She was admitted to our clinic from 11/23/2020\nto 12/01/2020.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done presented for a follow-up visit on 11/23/2020. Over the past\nfew months, she reported fatigue and intermittent bouts of nausea. Of\nsignificant concern were newly identified skin changes located on her\nright arm.\n\n**Clinical Findings:**\n\nSkin: Multiple macules and patches on the right arm, the largest\nmeasuring about 1.5cm in diameter, hyperpigmented with irregular\nborders.\n\n**US: **\n\nUltrasound imaging of the right arm revealed no deep extension or\ninvasion of underlying structures. This preliminary assessment was\ncrucial, suggesting that if malignancy is present, it might be in early\nstages.\n\n**Histology: **\n\nHistological examination: Gross Description: The sample consists of\nmultiple tan-pink soft tissue fragments, aggregating to 1.8 cm in the\ngreatest dimension.\n\nMicroscopic description: Sections show a proliferation of atypical\nmelanocytes arranged in nests and as single units at the dermoepidermal\njunction. Some of these cells infiltrate the papillary dermis.\n\nImmunohistochemistry: The atypical cells are positive for HMB-45 and\nS-100. Melan A is focally positive. Ki-67 proliferation index is about\n10%.\n\nFinal Diagnosis: Dysplastic nevus with severe atypia; margins appear\nclear. Further excision is recommended to ensure complete removal and to\nrule out invasive melanoma.\n\n**Lab results: **\n\nComplete Blood Count (CBC):\n\nHemoglobin: 12.3 g/dL (Normal range: 12-16 g/dL)\n\nWhite Blood Cell Count: 6,200 cells/µL (Normal range: 4,000-11,000\ncells/µL)\n\nPlatelet Count: 290,000 cells/µL (Normal range: 150,000-450,000\ncells/µL)\n\nDifferential:\n\nNeutrophils 65%, Lymphocytes 25%, Monocytes 8%, Eosinophils 2%. B.\n\nLiver Function Tests (LFTs):\n\nALT (Alanine Aminotransferase): 40 U/L (Normal range: 7-56 U/L)\n\nAST (Aspartate Aminotransferase): 38 U/L (Normal range: 10-40 U/L)\n\nALP (Alkaline Phosphatase): 90 U/L (Normal range: 44-147 U/L)\n\nTotal Bilirubin: 1.0 mg/dL (Normal range: 0.1-1.2 mg/dL)\n\nAlbumin: 4.2 g/dL (Normal range: 3.4-5.4 g/dL)\n\nAssessment/Recommendations:\n\nGiven her history and the suspicious nature of the new skin changes, we\nhave decided to send the biopsy for urgent histological assessment.\n\nFurthermore, considering her reported symptoms, we have conducted a\nthorough internal check-up, including blood tests and liver function\ntests, to rule out any systemic side effects of the immunotherapy.\n\nWe recommend continuous monitoring of Mrs. Done's condition and kindly\nrequest your valuable input in managing her case optimally. A\nmultidisciplinary approach, given her complicated medical history, will\nbe most beneficial for the patient.\n\nPlease find attached the detailed examination and investigative reports\nfor your reference.\n\nWith kind regards,\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe wish to provide a comprehensive update regarding our mutual patient,\nMrs. Jane Done, born on 01.01.1966. She has had a history of various\nmedical conditions and treatments, which we believe is essential to\ndiscuss for her optimal management and was admitted to our clinical from\n01/01/2021 to 01/28/2021.\n\n**Previous Diagnoses and Therapies:**\n\nMetastatic malignant melanoma (presumed ID 2018); M1, stage IV according\nto UICC. Resection of primary tumor (malignant melanoma) on the left\nupper back (02/2018)\n\n01/20 Microsurgical resection right frontal tumor\n\n02/20 Excision of empyema\n\n02-03/20: Radiation therapy\n\n05/02/20: Start of immunotherapy with Nivolumab\n\n05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\nImaging 01/02/2021: PET/CT: Cervical lymph node metastasis;\n\ncMRI: no evidence of metastases. Contrast-enhancing meninges.\n\n**Virology: **\n\nUpon Admission: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load\nof 7,000 Geq/mL and a Ct value of 32.\n\nAt Discharge: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load of\n2,350 Geq/mL and a Ct value of 32.\n\n**Microbiology: **\n\nMRSA Screening Upon Admission: Nasal Swab: Normal flora detected; MRSA\nnot present. Throat Swab: Normal flora detected; MRSA not present.\n\nProcedures:\n\n\\- Presentation to neurology for CSF puncture (e.g., exclude\nmeningeosis)\n\n\\- Panel sequencing complement\n\n\\- Surgery/therapy: Neck dissection followed by adjuvant therapy with\npembrolizumab.\n\nClinical examination:\n\nExamination findings: Patient in normal general and nutritional\ncondition, consciousness unremarkable. Cranial mobility free, ocular\nmobility normal. Pupils are isocor, pupillary reflex prompt to\naccommodation and light. Regular, normocardial heart rate on admission.\nNo typical heart murmurs. Abdomen: abdominal wall soft, liver and spleen\nnot enlarged, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged in the axillary or inguinal region palpable.\n\nPET-CT from 01/02/2021:\n\nIntense metabolically active lymph node metastases, otherwise no\nevidence of vital tumor tissue in the study area.\n\n**PET CT report from 01/02/2021: **\n\nProcedure: PET/CT with 246 MBq (F-18)-fluorodeoxyglucose and a 60-minute\nuptake period.\n\nFindings: CT Findings: Neck: Right Level II: Three lymph nodes, largest\nmeasuring 2.1 x 1.8 cm with central necrosis. Right Level III: Two lymph\nnodes, largest measuring 1.5 x 1.2 cm. Left Level II: One lymph node\nmeasuring 1.3 x 1.1 cm. Left Level IV: Two lymph nodes, largest\nmeasuring 1.7 x 1.4 cm. Retropharyngeal space: One lymph node measuring\n1.0 x 0.9 cm.\n\nPET Findings: Neck: Right Level II: Increased FDG uptake with SUVmax of\n7.8, consistent with metastatic disease. Right Level III: Increased FDG\nuptake with SUVmax of 6.5. Left Level II: Increased FDG uptake with\nSUVmax of 6.0. Left Level IV: Increased FDG uptake with SUVmax of 7.2.\nRetropharyngeal space: Increased FDG uptake with SUVmax of 6.1.\nImpression: Cervical Lymph Nodes: Multiple pathologically enlarged\ncervical lymph nodes in bilateral level II, right level III, left level\nIV, and retropharyngeal space with increased FDG uptake, highly\nsuggestive of metastatic involvement from the known primary melanoma.\n\n**Surgery report 01/05/2021: **\n\nThe surgery commenced with a collaborative discussion with the\nanesthesia team and a standard team time-out was executed. The patient\nwas properly positioned, and the surgical site was aseptically draped.\nThe facial neuromonitoring system was set up and verified. Local\nanesthesia was then administered at the site of the skin incision, which\nwas located near the previous scar. This incision followed the anterior\nborder of the sternocleidomastoid muscle in a curved pattern. Upon\nincising the subcutaneous tissue, the external jugular vein became\nvisible and was selectively ligated. The encountered tissue appeared\nnotably fibrotic and scarred. A skin incision extended from the mastoid\nregion down nearly to the clavicle. The platysma muscle was subsequently\ncut. Due to the presence of a lymph node mass, the auricularis magnus\nnerve had to be severed. The sternocleidomastoid muscle and the\nposterior belly of the digastric muscle were then exposed. Multiple\ndarkened lymph node metastases were identified, both beneath the skin\nand within the sternocleidomastoid muscle. In subsequent steps, efforts\nwere made to distinguish the internal jugular vein from the surrounding\nscarred tissue. A lymph node mass, which exhibited characteristics\nhighly suggestive of metastasis (given its darkened color), was removed.\nThe accessory nerve was identified and preserved. Further dissection was\ndone posteriorly to the sternocleidomastoid muscle, in the direction of\nlevel V. An expansive mass of lymph nodes was excised in this region.\nThe trapezoid branch of the accessory nerve was visualized, and its\nfunction was monitored and preserved with the aid of neuromonitoring.\nThe removed lymph node mass, some excised tissue, and portions of the\nsternocleidomastoid muscle with embedded lymph nodes were sent for\nhistological analysis. During the procedure, care was taken to avoid\ndamaging major neck vessels and nerves. Concluding the procedure, 8 and\n10 French Redon drains were placed, the wound was closed in layers, and\nthen covered with a spray-on bandage, steristrips, and a pressure\ndressing. The surgical site appeared bloodless at the conclusion of the\nsurgery.\n\n**Macroscopy:**\n\n**Macroscopic Description:**\n\nDimensions: 6.8 x 0.7 x 0.4 cm spindle-shaped, non-oriented skin and\nsubcutaneous tissue resection. Central area shows an irritation-free,\nfine scar measuring up to 6.3 x 4.8 cm. The cut surface appears\nconsistently off-white.\n\nInk markings: soft tissue margin of specimen = green. A: central\nlamellae B: spindle tips perpendicular\n\nAnterior Margin of Upper Third of Sternocleidomastoid Muscle:\nDimensions: Four combined tissue samples totaling 4.7 x 3.8 x 1.1 cm.\n\nAppearance: Tan, fibrous soft tissues with multiple uniformly dark\nnodules on the cut surface, each measuring up to 1.1 cm.\n\nA, B: one nodule each halved C, D: other nodular sections E: remaining\ntan fibrous sections Anterior Margin of Lower Third of\nSternocleidomastoid Muscle: Largest measurement: 3.4 cm.\n\nAppearance: Grayish-brown with some fibrous regions and homogeneously\ndark-brown nodes up to 1.5 cm in size on the cut surface. A, B: one node\neach halved C: other nodes D: brown-fibrous sections Region V Occipital:\nLargest measurement: Two samples, each up to 3.8 cm.\n\nAppearance: Mixture of grayish-tan and light brown fibrous soft tissue\nwith nodes up to 2.2 cm, uniformly dark brown.\n\nA, B: one node halved C, D: another node halved each Processing: 16\nparaffin blocks, HE stained.\n\nMicroscopic Description: Dermis and subcutaneous resection shows\nscarring with fibrosis. Epidermis is regular, without any atypical\ncells. No evidence of melanoma or carcinoma. 2./3.\n\nMultiple nodular tumor clusters present in the soft tissue and skeletal\nmuscles, lacking lymph node structure. Tumor cells are polygonal, with\nsome spindle-shaped cells having moderately large, irregular nuclei and\nnoticeable nucleoli. Cytoplasm appears slightly granular with a light\nbrownish pigment.\n\nSeven lymph nodes (measuring up to 3.6 cm) indicate metastasis from the\npreviously mentioned tumor, with extracapsular spread. Four other lymph\nnodes are free from the tumor.\n\n**Critical Findings:** Multiple nodular soft tissue metastases, with the\nlargest measuring 1.3 cm, indicative of melanoma present in both soft\ntissue and muscle. Resection margins are mostly free of tumor, with the\nclosest approach being less than 0.15 cm (points 2 and 3). Seven lymph\nnodes (up to 3.6 cm in size) show metastasis from the melanoma, with\nextracapsular spread. Four lymph nodes are tumor-free (7 out of 11\nnodes, ECE positive) (point 4). Dermis and subcutaneous excision shows\nscarring fibrosis (point 1).\n\nFor the optimal management of Mrs. Done, close monitoring and a\nmultidisciplinary approach will be essential. Thank you for your\ncontinued collaboration in ensuring the best care for our mutual\npatient.\n\n**Lab values upon discharge: **\n\n **Parameter** **Result** **Reference Range** **Interpretation**\n -------------------------------- -------------- ---------------------------------------- ---------------------\n **Complete Blood Count (CBC)** \n Hemoglobin (Hb) 12.4 g/dL 12.0 - 16.0 g/dL Within normal range\n White Blood Cell (WBC) 9.2 x10\\^9/L 4.0 - 10.0 x10\\^9/L Within normal range\n Platelets 250 x10\\^9/L 150 - 400 x10\\^9/L Within normal range\n **Liver Function Tests (LFT)** \n AST 28 U/L 10 - 35 U/L Within normal range\n ALT 32 U/L 10 - 40 U/L Within normal range\n Total Bilirubin 0.8 mg/dL 0.2 - 1.2 mg/dL Within normal range\n **Kidney Function Test** \n Serum Creatinine 0.9 mg/dL 0.5 - 1.2 mg/dL Within normal range\n Blood Urea Nitrogen (BUN) 15 mg/dL 7 - 20 mg/dL Within normal range\n **Electrolytes** \n Sodium 138 mEq/L 135 - 145 mEq/L Within normal range\n Potassium 4.2 mEq/L 3.5 - 5.0 mEq/L Within normal range\n Chloride 101 mEq/L 95 - 105 mEq/L Within normal range\n **Thyroid Function Tests** \n TSH 3.1 mU/L 0.5 - 5.0 mU/L Within normal range\n Free T4 1.4 ng/dL 0.9 - 2.4 ng/dL Within normal range\n **Lipid Profile** \n Total Cholesterol 190 mg/dL \\< 200 mg/dL Desirable\n LDL Cholesterol 100 mg/dL \\< 100 mg/dL Optimal\n HDL Cholesterol 55 mg/dL \\> 40 mg/dL (Men), \\> 50 mg/dL (Women) Normal\n Triglycerides 110 mg/dL \\< 150 mg/dL Normal\n\n**Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ---------------- ------------ ----------- -----------------------------\n Pembrolizumab 200mg IV Every 3 weeks\n Nivolumab 60mg IV As per oncologist\\'s advice\n Ipilimumab 200mg IV As per oncologist\\'s advice\n Paracetamol 500mg Oral Every 4-6 hours as needed\n Omeprazole 20mg Oral Once daily\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/14/2022 to\n03/01/2022.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done showed multiple metastases in her CT examination. On physical\nexamination, Mrs. Done appears well-nourished and in no acute distress.\nHer vital signs are stable. Cardiovascular examination reveals regular\nheart sounds with no murmurs. Respiratory examination shows clear breath\nsounds bilaterally. Abdominal examination reveals no palpable masses or\norganomegaly. Neurological examination is within normal limits.\n\n**Radiology/Nuclear Medicine**\n\n**CT thorax/abdomen/pelvis + Contrast from 02/10/2022**\n\n**Technique:** Multi-phase, multi-slice computed tomography of the\nthorax, abdomen, and pelvis was performed following the intravenous\nadministration of contrast material. Coronal and sagittal\nreconstructions were obtained.\n\n**Thorax:** In the thoracic region, the lungs are notable for multiple\nnodular opacities across both lung fields, consistent with metastatic\ndeposits. The most sizable lesion is seen in the right upper lobe,\napproximately 1.5 cm in diameter. No associated cavitation or pleural\neffusion is detected. A concerning 2 cm mass abutting the lateral wall\nof the left ventricle is noted, raising the suspicion for cardiac\nmetastasis. The mediastinum also exhibits lymphadenopathy with a\ndominant node in the prevascular space, measuring 2.2 cm. Further, there\nare lytic lesions involving the sternum and right 4th rib, consistent\nwith osseous metastatic disease.\n\n**Abdomen/pelvis**: Liver shows multiple hypodense lesions throughout\nboth lobes, indicative of metastatic spread. The dominant lesion in the\nright lobe measures 3 cm. The kidneys, however, are unremarkable without\ndiscernible metastatic deposits. Retroperitoneal lymphadenopathy is also\npresent, highlighted by a node anterior to the aorta of 1.8 cm. In\naddition, there is a 2.5 cm mass identified within the left psoas\nmuscle, consistent with muscular metastasis. Both the left acetabulum\nand the right iliac wing manifest with lytic lesions, suggestive of\nmetastatic involvement. There is also enlargement of the bilateral\ninternal iliac lymph nodes, with the left side\\'s node measuring up to\n1.6 cm. Bladder, prostate, and rectum with no discernible pathology.\n\n**Impression**: Multiple pulmonary nodules consistent with pulmonary\nmetastases. Cardiac lesion suggestive of metastatic involvement.\nEvidence of skeletal metastases in the thorax and pelvis. Hepatic and\nmuscular metastases, indicative of disseminated disease. Lymphadenopathy\nin the mediastinal, retroperitoneal, and pelvic regions.\n\n**PET-CT scan from 02/11/2022**\n\n**Clinical Indication:** Follow-up evaluation of a known case of\nMetastatic Melanoma, Stage IV, M1c with notable findings from a CT scan\ndated 12/01/2014.\n\n**Technique:** Whole-body PET-CT scan was conducted after intravenous\nadministration of 18F-FDG. The patient fasted for 6 hours prior to the\nscan, and blood glucose levels were confirmed to be within the\nacceptable range. Both CT and PET images were acquired, and images were\nco-registered for optimal evaluation. Standard uptake values (SUVs) were\ncalculated for areas of interest.\n\n**Findings: **\n\n**Thorax:** Both lungs depict several hypermetabolic foci, corroborating\nthe CT findings of multiple nodules. The largest lesion in the right\nupper lobe demonstrates an SUVmax of 8.2, indicative of active metabolic\ndisease. The cardiac mass adjacent to the left ventricle, measuring\napproximately 2 cm, also reveals increased 18F-FDG uptake with an SUVmax\nof 9.5, strengthening the suspicion of cardiac metastasis. Enlarged\nmediastinal lymph nodes, particularly the node in the prevascular space,\nshows marked hypermetabolism with an SUVmax of 7.4. Notably, the lytic\nskeletal lesions identified on the CT in the sternum and right 4th rib\nalso display increased metabolic activity, consistent with metastatic\nbone disease.\n\n**Abdomen/Pelvis:** Hepatic lesions are congruent with the findings of\nthe preceding CT, showing heightened metabolic activity. The most\nprominent lesion in the right lobe exhibits an SUVmax of 8.8.\nRetroperitoneal lymph nodes are metabolically active, with the anterior\naortic node demonstrating an SUVmax of 6.9. The 2.5 cm left psoas muscle\nmass also reveals increased uptake with an SUVmax of 7.3, suggesting\nactive muscular metastasis. In the pelvic region, the lytic lesions\nidentified in the left acetabulum and right iliac wing on the CT confirm\ntheir malignant nature with notable metabolic activity. Bilateral\ninternal iliac lymph nodes show hypermetabolism with the left node\\'s\nSUVmax reaching 7.1. Other pelvic organs, including the bladder,\nprostate, and rectum, did not show any significant 18F-FDG uptake, in\nline with the unremarkable CT findings.\n\n**Impression:** The PET-CT findings are consistent with active\nmetastatic disease. There is evidence of hypermetabolic pulmonary\nnodules, a likely cardiac metastasis, hepatic and muscular metastases,\nand metabolically active skeletal lesions in both the thorax and pelvis.\nAdditionally, there is hypermetabolism in the lymph nodes across\nmultiple regions. These findings align closely with the previously\ndiagnosed metastatic melanoma, Stage IV, M1c**. **\n\n**Discussion**\n\nMrs. Done has been diagnosed with recurrent metastatic melanoma with\nlymph node involvement. This poses significant implications for her\nprognosis, emphasizing the need for urgent and comprehensive\nintervention.\n\nHer molecular profile has revealed the presence of the BRAF V600E\nmutation.\n\nOur recommended therapeutic combination includes Vemurafenib and\nCobimetinib, both of which are aimed at disrupting the aberrant BRAF-MEK\nsignaling cascade. Complementing this, we suggest the administration of\nPembrolizumab.\n\nMrs. Done is scheduled for six cycles of this treatment regimen. We will\nmonitor her laboratory parameters, such as blood counts, electrolytes,\nand hepatic and renal profiles, bi-weekly. It is imperative to note that\nany fevers surpassing 38.3°C warrant immediate medical attention.\n\nComprehensive patient education module has been designed to enable Mrs.\nDone to identify and manage any potential side effects efficiently.\n\nWe will ensure rigorous monitoring of her blood pressure and lipid\nmetrics, with the possibility of introducing alternative medications if\nclinical scenarios demand.\n\nWe deeply value your collaboration in Mrs. Done\\'s healthcare journey.\nOur team remains at your disposal for any queries or clarifications.\n\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n\n\n\n\nHere is the query:\nMr. Nilsson's Gamma-GT levels showed which change from March 2008 to July 2008?\n\nChoose the correct answer from the following options:\nA. Increased significantly.\nB. Decreased significantly.\nC. Remained stable.\nD. Were not measured in March 2008.\nE. Were only measured in October 2021.\n\n\nYour response:\n", "role": "user" }, { "content": "Decreased significantly.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n\n\n### text_3\n**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n\n\n### text_7\n**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n\n\n### text_8\n**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n\n\n### text_9\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n\n\n### text_10\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n\n\n### text_11\n**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n\n\n### text_12\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n\n\n\n\nHere is the query:\nWhat was the diagnosis for Mrs. Anderson during her inpatient treatment from 07/20/2023 to 09/12/2023?\n\nChoose the correct answer from the following options:\nA. Seropneumothorax due to a clot at the port tip\nB. Seropneumothorax due to lung metastasis from pancreatic carcinoma\nC. Seropneumothorax secondary to punction of a malignant pleural effusion with progressive pulmonary metastasis of a pancreatic head carcinoma\nD. Pneumothorax due to lung metastasis from pancreatic carcinoma\nE. Seropneumothorax due to gemcitabine toxicity\n\n\nYour response:\n", "role": "user" }, { "content": "Seropneumothorax secondary to punction of a malignant pleural effusion with progressive pulmonary metastasis of a pancreatic head carcinoma", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n", "title": "text_9" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n", "title": "text_10" }, { "content": "**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n", "title": "text_11" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n", "title": "text_12" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was under our inpatient care from 03/25/2016 to\n03/30/2016.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- Uncomplicated biopsy, pending results\n\n- LifeVest has been adjusted\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Medical History:** The patient was admitted with suspected myocarditis\ndue to a significantly impaired pump function noticed during outpatient\nvisits. Anamnestically, the patient reported experiencing fatigue and\nexertional dyspnea since mid-December, with no recollection of a\npreceding infection. Antiviral therapy with Interferon/Ribavirin for\nchronic Hepatitis C had been ongoing since November. An outpatient\nevaluation had excluded relevant coronary artery disease.\n\n**Current Presentation:** Suspected inflammatory/dilated cardiomyopathy,\nIndication for biopsy\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Coronary Angiography**: Globally significantly impaired left\nventricular function (EF: 28%)\n\n[Myocardial biopsy:]{.underline} Uncomplicated retrieval of LV\nendomyocardial biopsies\n\n[Recommendation]{.underline}: A conservative medical approach is\nrecommended, and further therapeutic decisions will depend on the\nhistological, immunohistological, and molecular biological examination\nresults of the now-retrieved myocardial biopsies.\n\n[Procedure]{.underline}: Femoral closure system is applied, 6 hours of\nbed rest, administration of 100 mg/day of Aspirin for 4 weeks following\nleft ventricular heart biopsy.\n\n**Echocardiography before Heart Catheterization**:\n\nPerformed in sinus rhythm. Satisfactory ultrasound condition.\n\n[Findings]{.underline}: Moderately dilated left ventricle (LVDd 64mm).\nMarkedly reduced systolic LV function (EF 28%). Global longitudinal\nstrain (2D speckle tracking): -8.6%.\n\nRegional wall motion abnormalities: despite global hypokinesia, the\nposterolateral wall (basal) contracts best. Diastolic dysfunction Grade\n1 (LV relaxation disorder) (E/A 0.7) (E/E\\' mean 13.8). No LV\nhypertrophy. Morphologically age-appropriate heart valves. Moderately\ndilated left atrium (LA Vol. 71ml). Mild mitral valve insufficiency\n(Grade 1 on a 3-grade scale). Normal-sized right ventricle. Moderately\nreduced RV function Normal-sized right atrium. Minimal tricuspid valve\ninsufficiency (Grade 0-1 on a 3-grade scale). Systolic pulmonary artery\npressure in the normal range (systolic PAP 27mmHg).\n\nNo thrombus detected. Minimal pericardial effusion, circular, maximum\n2mm, no hemodynamic relevance.\n\n**Echocardiography after Heart Catheterization:**\n\n[Indication]{.underline}: Follow-up on pericardial effusion.\n\n[Examination]{.underline}: TTE at rest, including duplex and\nquantitative determination of parameters. [Echocardiographic\nFinding:]{.underline} Regarding pericardial effusion, the status is the\nsame. Circular effusion, maximum 2mm.\n\n**ECG after Heart Catheterization:**\n\n76/min, sinus rhythm, complete left bundle branch block.\n\n**Summary:** On 03/26/2016, biopsy and left heart catheterization were\nsuccessfully performed without complications. Here, too, the patient\nexhibited a significantly impaired pump function, currently at 28%.\n\n**Therapy and Progression:**\n\nThroughout the inpatient stay, the patient remained cardiorespiratorily\nstable at all times. Malignant arrhythmias were ruled out via telemetry.\nAfter the intervention, echocardiography showed no pericardial effusion.\nThe results of the endomyocardial biopsies are still pending. An\nappointment for results discussion and evaluation of further procedures\nat our facility should be scheduled in 3 weeks. Following the biopsy,\nAspirin 100 as specified should be given for 4 weeks. We intensified the\nongoing heart failure therapy and added Spironolactone to the\nmedication, recommending further escalation based on hemodynamic\ntolerability.\n\n**Current Recommendations:** Close cardiological follow-up examinations,\nelectrolyte monitoring, and echocardiography are advised. Depending on\nthe left ventricular ejection fraction\\'s course, the implantation of an\nICD or ICD/CRT system should be considered after 3 months. On the day of\ndischarge, we initiated the adjustment of a Life Vest, allowing the\npatient to return home in good general condition.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------ ------------- ---------------------\n Absolute Erythroblasts 0.01/nL \\< 0.01/nL\n Sodium 134 mEq/L 136-145 mEq/L\n Potassium 4.5 mEq/L 3.5-4.5 mEq/L\n Creatinine (Jaffé) 1.25 mg/dL 0.70-1.20 mg/dL\n Urea 50 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n CRP 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine 14.2 ng/L 9.30-17.00 ng/L\n TSH 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Erythrocytes 3.7 /pL 4.3-5.8/pL\n Leukocytes 9.56/nL 3.90-10.50/nL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n PTT Actin-FS 25.3 sec. 22.0-29.0 sec.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the pending findings of the myocardial biopsies\ntaken from Mr. David Romero, born on 02/16/1942 on 03/26/2016 due to the\ndeterioration of LV function from 40% to 28% after interferon therapy\nfor HCV infection.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Myocardial Biopsy on 01/27/2014:**\n\n[Molecular Biology:]{.underline}\n\nPCR examinations performed under the question of myocardial infection\nwith cardiotropic pathogens yielded a positive detection of HCV-specific\nRNA in myocardial tissue without quantification possibility\n(methodically determined). Otherwise, there was no evidence of\nmyocardial infection with enteroviruses, adenoviruses, Epstein-Barr\nvirus, Human Herpes Virus Type 6 A/B, or Erythrovirus genotypes 1/2 in\nthe myocardium.\n\n[Assessment]{.underline}: Positive HCV-mRNA detection in myocardial\ntissue. This positive test result does not unequivocally prove an\ninfection of myocardial cells, as contamination of the tissue sample\nwith HCV-infected peripheral blood cells cannot be ruled out in chronic\nhepatitis.\n\n**Histology and Immunohistochemistry**:\n\nUnremarkable endocardium, normal cell content of the interstitium with\nonly isolated lymphocytes and histiocytes in the histologically examined\nsamples. Quantitatively, immunohistochemically examined native\npreparations showed borderline high CD3-positive lymphocytes with a\ndiffuse distribution pattern at 10.2 cells/mm2. No increased\nperforin-positive cytotoxic T cells. The expression of cell adhesion\nmolecules is discreetly elevated. Otherwise, only slight perivascular\nbut no interstitial fibrosis. Cardiomyocytes are properly arranged and\nslightly hypertrophied (average diameter around 23 µm), the surrounding\ncapillaries are unremarkable. No evidence of acute\ninflammation-associated myocardial cell necrosis (no active myocarditis)\nand no interstitial scars from previous myocyte loss. No lipomatosis.\n\n[Assessment:]{.underline} Based on the myocardial biopsy findings, there\nis positive detection of HCV-RNA in the myocardial tissue samples, with\nthe possibility of tissue contamination with HCV-infected peripheral\nblood cells. Significant myocardial inflammatory reaction cannot be\ndocumented histologically and immunohistochemically. In the endocardial\nsamples, apart from mild hypertrophy of properly arranged\ncardiomyocytes, there are no significant signs of myocardial damage\n(interstitial fibrosis or scars from previous myocyte loss). Therefore,\nthe present findings do not indicate the need for specific further\nantiviral or anti-inflammatory therapy, and the existing heart failure\nmedication can be continued unchanged. If LV function impairment\npersists for an extended period, there is an indication for\nantiarrhythmic protection of the patient using an ICD.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe thank you for referring your patient Mr. David Romero, born on\n02/16/1942, to us for echocardiographic follow-up on 05/04/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Echocardiography: M-mode and 2-dimensional.**\n\nThe left ventricle measures approximately 65/56 mm (normal up to 56 mm).\n\nThe right atrium and right ventricle are of normal dimensions.\n\nGlobal progressive reduction in contractility, morphologically\nunremarkable.\n\nIn Doppler echocardiography, normal heart valves are observed.\n\nMitral valve insufficiency Grade I.\n\n[Assessment]{.underline}: Dilated cardiomyopathy with slightly reduced\nleft ventricular function. MI I TII °, PAP 23 mm Hg + CVP. No more\npulmonary embolism detectable.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942 to us for echocardiographic follow-up on 06/15/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Echocardiography from 06/15/2016**: Good ultrasound conditions.\n\nThe left ventricle is dilated to approximately 65/57 mm (normal up to 56\nmm). The left atrium is dilated to 48 mm. Normal thickness of the left\nventricular myocardium. Ejection fraction is around 28%. Heart valves\nshow normal flow velocities.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing,\npotassium and creatinine levels were obtained. If EF remains this low,\nan ICD may be indicated.\n\n**Lab results from 06/15/2016:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.8 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n Platelet Count 280 K/µL 150-370 K/µL\n MC 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting to you about Mr. David Romero, born on 02/16/1942, who\npresented himself at our Cardiology University Outpatient Clinic on\n06/30/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ---------------- ---------------\n Aspirin 100 mg/tablet 1-0-0\n Ramipril (Altace) 2.5 mg/tablet 1-0-1\n Carvedilol (Coreg) 12.5 mg/tablet 1-0-1\n Torasemide (Torem) 5 mg/tablet 1-0-0\n Spironolactone (Aldactone) 25 mg/tablet 1-0-0\n L-Thyroxine (Synthroid) 50 µg/tablet 1-0-0\n\n**Echocardiography on 06/30/2016:** In sinus rhythm. Adequate ultrasound\nwindow.\n\nModerately dilated left ventricle (LVDd 63mm). Significantly reduced\nsystolic LV function (EF biplane 29%). No LV hypertrophy.\n\n**ECG on 06/30/2016:** Sinus rhythm, regular tracing, heart rate 69/min,\ncomplete left bundle branch block, QRS 135 ms, ERBS with left bundle\nbranch block.\n\n**Assessment**: Mr. Romero presents himself for the follow-up assessment\nof known dilated cardiomyopathy. He currently reports minimal dyspnea.\nCoronary heart disease has been ruled out. No virus was detected\nbioptically. However, the recent echocardiography still shows severely\nimpaired LV function.\n\n**Current Recommendations:** Given the presence of left bundle branch\nblock, there is an indication for CRT-D implantation. For this purpose,\nwe have scheduled a pre-admission appointment, with the implantation\nplanned for 07/04/2016. We kindly request a referral letter. The\nLifeVest should continue to be worn until the implantation, despite the\npressure sores on the thorax.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was in our inpatient care from 07/04/2016 to\n07/06/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation:** The current admission was elective for CRT-D\nimplantation in dilated cardiomyopathy with severely impaired LV\nfunction despite full heart failure medication and complete left bundle\nbranch block. Please refer to previous medical records for a detailed\nhistory. On 07/05/2016, a CRT-ICD system was successfully implanted. The\nperi- and post-interventional course was uncomplicated. Pneumothorax was\nruled out post-interventionally. The wound conditions are\nirritation-free. The ICD card was given to the patient. We request\noutpatient follow-up on the above-mentioned date for wound inspection\nand CRT follow-up. Please adjust the known cardiovascular risk factors.\n\n**Findings:**\n\n**ECG upon Admission:** Sinus rhythm 66/min, PQ 176ms, QRS 126ms, QTc\n432ms, Complete left bundle branch block with corresponding excitation\nregression disorder.\n\n**Procedure**: Implantation of a CRT-D with left ventricular multipoint\npacing left pectoral. Smooth triple puncture of the lateral left\nsubclavian vein and implantation of an active single-coil electrode in\nthe RV apex with very good electrical values. Trouble-free probing of\nthe CS and direct venography using a balloon occlusion catheter.\nIdentification of a suitable lateral vein and implantation of a\nquadripolar electrode (Quartet, St. Jude Medical) with very good\nelectrical values. No phrenic stimulation up to 10 volts in all\npolarities. Finally, implantation of an active P/S electrode in the\nright atrial roof with equally very good electrical values. Connection\nto the device and submuscular implantation. Wound irrigation and layered\nwound closure with absorbable suture material. Finally, extensive\ntesting of all polarities of the LV electrode and activation of\nmultipoint pacing. Final setting of the ICD.\n\n**Chest X-ray on 07/05/2016:**\n\n[Clinical status, question, justifying indication:]{.underline} History\nof CRT-D implantation. Question about lead position, pneumothorax?\n\n**Findings**: New CRT-D unit left pectoral with leads projected onto the\nright ventricle, the right atrium, and the sinus coronarius. No\npneumothorax.\n\nNormal heart size. No pulmonary congestion. No diffuse infiltrates. No\npleural effusions.\n\n**ECG at Discharge:** Continuous ventricular PM stimulation, HR: 66/min.\n\n**Current Recommendations:**\n\n- We request a follow-up appointment in our Pacemaker Clinic. Please\n provide a referral slip.\n\n- We ask for the protection of the left arm and avoidance of\n elevations \\> 90 degrees. Self-absorbing sutures have been used.\n\n- We request regular wound checks.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942, who presented to our Cardiological University Outpatient\nClinic on 08/26/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation**: Slightly increasing exertional dyspnea, no\ncoronary heart disease.\n\n**Cardiovascular Risk Factors:**\n\n- Family history: No\n\n- Smoking: No\n\n- Hypertension: No\n\n- Diabetes: Yes\n\n- Dyslipidemia: Yes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Findings**:\n\n**Resting ECG:** Sinus rhythm, 83 bpm. Blood pressure: 120/70 mmHg.\n\n**Echocardiography: M-mode and 2-dimensional**\n\nLeft ventricle dimensions: Approximately 57/45 mm (normal up to 56 mm),\nmoderately dilated\n\n- Right atrium and right ventricle: Normal dimensions\n\n- Normal thickness of left ventricular muscle\n\n- Globally, mild reduction in contractility\n\n- Heart valves: Morphologically normal\n\n- Doppler-Echocardiography: No significant valve regurgitation\n\n**Assessment**: Mildly dilated cardiomyopathy with slightly reduced left\nventricular function. Ejection fraction at 45 - 50%. Mild diastolic\ndysfunction. Mild tricuspid regurgitation, pulmonary artery pressure 22\nmm Hg, and left ventricular filling pressure slightly increased.\n\n**Stress Echocardiography: Stress echocardiography with exercise test**\n\n- Stress test protocol: Treadmill exercise test\n\n- Reason for stress test: Exertional dyspnea\n\n- Quality of the ultrasound: Good\n\n- Initial workload: 50 watts\n\n- Maximum workload achieved: 150 Watt\n\n- Blood pressure response: Systolic BP increased from 112/80 mmHg to\n 175/90 mmHg\n\n- Heart rate response: Increased from 71bpm to 124bpm\n\n- Exercise terminated due to leg pain\n\n**Resting ECG:** Sinus rhythm**.** No significant changes during\nexercise\n\n**Echocardiography at rest:** Normokinesis of all left ventricular\nsegments EF: 45 - 50%\n\n**Echocardiography during exercise:** Increased contractility and wall\nthickening of all segments\n\n[Summary]{.underline}: No dynamic wall motion abnormalities. No evidence\nof exercise-induced myocardial ischemia\n\n**Carotid Doppler Ultrasound:** Both common carotid arteries are\nsmooth-walled**.** Intima-media thickness: 0.8 mm**.** Small plaque in\nthe carotid bulb on both sides**.** Normal flow in the internal and\nexternal carotid arteries**.** Normal dimensions and flow in the\nvertebral arteries\n\n**Summary:** Non-obstructive carotid plaques**.** Indicated to lower LDL\nto below 1.8 mmol/L\n\n**Summary:**\n\n- Stress echocardiography shows no evidence of ischemia, EF \\>45-50%\n\n- Carotid duplex shows minimal non-obstructive plaques\n\n- Increase Simvastatin to 20 mg, target LDL-C \\< 1.8 mmol/L\n\n\n\n### text_7\n**Dear colleague, **\n\nWe would like to inform you about the results of the cardiac\ncatheterization of Mr. David Romero, born on 02/16/1942 performed by us\non 08/10/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Procedure:** Right femoral artery puncture. Left ventriculography with\na 5F pigtail catheter in the right anterior oblique projection. Coronary\nangiography with 5F JL4.0 and 5F JR 4.0 catheters. End-diastolic\npressure in the left ventricle within the normal range, measured in\nmmHg. No pathological pressure gradient across the aortic valve.\n\n**Coronary angiography:**\n\n- Unremarkable left main stem.\n\n- The left anterior descending (LAD) artery shows mild wall changes,\n with a maximum stenosis of 20-\\<30%.\n\n- The robust right coronary artery (RCA) is stenosed proximally by\n 30-40%, subsequently ectatic and then stenosed to 40-\\<50% distally.\n Slow contrast clearance. The right coronary artery is also stenosed\n up to 30%.\n\n- Left-dominant coronary circulation.\n\n**Assessment**: Diffuse coronary atherosclerosis with less than 50%\nstenosis in the RCA and evidence of endothelial dysfunction.\n\n**Current Recommendations:**\n\n- Initiation of Ranolazine\n\n- Additional stress myocardial perfusion scintigraphy\n\n\n\n### text_8\n**Dear colleague, **\n\nWe would like to inform you about the results of the Myocardial\nPerfusion Scintigraphy performed on our patient, Mr. David Romero, born\non 02/16/1942, on 09/23/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Myocardial Perfusion Scintigraphy:**\n\nThe myocardial perfusion scintigraphy was conducted using 365 MBq of\n99m-Technetium MIBI during pharmacological stress and 383 MBq of\n99m-Technetium MIBI at rest.\n\n[Technique]{.underline}: Initially, the patient was pharmacologically\nstressed with the intravenous administration of 400 µg of Regadenoson\nover 20 seconds, accompanied by ergometer exercise at 50 W.\nSubsequently, the intravenous injection of the radiopharmaceutical was\nperformed. The maximum blood pressure achieved during the stress phase\nwas 143/84 mm Hg, and the maximum heart rate reached was 102 beats per\nminute.\n\nApproximately 60 minutes later, ECG-triggered acquisition of a\n360-degree SPECT study was conducted with reconstructions of short and\nlong-axis slices.\n\nDue to inhomogeneities in the myocardial wall segments during stress,\nrest images were acquired on another examination day. Following the\nintravenous injection of the radiopharmaceutical, ECG-triggered\nacquisition of a 360-degree SPECT study was performed, including\nshort-axis and long-axis slices, approximately 60 minutes later.\n\n[Clinical Information:]{.underline} Known coronary heart disease (RCA\n50%). ICD/CRT pacemaker.\n\n[Findings]{.underline}: No clear perfusion defects are seen in the\nscintigraphic images acquired after pharmacologic exposure to\nRegadenoson. This finding remains unchanged in the scintigraphic images\nacquired at rest.\n\nQuantitative analysis shows a normal-sized ventricle with a normal left\nventricular ejection fraction (LVEF) of 53% under exercise conditions\nand 47% at rest (EDV 81 mL). There are no clear wall motion\nabnormalities. In the gated SPECT analysis, there are no definite wall\nmotion abnormalities observed in both stress and rest conditions.\n\n**Quantitative Scoring:**\n\n- SSS (Summed Stress Score): 3 (4.4%)\n\n- SRS (Summed Rest Score): 0 (0.0%)\n\n- SDS (Summed Difference Score): 3 (4.4%)\n\n**Assessment**: No evidence of myocardial perfusion defects with\nRegadenoson stress or at rest. Normal ventricular size and function with\nno significant wall motion abnormalities.\n\n\n\n### text_9\n**Dear colleague, **\n\nWe would like to report on our patient, Mr. David Romero, born on\n02/16/1942, who was under our inpatient care from 05/20/2023 to\n05/21/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medical History:** The patient was admitted for device replacement due\nand upgrading to a CRT-P pacemaker. At admission, the patient reported\nno complaints of fever, cough, dyspnea, chest pain, or melena.\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Medication upon Admission**\n\n **Medication** **Dosage** **Frequency**\n --------------------------- -------------- ----------------------\n Insulin glargine (Lantus) 450 E/1.5 ml 0-0-0-6-8 IU\n Insulin lispro (Humalog) 300 E/3 ml 5-8 IU-5-8 IU-5-8 IU\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Colecalciferol 12.5 mcg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n\n**Therapy and Progression:** The patient\\'s current admission was\nelective for the implantation of a 3-chamber CRT-D device due to device\ndepletion. The procedure was performed without complications on\n05/20/2023. The post-interventional course was uneventful. The\nimplantation site showed no irritation or significant hematoma at the\ntime of discharge, and no pneumothorax was detected on X-ray.\n\nTo protect the surgical wound, we request dry wound dressing for the\nnext 10 days and clinical wound checks. Suture removal is not necessary\nwith absorbable suture material. We advise against arm elevation for the\nnext 4 weeks, avoiding heavy lifting on the side of the device pocket\nand gradual, pain-adapted full range of motion after 4 weeks.\n\n**Current Recommendations:** We kindly request an outpatient follow-up\nappointment in our Pacemaker Clinic.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage ** **Frequency**\n ----------------------------- --------------- -----------------------\n Insulin glargine (Lantus) 450 E./1.5 ml 0-0-0-/6-8 IU\n Insulin lispro (Humalog) 300 E./3 ml 5-8 IU/-5-8 IU/5-8 IU\n Levothyroxine (Synthroid) 100 µg 1-0-0-0\n Colecalciferol (Vitamin D3) 12.5 µg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Colecalciferol 12.5 µg 2-0-0-0\n\n**Addition: Findings:**\n\n**ECG at Discharge:** Sinus rhythm, ventricular pacing, QRS 122ms, QTc\n472ms\n\n**Rhythm Examination on 05/20/2023:**\n\n[Results:]{.underline} Replacement of a 3-chamber CRT-D device (new:\nSJM/Abbott Quadra Assura) due to impending battery depletion:\nUncomplicated replacement. Tedious freeing of the submuscular device and\nproximal lead portions using a plasma blade. Extraction of the old\ndevice. Connection to the new device. Avoidance of device fixation in\nthe submuscular position. Hemostasis by electrocauterization. Layered\nwound closure. Skin closure with absorbable intracutaneous sutures. End\nadjustment of the CRT-D device is complete. [Procedure]{.underline}:\nCompression of the wound with a sandbag and local cooling. First\noutpatient follow-up in 8 weeks through our pacemaker clinic (please\nschedule an appointment before discharge). Postoperative chest X-ray is\nnot necessary. Cefuroxime 1.5 mg again tonight.\n\n**Transthoracic Echocardiography on 05/18/2023**\n\n**Results:** Globally mildly impaired systolic LV function. Diastolic\ndysfunction Grade 1 (LV relaxation disorder).\n\n- Right Ventricle: Normal-sized right ventricle. Normal RV function.\n Pulmonary arterial pressure is normal.\n\n- Left Atrium: Slightly dilated left atrium.\n\n- Right Atrium: Normal-sized right atrium.\n\n- Mitral Valve: Morphologically unremarkable. Minimal mitral valve\n regurgitation.\n\n- Aortic Valve: Mildly sclerotic aortic valve cusps. No aortic valve\n insufficiency. No aortic valve stenosis (AV PGmax 7 mmHg).\n\n- Tricuspid Valve: Delicate tricuspid valve leaflets. Minimal\n tricuspid valve regurgitation (TR Pmax 26 mmHg).\n\n- Pulmonary Valve: No pulmonary valve insufficiency. Pericardium: No\n pericardial effusion.\n\n**Assessment**: Examination in sinus rhythm with bundle branch block.\nModerate ultrasound windows. Normal-sized left ventricle (LVED 54 mm)\nwith mildly reduced systolic LV function (EF biplan 55%) with mildly\nreduced contractility without regional emphasis. Mild LV hypertrophy,\npredominantly septal, without obstruction. Diastolic dysfunction Grade 1\n(E/A 0.47) with a normal LV filling index (E/E\\' mean 3.5). Slightly\nsclerotic aortic valve without stenosis, no AI. Slightly dilated left\natrium (LAVI 31 ml/m²). Minimal MI. Normal-sized right ventricle with\nnormal function. Normal-sized right atrium (RAVI 21 ml/m²). Minimal TI.\nAs far as assessable, systolic PA pressure is within the normal range.\nThe IVC cannot be viewed from the subcostal angle. No thrombi are\nvisible. As far as assessable, no pericardial effusion is visible.\n\n**Chest X-ray in two planes on 05/20/2023: **\n\n[Clinical Information, Question, Justification:]{.underline} Post CRT\ndevice replacement. Inquiry about position, pneumothorax.\n\n[Findings]{.underline}: No pneumothorax following CRT device\nreplacement.\n\n\n\n### text_10\n**Dear colleague, **\n\nWe are writing to provide an update on Mr. David Romero, born on\n02/16/1942, who presented at our Rhythm Clinic on 09/29/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ------------------ ---------------\n Lantus (Insulin glargine) 450 Units/1.5 mL 0-0-0-/6-8\n Humalog (Insulin lispro) 300 Units/3 mL 5-8/0/5-8/5-8\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n Lipitor (Atorvastatin) 21.7 mg 0-0-1-0\n Norvasc (Amlodipine) 6.94 mg 1-0-0-0\n Altace (Ramipril) 5 mg 1-0-0-0\n Demadex (Torasemide) 5 mg 0-0-0.5-0\n Coreg (Carvedilol) 25 mg 0.5-0-0.5-0\n Zocor (Simvastatin) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n\n**Measurement Results:**\n\nBattery/Capacitor: Status: OK, Voltage: 8.4V\n\n- Right Atrial: 375 Ohms 3.80 mV 0.375 V 0.50 ms\n\n- Right Ventricular: 388 Ohms 11.80 mV 0.750 V 0.50 ms\n\n- Left Ventricular: 350 Ohms 0.625 V 0.50 ms\n\n- Defibrillation Impedance: Right Ventricular: 48 Ohms\n\n**Implant Settings:**\n\n- Bradycardia Setting: Mode: DDD\n\n- Tachycardia Settings: Zone Detection Interval (ms) Detection Beats\n ATP Shocks Details Status\n\n - VFVF 260 ms 30 /\n\n - VTVT1 330 ms 55 /\n\n<!-- -->\n\n- Probe Settings: Lead Sensitivity Sensing Polarity/Vector\n Amplification/Pulse Width Stimulation Polarity/Vector Auto Amplitude\n Control\n\n - Right Atrial: 0.30 mV Bipolar/ 1.375 V/0.50 ms Bipolar/\n\n - Right Ventricular: Bipolar/ 2.000 V/0.50 ms Bipolar/\n\n - Left Ventricular: 2.000 V/0.50 ms tip 1 - RV Coil\n\n**Assessment:**\n\n- Routine visit with normal device function.\n\n- Normal sinus rhythm with a heart rate of 65/min.\n\n- Balanced heart rate histogram with a plateau at 60-70 bpm.\n\n- Wound conditions are unremarkable.\n\n- Battery status: OK.\n\n- Atrial probe: Intact\n\n- Right ventricular probe: Intact\n\n- Left ventricular probe: Intact\n\n- A follow-up appointment for the patient is requested in 6 months.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.8 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 5.9 mg/L \\< 5.0 mg/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n MCV 92.7 fL 80.0-99.0 fL\n MCH 31.8 pg 27.0-33.5 pg\n MCHC 33.9 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.2% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n\n\n\nHere is the query:\nWhat was the new diagnosis added to Mr. Romero's medical history as of 05/04/2016?\n\nChoose the correct answer from the following options:\nA. Hypothyroidism\nB. Type 2 diabetes mellitus\nC. Chronic Hepatitis C\nD. Post-antiviral therapy\nE. Status post Hepatitis A\n\n\nYour response:\n", "role": "user" }, { "content": "Type 2 diabetes mellitus", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was under our inpatient care from 03/25/2016 to\n03/30/2016.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- Uncomplicated biopsy, pending results\n\n- LifeVest has been adjusted\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Medical History:** The patient was admitted with suspected myocarditis\ndue to a significantly impaired pump function noticed during outpatient\nvisits. Anamnestically, the patient reported experiencing fatigue and\nexertional dyspnea since mid-December, with no recollection of a\npreceding infection. Antiviral therapy with Interferon/Ribavirin for\nchronic Hepatitis C had been ongoing since November. An outpatient\nevaluation had excluded relevant coronary artery disease.\n\n**Current Presentation:** Suspected inflammatory/dilated cardiomyopathy,\nIndication for biopsy\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Coronary Angiography**: Globally significantly impaired left\nventricular function (EF: 28%)\n\n[Myocardial biopsy:]{.underline} Uncomplicated retrieval of LV\nendomyocardial biopsies\n\n[Recommendation]{.underline}: A conservative medical approach is\nrecommended, and further therapeutic decisions will depend on the\nhistological, immunohistological, and molecular biological examination\nresults of the now-retrieved myocardial biopsies.\n\n[Procedure]{.underline}: Femoral closure system is applied, 6 hours of\nbed rest, administration of 100 mg/day of Aspirin for 4 weeks following\nleft ventricular heart biopsy.\n\n**Echocardiography before Heart Catheterization**:\n\nPerformed in sinus rhythm. Satisfactory ultrasound condition.\n\n[Findings]{.underline}: Moderately dilated left ventricle (LVDd 64mm).\nMarkedly reduced systolic LV function (EF 28%). Global longitudinal\nstrain (2D speckle tracking): -8.6%.\n\nRegional wall motion abnormalities: despite global hypokinesia, the\nposterolateral wall (basal) contracts best. Diastolic dysfunction Grade\n1 (LV relaxation disorder) (E/A 0.7) (E/E\\' mean 13.8). No LV\nhypertrophy. Morphologically age-appropriate heart valves. Moderately\ndilated left atrium (LA Vol. 71ml). Mild mitral valve insufficiency\n(Grade 1 on a 3-grade scale). Normal-sized right ventricle. Moderately\nreduced RV function Normal-sized right atrium. Minimal tricuspid valve\ninsufficiency (Grade 0-1 on a 3-grade scale). Systolic pulmonary artery\npressure in the normal range (systolic PAP 27mmHg).\n\nNo thrombus detected. Minimal pericardial effusion, circular, maximum\n2mm, no hemodynamic relevance.\n\n**Echocardiography after Heart Catheterization:**\n\n[Indication]{.underline}: Follow-up on pericardial effusion.\n\n[Examination]{.underline}: TTE at rest, including duplex and\nquantitative determination of parameters. [Echocardiographic\nFinding:]{.underline} Regarding pericardial effusion, the status is the\nsame. Circular effusion, maximum 2mm.\n\n**ECG after Heart Catheterization:**\n\n76/min, sinus rhythm, complete left bundle branch block.\n\n**Summary:** On 03/26/2016, biopsy and left heart catheterization were\nsuccessfully performed without complications. Here, too, the patient\nexhibited a significantly impaired pump function, currently at 28%.\n\n**Therapy and Progression:**\n\nThroughout the inpatient stay, the patient remained cardiorespiratorily\nstable at all times. Malignant arrhythmias were ruled out via telemetry.\nAfter the intervention, echocardiography showed no pericardial effusion.\nThe results of the endomyocardial biopsies are still pending. An\nappointment for results discussion and evaluation of further procedures\nat our facility should be scheduled in 3 weeks. Following the biopsy,\nAspirin 100 as specified should be given for 4 weeks. We intensified the\nongoing heart failure therapy and added Spironolactone to the\nmedication, recommending further escalation based on hemodynamic\ntolerability.\n\n**Current Recommendations:** Close cardiological follow-up examinations,\nelectrolyte monitoring, and echocardiography are advised. Depending on\nthe left ventricular ejection fraction\\'s course, the implantation of an\nICD or ICD/CRT system should be considered after 3 months. On the day of\ndischarge, we initiated the adjustment of a Life Vest, allowing the\npatient to return home in good general condition.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------ ------------- ---------------------\n Absolute Erythroblasts 0.01/nL \\< 0.01/nL\n Sodium 134 mEq/L 136-145 mEq/L\n Potassium 4.5 mEq/L 3.5-4.5 mEq/L\n Creatinine (Jaffé) 1.25 mg/dL 0.70-1.20 mg/dL\n Urea 50 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n CRP 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine 14.2 ng/L 9.30-17.00 ng/L\n TSH 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Erythrocytes 3.7 /pL 4.3-5.8/pL\n Leukocytes 9.56/nL 3.90-10.50/nL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n PTT Actin-FS 25.3 sec. 22.0-29.0 sec.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the pending findings of the myocardial biopsies\ntaken from Mr. David Romero, born on 02/16/1942 on 03/26/2016 due to the\ndeterioration of LV function from 40% to 28% after interferon therapy\nfor HCV infection.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Myocardial Biopsy on 01/27/2014:**\n\n[Molecular Biology:]{.underline}\n\nPCR examinations performed under the question of myocardial infection\nwith cardiotropic pathogens yielded a positive detection of HCV-specific\nRNA in myocardial tissue without quantification possibility\n(methodically determined). Otherwise, there was no evidence of\nmyocardial infection with enteroviruses, adenoviruses, Epstein-Barr\nvirus, Human Herpes Virus Type 6 A/B, or Erythrovirus genotypes 1/2 in\nthe myocardium.\n\n[Assessment]{.underline}: Positive HCV-mRNA detection in myocardial\ntissue. This positive test result does not unequivocally prove an\ninfection of myocardial cells, as contamination of the tissue sample\nwith HCV-infected peripheral blood cells cannot be ruled out in chronic\nhepatitis.\n\n**Histology and Immunohistochemistry**:\n\nUnremarkable endocardium, normal cell content of the interstitium with\nonly isolated lymphocytes and histiocytes in the histologically examined\nsamples. Quantitatively, immunohistochemically examined native\npreparations showed borderline high CD3-positive lymphocytes with a\ndiffuse distribution pattern at 10.2 cells/mm2. No increased\nperforin-positive cytotoxic T cells. The expression of cell adhesion\nmolecules is discreetly elevated. Otherwise, only slight perivascular\nbut no interstitial fibrosis. Cardiomyocytes are properly arranged and\nslightly hypertrophied (average diameter around 23 µm), the surrounding\ncapillaries are unremarkable. No evidence of acute\ninflammation-associated myocardial cell necrosis (no active myocarditis)\nand no interstitial scars from previous myocyte loss. No lipomatosis.\n\n[Assessment:]{.underline} Based on the myocardial biopsy findings, there\nis positive detection of HCV-RNA in the myocardial tissue samples, with\nthe possibility of tissue contamination with HCV-infected peripheral\nblood cells. Significant myocardial inflammatory reaction cannot be\ndocumented histologically and immunohistochemically. In the endocardial\nsamples, apart from mild hypertrophy of properly arranged\ncardiomyocytes, there are no significant signs of myocardial damage\n(interstitial fibrosis or scars from previous myocyte loss). Therefore,\nthe present findings do not indicate the need for specific further\nantiviral or anti-inflammatory therapy, and the existing heart failure\nmedication can be continued unchanged. If LV function impairment\npersists for an extended period, there is an indication for\nantiarrhythmic protection of the patient using an ICD.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient Mr. David Romero, born on\n02/16/1942, to us for echocardiographic follow-up on 05/04/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Echocardiography: M-mode and 2-dimensional.**\n\nThe left ventricle measures approximately 65/56 mm (normal up to 56 mm).\n\nThe right atrium and right ventricle are of normal dimensions.\n\nGlobal progressive reduction in contractility, morphologically\nunremarkable.\n\nIn Doppler echocardiography, normal heart valves are observed.\n\nMitral valve insufficiency Grade I.\n\n[Assessment]{.underline}: Dilated cardiomyopathy with slightly reduced\nleft ventricular function. MI I TII °, PAP 23 mm Hg + CVP. No more\npulmonary embolism detectable.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942 to us for echocardiographic follow-up on 06/15/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Echocardiography from 06/15/2016**: Good ultrasound conditions.\n\nThe left ventricle is dilated to approximately 65/57 mm (normal up to 56\nmm). The left atrium is dilated to 48 mm. Normal thickness of the left\nventricular myocardium. Ejection fraction is around 28%. Heart valves\nshow normal flow velocities.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing,\npotassium and creatinine levels were obtained. If EF remains this low,\nan ICD may be indicated.\n\n**Lab results from 06/15/2016:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.8 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n Platelet Count 280 K/µL 150-370 K/µL\n MC 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about Mr. David Romero, born on 02/16/1942, who\npresented himself at our Cardiology University Outpatient Clinic on\n06/30/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ---------------- ---------------\n Aspirin 100 mg/tablet 1-0-0\n Ramipril (Altace) 2.5 mg/tablet 1-0-1\n Carvedilol (Coreg) 12.5 mg/tablet 1-0-1\n Torasemide (Torem) 5 mg/tablet 1-0-0\n Spironolactone (Aldactone) 25 mg/tablet 1-0-0\n L-Thyroxine (Synthroid) 50 µg/tablet 1-0-0\n\n**Echocardiography on 06/30/2016:** In sinus rhythm. Adequate ultrasound\nwindow.\n\nModerately dilated left ventricle (LVDd 63mm). Significantly reduced\nsystolic LV function (EF biplane 29%). No LV hypertrophy.\n\n**ECG on 06/30/2016:** Sinus rhythm, regular tracing, heart rate 69/min,\ncomplete left bundle branch block, QRS 135 ms, ERBS with left bundle\nbranch block.\n\n**Assessment**: Mr. Romero presents himself for the follow-up assessment\nof known dilated cardiomyopathy. He currently reports minimal dyspnea.\nCoronary heart disease has been ruled out. No virus was detected\nbioptically. However, the recent echocardiography still shows severely\nimpaired LV function.\n\n**Current Recommendations:** Given the presence of left bundle branch\nblock, there is an indication for CRT-D implantation. For this purpose,\nwe have scheduled a pre-admission appointment, with the implantation\nplanned for 07/04/2016. We kindly request a referral letter. The\nLifeVest should continue to be worn until the implantation, despite the\npressure sores on the thorax.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was in our inpatient care from 07/04/2016 to\n07/06/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation:** The current admission was elective for CRT-D\nimplantation in dilated cardiomyopathy with severely impaired LV\nfunction despite full heart failure medication and complete left bundle\nbranch block. Please refer to previous medical records for a detailed\nhistory. On 07/05/2016, a CRT-ICD system was successfully implanted. The\nperi- and post-interventional course was uncomplicated. Pneumothorax was\nruled out post-interventionally. The wound conditions are\nirritation-free. The ICD card was given to the patient. We request\noutpatient follow-up on the above-mentioned date for wound inspection\nand CRT follow-up. Please adjust the known cardiovascular risk factors.\n\n**Findings:**\n\n**ECG upon Admission:** Sinus rhythm 66/min, PQ 176ms, QRS 126ms, QTc\n432ms, Complete left bundle branch block with corresponding excitation\nregression disorder.\n\n**Procedure**: Implantation of a CRT-D with left ventricular multipoint\npacing left pectoral. Smooth triple puncture of the lateral left\nsubclavian vein and implantation of an active single-coil electrode in\nthe RV apex with very good electrical values. Trouble-free probing of\nthe CS and direct venography using a balloon occlusion catheter.\nIdentification of a suitable lateral vein and implantation of a\nquadripolar electrode (Quartet, St. Jude Medical) with very good\nelectrical values. No phrenic stimulation up to 10 volts in all\npolarities. Finally, implantation of an active P/S electrode in the\nright atrial roof with equally very good electrical values. Connection\nto the device and submuscular implantation. Wound irrigation and layered\nwound closure with absorbable suture material. Finally, extensive\ntesting of all polarities of the LV electrode and activation of\nmultipoint pacing. Final setting of the ICD.\n\n**Chest X-ray on 07/05/2016:**\n\n[Clinical status, question, justifying indication:]{.underline} History\nof CRT-D implantation. Question about lead position, pneumothorax?\n\n**Findings**: New CRT-D unit left pectoral with leads projected onto the\nright ventricle, the right atrium, and the sinus coronarius. No\npneumothorax.\n\nNormal heart size. No pulmonary congestion. No diffuse infiltrates. No\npleural effusions.\n\n**ECG at Discharge:** Continuous ventricular PM stimulation, HR: 66/min.\n\n**Current Recommendations:**\n\n- We request a follow-up appointment in our Pacemaker Clinic. Please\n provide a referral slip.\n\n- We ask for the protection of the left arm and avoidance of\n elevations \\> 90 degrees. Self-absorbing sutures have been used.\n\n- We request regular wound checks.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942, who presented to our Cardiological University Outpatient\nClinic on 08/26/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation**: Slightly increasing exertional dyspnea, no\ncoronary heart disease.\n\n**Cardiovascular Risk Factors:**\n\n- Family history: No\n\n- Smoking: No\n\n- Hypertension: No\n\n- Diabetes: Yes\n\n- Dyslipidemia: Yes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Findings**:\n\n**Resting ECG:** Sinus rhythm, 83 bpm. Blood pressure: 120/70 mmHg.\n\n**Echocardiography: M-mode and 2-dimensional**\n\nLeft ventricle dimensions: Approximately 57/45 mm (normal up to 56 mm),\nmoderately dilated\n\n- Right atrium and right ventricle: Normal dimensions\n\n- Normal thickness of left ventricular muscle\n\n- Globally, mild reduction in contractility\n\n- Heart valves: Morphologically normal\n\n- Doppler-Echocardiography: No significant valve regurgitation\n\n**Assessment**: Mildly dilated cardiomyopathy with slightly reduced left\nventricular function. Ejection fraction at 45 - 50%. Mild diastolic\ndysfunction. Mild tricuspid regurgitation, pulmonary artery pressure 22\nmm Hg, and left ventricular filling pressure slightly increased.\n\n**Stress Echocardiography: Stress echocardiography with exercise test**\n\n- Stress test protocol: Treadmill exercise test\n\n- Reason for stress test: Exertional dyspnea\n\n- Quality of the ultrasound: Good\n\n- Initial workload: 50 watts\n\n- Maximum workload achieved: 150 Watt\n\n- Blood pressure response: Systolic BP increased from 112/80 mmHg to\n 175/90 mmHg\n\n- Heart rate response: Increased from 71bpm to 124bpm\n\n- Exercise terminated due to leg pain\n\n**Resting ECG:** Sinus rhythm**.** No significant changes during\nexercise\n\n**Echocardiography at rest:** Normokinesis of all left ventricular\nsegments EF: 45 - 50%\n\n**Echocardiography during exercise:** Increased contractility and wall\nthickening of all segments\n\n[Summary]{.underline}: No dynamic wall motion abnormalities. No evidence\nof exercise-induced myocardial ischemia\n\n**Carotid Doppler Ultrasound:** Both common carotid arteries are\nsmooth-walled**.** Intima-media thickness: 0.8 mm**.** Small plaque in\nthe carotid bulb on both sides**.** Normal flow in the internal and\nexternal carotid arteries**.** Normal dimensions and flow in the\nvertebral arteries\n\n**Summary:** Non-obstructive carotid plaques**.** Indicated to lower LDL\nto below 1.8 mmol/L\n\n**Summary:**\n\n- Stress echocardiography shows no evidence of ischemia, EF \\>45-50%\n\n- Carotid duplex shows minimal non-obstructive plaques\n\n- Increase Simvastatin to 20 mg, target LDL-C \\< 1.8 mmol/L\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about the results of the cardiac\ncatheterization of Mr. David Romero, born on 02/16/1942 performed by us\non 08/10/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Procedure:** Right femoral artery puncture. Left ventriculography with\na 5F pigtail catheter in the right anterior oblique projection. Coronary\nangiography with 5F JL4.0 and 5F JR 4.0 catheters. End-diastolic\npressure in the left ventricle within the normal range, measured in\nmmHg. No pathological pressure gradient across the aortic valve.\n\n**Coronary angiography:**\n\n- Unremarkable left main stem.\n\n- The left anterior descending (LAD) artery shows mild wall changes,\n with a maximum stenosis of 20-\\<30%.\n\n- The robust right coronary artery (RCA) is stenosed proximally by\n 30-40%, subsequently ectatic and then stenosed to 40-\\<50% distally.\n Slow contrast clearance. The right coronary artery is also stenosed\n up to 30%.\n\n- Left-dominant coronary circulation.\n\n**Assessment**: Diffuse coronary atherosclerosis with less than 50%\nstenosis in the RCA and evidence of endothelial dysfunction.\n\n**Current Recommendations:**\n\n- Initiation of Ranolazine\n\n- Additional stress myocardial perfusion scintigraphy\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about the results of the Myocardial\nPerfusion Scintigraphy performed on our patient, Mr. David Romero, born\non 02/16/1942, on 09/23/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Myocardial Perfusion Scintigraphy:**\n\nThe myocardial perfusion scintigraphy was conducted using 365 MBq of\n99m-Technetium MIBI during pharmacological stress and 383 MBq of\n99m-Technetium MIBI at rest.\n\n[Technique]{.underline}: Initially, the patient was pharmacologically\nstressed with the intravenous administration of 400 µg of Regadenoson\nover 20 seconds, accompanied by ergometer exercise at 50 W.\nSubsequently, the intravenous injection of the radiopharmaceutical was\nperformed. The maximum blood pressure achieved during the stress phase\nwas 143/84 mm Hg, and the maximum heart rate reached was 102 beats per\nminute.\n\nApproximately 60 minutes later, ECG-triggered acquisition of a\n360-degree SPECT study was conducted with reconstructions of short and\nlong-axis slices.\n\nDue to inhomogeneities in the myocardial wall segments during stress,\nrest images were acquired on another examination day. Following the\nintravenous injection of the radiopharmaceutical, ECG-triggered\nacquisition of a 360-degree SPECT study was performed, including\nshort-axis and long-axis slices, approximately 60 minutes later.\n\n[Clinical Information:]{.underline} Known coronary heart disease (RCA\n50%). ICD/CRT pacemaker.\n\n[Findings]{.underline}: No clear perfusion defects are seen in the\nscintigraphic images acquired after pharmacologic exposure to\nRegadenoson. This finding remains unchanged in the scintigraphic images\nacquired at rest.\n\nQuantitative analysis shows a normal-sized ventricle with a normal left\nventricular ejection fraction (LVEF) of 53% under exercise conditions\nand 47% at rest (EDV 81 mL). There are no clear wall motion\nabnormalities. In the gated SPECT analysis, there are no definite wall\nmotion abnormalities observed in both stress and rest conditions.\n\n**Quantitative Scoring:**\n\n- SSS (Summed Stress Score): 3 (4.4%)\n\n- SRS (Summed Rest Score): 0 (0.0%)\n\n- SDS (Summed Difference Score): 3 (4.4%)\n\n**Assessment**: No evidence of myocardial perfusion defects with\nRegadenoson stress or at rest. Normal ventricular size and function with\nno significant wall motion abnormalities.\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nWe would like to report on our patient, Mr. David Romero, born on\n02/16/1942, who was under our inpatient care from 05/20/2023 to\n05/21/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medical History:** The patient was admitted for device replacement due\nand upgrading to a CRT-P pacemaker. At admission, the patient reported\nno complaints of fever, cough, dyspnea, chest pain, or melena.\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Medication upon Admission**\n\n **Medication** **Dosage** **Frequency**\n --------------------------- -------------- ----------------------\n Insulin glargine (Lantus) 450 E/1.5 ml 0-0-0-6-8 IU\n Insulin lispro (Humalog) 300 E/3 ml 5-8 IU-5-8 IU-5-8 IU\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Colecalciferol 12.5 mcg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n\n**Therapy and Progression:** The patient\\'s current admission was\nelective for the implantation of a 3-chamber CRT-D device due to device\ndepletion. The procedure was performed without complications on\n05/20/2023. The post-interventional course was uneventful. The\nimplantation site showed no irritation or significant hematoma at the\ntime of discharge, and no pneumothorax was detected on X-ray.\n\nTo protect the surgical wound, we request dry wound dressing for the\nnext 10 days and clinical wound checks. Suture removal is not necessary\nwith absorbable suture material. We advise against arm elevation for the\nnext 4 weeks, avoiding heavy lifting on the side of the device pocket\nand gradual, pain-adapted full range of motion after 4 weeks.\n\n**Current Recommendations:** We kindly request an outpatient follow-up\nappointment in our Pacemaker Clinic.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage ** **Frequency**\n ----------------------------- --------------- -----------------------\n Insulin glargine (Lantus) 450 E./1.5 ml 0-0-0-/6-8 IU\n Insulin lispro (Humalog) 300 E./3 ml 5-8 IU/-5-8 IU/5-8 IU\n Levothyroxine (Synthroid) 100 µg 1-0-0-0\n Colecalciferol (Vitamin D3) 12.5 µg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Colecalciferol 12.5 µg 2-0-0-0\n\n**Addition: Findings:**\n\n**ECG at Discharge:** Sinus rhythm, ventricular pacing, QRS 122ms, QTc\n472ms\n\n**Rhythm Examination on 05/20/2023:**\n\n[Results:]{.underline} Replacement of a 3-chamber CRT-D device (new:\nSJM/Abbott Quadra Assura) due to impending battery depletion:\nUncomplicated replacement. Tedious freeing of the submuscular device and\nproximal lead portions using a plasma blade. Extraction of the old\ndevice. Connection to the new device. Avoidance of device fixation in\nthe submuscular position. Hemostasis by electrocauterization. Layered\nwound closure. Skin closure with absorbable intracutaneous sutures. End\nadjustment of the CRT-D device is complete. [Procedure]{.underline}:\nCompression of the wound with a sandbag and local cooling. First\noutpatient follow-up in 8 weeks through our pacemaker clinic (please\nschedule an appointment before discharge). Postoperative chest X-ray is\nnot necessary. Cefuroxime 1.5 mg again tonight.\n\n**Transthoracic Echocardiography on 05/18/2023**\n\n**Results:** Globally mildly impaired systolic LV function. Diastolic\ndysfunction Grade 1 (LV relaxation disorder).\n\n- Right Ventricle: Normal-sized right ventricle. Normal RV function.\n Pulmonary arterial pressure is normal.\n\n- Left Atrium: Slightly dilated left atrium.\n\n- Right Atrium: Normal-sized right atrium.\n\n- Mitral Valve: Morphologically unremarkable. Minimal mitral valve\n regurgitation.\n\n- Aortic Valve: Mildly sclerotic aortic valve cusps. No aortic valve\n insufficiency. No aortic valve stenosis (AV PGmax 7 mmHg).\n\n- Tricuspid Valve: Delicate tricuspid valve leaflets. Minimal\n tricuspid valve regurgitation (TR Pmax 26 mmHg).\n\n- Pulmonary Valve: No pulmonary valve insufficiency. Pericardium: No\n pericardial effusion.\n\n**Assessment**: Examination in sinus rhythm with bundle branch block.\nModerate ultrasound windows. Normal-sized left ventricle (LVED 54 mm)\nwith mildly reduced systolic LV function (EF biplan 55%) with mildly\nreduced contractility without regional emphasis. Mild LV hypertrophy,\npredominantly septal, without obstruction. Diastolic dysfunction Grade 1\n(E/A 0.47) with a normal LV filling index (E/E\\' mean 3.5). Slightly\nsclerotic aortic valve without stenosis, no AI. Slightly dilated left\natrium (LAVI 31 ml/m²). Minimal MI. Normal-sized right ventricle with\nnormal function. Normal-sized right atrium (RAVI 21 ml/m²). Minimal TI.\nAs far as assessable, systolic PA pressure is within the normal range.\nThe IVC cannot be viewed from the subcostal angle. No thrombi are\nvisible. As far as assessable, no pericardial effusion is visible.\n\n**Chest X-ray in two planes on 05/20/2023: **\n\n[Clinical Information, Question, Justification:]{.underline} Post CRT\ndevice replacement. Inquiry about position, pneumothorax.\n\n[Findings]{.underline}: No pneumothorax following CRT device\nreplacement.\n\n", "title": "text_9" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mr. David Romero, born on\n02/16/1942, who presented at our Rhythm Clinic on 09/29/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ------------------ ---------------\n Lantus (Insulin glargine) 450 Units/1.5 mL 0-0-0-/6-8\n Humalog (Insulin lispro) 300 Units/3 mL 5-8/0/5-8/5-8\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n Lipitor (Atorvastatin) 21.7 mg 0-0-1-0\n Norvasc (Amlodipine) 6.94 mg 1-0-0-0\n Altace (Ramipril) 5 mg 1-0-0-0\n Demadex (Torasemide) 5 mg 0-0-0.5-0\n Coreg (Carvedilol) 25 mg 0.5-0-0.5-0\n Zocor (Simvastatin) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n\n**Measurement Results:**\n\nBattery/Capacitor: Status: OK, Voltage: 8.4V\n\n- Right Atrial: 375 Ohms 3.80 mV 0.375 V 0.50 ms\n\n- Right Ventricular: 388 Ohms 11.80 mV 0.750 V 0.50 ms\n\n- Left Ventricular: 350 Ohms 0.625 V 0.50 ms\n\n- Defibrillation Impedance: Right Ventricular: 48 Ohms\n\n**Implant Settings:**\n\n- Bradycardia Setting: Mode: DDD\n\n- Tachycardia Settings: Zone Detection Interval (ms) Detection Beats\n ATP Shocks Details Status\n\n - VFVF 260 ms 30 /\n\n - VTVT1 330 ms 55 /\n\n<!-- -->\n\n- Probe Settings: Lead Sensitivity Sensing Polarity/Vector\n Amplification/Pulse Width Stimulation Polarity/Vector Auto Amplitude\n Control\n\n - Right Atrial: 0.30 mV Bipolar/ 1.375 V/0.50 ms Bipolar/\n\n - Right Ventricular: Bipolar/ 2.000 V/0.50 ms Bipolar/\n\n - Left Ventricular: 2.000 V/0.50 ms tip 1 - RV Coil\n\n**Assessment:**\n\n- Routine visit with normal device function.\n\n- Normal sinus rhythm with a heart rate of 65/min.\n\n- Balanced heart rate histogram with a plateau at 60-70 bpm.\n\n- Wound conditions are unremarkable.\n\n- Battery status: OK.\n\n- Atrial probe: Intact\n\n- Right ventricular probe: Intact\n\n- Left ventricular probe: Intact\n\n- A follow-up appointment for the patient is requested in 6 months.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.8 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 5.9 mg/L \\< 5.0 mg/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n MCV 92.7 fL 80.0-99.0 fL\n MCH 31.8 pg 27.0-33.5 pg\n MCHC 33.9 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.2% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n", "title": "text_10" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, ****Dear colleague, **\n\n \n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who was treated in our clinic from 05/28/14 to 06/20/14.\n\n \n\n**Diagnoses: **\n\n- pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left\n midline tongue carcinoma\n\n- Arterial hypertension\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Idiopathic thrombocytopenia\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Hypothyroidism\n\n- Nicotine abuse\n\n<!-- -->\n\n- Panendoscopy with sampling on 04/14/2014 and 04/26/2014\n\n \n\n**Current Presentation**: With histologically confirmed carcinoma in the\nregion of the base of the tongue on the left side, Mr. Doe presents for\nsurgical treatment of the findings. In accordance with the tumor board\ndecision, resection is performed via a lateral pharyngotomy and neck\ndissection on both sides.\n\n \n\n**Physical Examination:** Patient in stable general condition (85 kg,\n188 cm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I° (L-thyroxine increased to 150 μg 1-0-0), hoarseness\n0°, hearing loss 0° (subjectively reduced), dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\nA tumorous mass can be inspected at the base of the left tongue. Tongue\nmobility is unremarkable.\n\n**CT chest, abdomen, pelvis on 05/28/14:**\n\nEmphasized mediastinal as well as abdominal lymph\nnodes.** **Vasosclerosis. Otherwise, there is no evidence for the\npresence of distant metastases with a suspected base of tongue\ncarcinoma. Liver cirrhosis.\n\n \n\n**CT neck on 06/11/14:**\n\nSuspected left tongue base carcinoma crossing midline with extension\ninto the left vallecula and compression of the left piriform sinus with\nsuspected lymph node metastases in levels I-III ipsilateral.\nContralateral prominent but not certainly suspicious lymph nodes. The\nprominent structure on the left supraclavicular side can also be\ninterpreted as circumscribed cystiform ectasia of the thoracic duct.\n\n \n\n**Ultrasound abdomen on 06/15/14:**\n\nImage of liver cirrhosis status post cholecystectomy.\nHepatosplenomegaly. Moderate aortic sclerosis.\n\n \n\n**X-ray pap swallow on 06/17/14:**\n\nClear tracheal aspiration in the absence of epiglottis envelope. The\ncough reflex is preserved. Otherwise, essentially unremarkable\nswallowing act. \n\n \n\n**Histology**: Invasive, moderately differentiated, squamous cell\ncarcinoma with keratinization of the medial left base of the tongue,\nmaximum extent 1.0 cm. Carcinoma- and dysplasia-free biopsies of the\nleft tonsil, the oropharyngeal tumor/tongue base on the left, deep\nresection of the tumor, lower tonsillar pole transition on the left\ntongue base, tongue base on the left and medial left tongue base, as\nwell as median tongue base.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** pT1. pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n \n\n**Therapy and Progression**: After the usual clinical and laboratory\npreparations, we performed the above-mentioned therapy on 05/29/14 in\nintubation anesthesia without complications. For perioperative infection\nprophylaxis, the patient received intravenous antibiotic therapy with\nAmpicillin and Sulbactam 3g three times daily for the duration of his\nhospital stay.\n\nDuring this procedure, the left lingual artery was interrupted\nprophylactically. No postoperative bleeding and no wound healing\ndisturbances occurred.\n\nA porridge swallow examination showed no evidence of a fistula. On the\nfollowing day, the patient was decannulated in consultation with the\ncolleagues of the speech therapy. After this, a food build-up was\ncarried out in cooperation with speech therapists. At the time of\ndischarge, the patient was receiving regular oral nutrition. The stoma\ncontinued to shrink. The patient was monitored, and if necessary, the\ntracheostoma was closed with local anesthesia. Histological findings\nwere pT1. Due to an RX status, adjuvant radiotherapy will be performed\nas decided by the tumor board. A prophylactic presentation at the\ncolleagues of the MKG as a preparatory measure for the upcoming\nradiotherapy. We asked for a control re-presentation in our outpatient\nclinic on 06/26/14 at 3:00 PM. Further controls take place at the half\nand at the end of the radiotherapy and further in 4-6 weeks rhythm. In\ncase of acute complaints, an immediate re-presentation is possible at\nany time.\n\n \n\n**Type of surgery**: Lateral pharyngotomy with resection of the base of\nthe tongue on the left as well as selective neck dissection on both\nsides level II-IV with ligature of the lingual artery on the left side,\ncreation of a stable tracheostoma and tonsillectomy on the left side.\n\n**Surgery report: **First, tracheotomy in a typical manner. A horizontal\nincision was made on the skin, positioned approximately two transverse\nfinger widths above the jugulum. Subsequently, the subcutaneous tissue\nand the platysma colli were incised. To facilitate access to the\ntrachea, the laryngeal muscles were carefully displaced to the side. The\nthyroid isthmus was undermined and clamped bilaterally. A precise\ntransection of the thyroid isthmus followed, with both halves of the\nthyroid gland being meticulously sutured using 0- Vicryl. The thyroid\nhalves were repositioned to expose the trachea. A visceral tracheotomy\nwas performed, and re-intubation was achieved utilizing a U-tube. The\nsurgical procedure then transitioned to a neck dissection on the left\nside. This phase began with an incision along the anterior edge of the\nsternocleidomastoid muscle. The subcutaneous tissue and platysma colli\nwere carefully cut, with due respect to the auricularis magnus nerve.\nDissection continued dorsally along the sternocleidomastoid muscle to\nreach the anterior border of the trapezius muscle. Further exposure\ninvolved the accessorius nerve in a cranialward direction, with\npreservation of this neural structure. Dissection proceeded along the\ncervical vascular sheath, revealing the common carotid artery, internal\njugular vein, and vagus nerve up to the digastric muscle. Below this\nlevel, exposure of the hypoglossal nerve was achieved.\n\nSuccessive dissection involved the lymph node fat package, progressing\nfrom level II to level IV in a cranial to caudal and ventral to dorsal\ndirection. Throughout this process, careful attention was paid to\nsparing the aforementioned neural and vascular structures. Subsequently,\naccess to the lateral pharyngectomy area was gained, allowing\nvisualization of the external carotid artery along with its branches,\nincluding the superior thyroid artery, superior laryngeal artery, and\nlingual artery. Notably, the lingual artery was interrupted during this\nstage.\n\nFurther exploration revealed the superior laryngeal nerve and\nhypoglossal nerve intersecting in a loop above the internal carotid\nartery and externally below the external jugular vein. Additional\ndissection in a ventral direction followed. The hypoglossal nerve was\nprepared meticulously. Exposure of the hyoid bone was achieved, with a\nposterior resection of half of the hyoid bone. Importantly, the\nhypoglossal nerve was spared during this procedure. Subsequent to these\nsteps, the lateral pharynx wall was opened, exposing the base of the\nhyoid. The next phase of the procedure involved enoral tumor\ntonsillectomy on the left side. Starting from the left side, the\nsurgical team identified the tonsil capsule at the anterior palatal arch\nusing a Henke spatula. The upper tonsillar pole was then dislodged and\ndissected with the Rosenblatt instrument, proceeding from cranial to\ncaudal. Hemostasis was meticulously achieved through swab pressure and\nelectrocautery. The excised tonsil tissue was sent for frozen section\nexamination for further analysis.\n\n**Frozen Section Report: **No evidence of malignancy was found. The\nresection was carried out at the junction of the caudal tonsillar pole\nand the base of the tongue. At this location, tissue from the base of\nthe tongue was resected and sent for a frozen section examination, which\nrevealed no indication of malignancy. Subsequently, a medial resection\nof the base of the tongue was performed, confirming the presence of\nsquamous cell carcinoma in the frozen section analysis. Mucosal suturing\nwith inverting sutures was then conducted. On the left side, a neck\ndissection procedure was performed. The dissection extended along the\nsternocleidomastoid muscle, reaching dorsally to the anterior border of\nthe trapezius muscle. This approach allowed for cranial exposure of the\naccessorius nerve while sparing the same. Dissection continued along the\ncervical vascular sheath, exposing the common carotid artery, internal\njugular vein, and the vagus nerve up to the digastric muscle. Below\nthis, the hypoglossal nerve was exposed. Subsequently, the lymph node\nfat package was dissected systematically from level II to level IV,\nprogressing from cranial to caudal and ventral to dorsal, while\ncarefully preserving the mentioned structures. The surgical procedure\nconcluded with the placement of a drain, subcutaneous suturing, and skin\nsuturing.\n\n**Frozen section report:** Invasive squamous cell carcinoma.\n\n \n\n**Microscopy:**\n\nEven after paraffin embedding, mucosal cross-sections show a covering of\nstratified, non-keratinizing squamous epithelium with occasional\nsignificant stratification disturbances extending into superficial cell\nlayers. This transitions into invasive growth with solid clusters of\npolygonal tumor cells, some of which exhibit identifiable intercellular\nbridges. The cell nuclei are enlarged, round to oval, with occasional\nsmall nucleoli and mild to moderate nuclear pleomorphism. Dyskeratosis\nis observed in some areas.\n\n**Lab results upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- ----------------------- -----------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.0 mg/dL 0.7 - 1.3 mg/dL\n Calcium 9.04 mg/dL 8.8 - 10.6 mg/dL\n GFR (MDRD) \\> 60 mL/min/1.73m\\^2 \\> 60 mL/min/1.73m\\^2\n GFR (CKD-EPI,CREA) 80 mL/min/1.73m\\^2 \\> 90 mL/min/1.73m\\^2\n C-reactive protein 1.0 mg/dL \\< 0.5 mg/dL\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who presented to our outpatient clinic on 09/14/2014.\n\n**Diagnosis: **Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21)\nL0 V0 Pn0 G2 RX\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n- Since 03/2014: Odynophagia\n\n<!-- -->\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Histology:**\n\nInvasive, moderately differentiated, squamous cell carcinoma with\nkeratinization of the medial left base of the tongue, maximum extent 1.0\ncm. Carcinoma- and dysplasia-free biopsies of the left tonsil, the\noropharyngeal tumor/tongue base on the left, deep resection of the\ntumor, lower tonsillar pole transition on the left tongue base, tongue\nbase on the left and medial left tongue base, as well as median tongue\nbase.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** min pT1, pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n**Current Radiotherapy:**\n\n**Indication**: According to the decision made by the interdisciplinary\ntumor board for head and neck tumors, it was determined by our medical\nteam that, in the postoperative condition following the resection of a\ntongue base carcinoma with an unclear resection status, there is an\nindication for radiation therapy of the former tumor site.\n\n**Technique:** Percutaneous radiotherapy of the former primary tumor\nregion with 6-MeVPhotons, in Rapid-Arc technique, with a single dose of\n2 Gy up to a total dose of 60 Gy.\n\n**Radiotherapy 07/27/2014 - 09/06/2014:**\n\nDuring the course of radiotherapy, the patient experienced enoral\nmucositis (grade II according to CTCAE) leading to subsequent\nodynophagia and dysphagia. We managed these symptoms with oral rinses\nand initiated pain management using Acetaminophen, resulting in an\nacceptable reduction of pain over time. At the end of the therapy, the\npatient\\'s general condition remained stable (ECOG performance status:\n70%). Second-degree mucositis enoral persisted, causing ongoing\ndysphagia and odynophagia. Additionally, the patient exhibited localized\nradiodermatitis (grade II according to CTCAE) within the radiation\nfield. The patient did not report xerostomia or dysgeusia.\n\n**Current Recommendations:**\n\nThe patient received comprehensive instructions on continued skincare\nand side-effect management. An initial follow-up appointment with the\nradio-oncology team has been scheduled in our outpatient clinic. We\nkindly request the patient to provide a renewed referral for\nradiotherapy on the day of the appointment.\n\nThe ongoing oncological treatment plan will be determined by the\npatient\\'s Ear, Nose, and Throat specialists. Regular follow-up\nexaminations are strongly recommended. Additionally, for patients who\nhave completed radiation therapy in the ENT region, we advise lifelong\nadherence to fluoride prophylaxis and antibiotic therapy during any\ndental procedures.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965, who presented\nto our outpatient clinic for phoniatrics and pedaudiology on 10/10/2014.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Medical History: **We may kindly assume the detailed history as known.\n\n**Phoniatrics: Fiberoptic endoscopic swallow examination:**\n\nTongue motor function is well preserved, sensitivity of lip and tongue\nlaterally equal,\n\nMucous membranes non-irritant on all sides. Tracheal mucosa\nnon-irritant, no evidence of saliva intratracheal. Neopharynx\ninconspicuous, air bubbles visible above Provox outlet on pressing\nattempt. Tongue retraction slightly limited. Velopharyngeal closure\ngood.\n\n**Therapy and Course:** After completion of the adjuvant radiotherapy\napproximately 6 weeks ago, phonation via the Provox voice prosthesis was\nno longer possible after this had initially worked after the operation.\nAdditionally, there were issues with regurgitation of ingested\nsubstances, regardless of their consistency. In some cases, nasal\npenetration with fluids occurred. There were no indications of\naspiration. A self-assessment, involving the use of blue-colored liquid,\nrevealed no signs of leakage from the Provox device.\n\n**Current Recommendations:** Oncological follow-up in 12 months.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965 who presented\nat our outpatient clinic for radio-oncological follow-up on 10/09/2020.\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n \n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for a radio-oncological follow-up on 10/09/2020 in the\npresence of his wife.\n\n**Physical Examination**: Patient in stable general condition (85 kg,188\ncm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I°, hoarseness 0°, hearing loss 0° (subjectively\nreduced), dyspnea: 0°, pneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\n**MRI scan of the neck from 10/09/2020:** \n\nClear post-therapeutic changes in the resection and radiation area after\nadjuvant RTx following tumor resection with laryngectomy for extensive\nrecurrence of oropharyngeal cancer. \n\nSize constant, but still clearly accentuated lymph nodes in level Ib/IIa\non the left. Regredience of seroma formation under the left\nsternocleidomastoid muscle.\n\n**Current Recommendations: **Primary oncological care and follow-up,\nincluding imaging, will be provided by the ENT clinic according to the\nguidelines. A re-appointment for a further radio-oncological follow-up\nat the follow-up appointment at the Radiation Therapy Tumor Therapy\nCenter has been scheduled. After head and neck radiation therapy,\nregular fluoridation of the teeth and guideline-based antibiotic\nprophylaxis is required prior to major dental procedures. We also\nrecommend temporomandibular joint opening exercises to prevent\ntemporomandibular joint fibrosis and consecutive temporomandibular joint\nopening obstruction. We also refer to regular control of thyroid\nfunction parameters and, if necessary, initiation of substitution\ntherapy after radiotherapy to the neck.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe hereby report on our patient Mr. Paul Doe, born 08/08/1965 for\nradio-oncological follow-up on 09/24/2021.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for radio-oncological follow-up on 09/24/2021. \n\n**Physical Examination: **Patient in reduced general condition (KPS 60%,\n86 kg,188 cm). Weight loss 0°, MUST score: 0, pain VAS 1-2/10, fatigue\nI°, dysphagia I° with solid food (liquids occasionally flow out of the\nnose again when swallowing), aspiration 0°, ulcer 0°, trismus 0°, taste\ndisorder I° (present in approx. 80%), xerostomia I°, osteonecrosis 0°,\nhypothyroidism II°, hoarseness II°, hearing loss, I°, dyspnea: 0°,\npneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**MR neck plain + contrast agent on 09/24/2021**:\n\n[Technique]{.underline}: STIR triplanar, T1 ax -/+ contrast agent, T1\nmDixon cor after\n\ncontrast agent.\n\n[Findings]{.underline}: Known status post tumor resection with\nlaryngectomy for extensive recurrence of oropharyngeal Carcinoma;\nFollow-up after RTx. Somewhat increasing swelling of nasopharynx to\noropharynx. From the uvula the swelling is stable. As far as can be\nassessed, no clear recurrence-specific tissue proliferation or contrast\nuptake. Unchanged accentuated lymph nodes in level Ib/IIa on the left\n(one exemplary measured lymph node borderline large, idem to preliminary\nexamination). Mastoid cells minimally displaced on the left. Moderate\ndegenerative changes of the cervical spine. Assessment. Increasing\nswelling of the naso- to oropharynx. Neopharynx unchanged swollen. No\nevidence of malignancy-suspicious lymph nodes.\n\n**CT scan of the thorax on 09/24/2021**:\n\nSize-constant visualization of interlobar oval compaction in the left\nupper lobe corresponding to an interlobar lymph node. New to the\nprevious examination, two small nodular condensations appear, basal in\nthe right and in the left lower lobe, differentially inflammatory;\nfollow-up is recommended. Unchanged the prominent mediastinal lymph\nnodes, constant in size and number.\n\n**Current Recommendations:**\n\nPrimary oncologic care and follow-up including imaging will take place\nvia the ENT clinic on 01/14/22 at 11:00 AM. A re-appointment for the\nnext radio-oncological follow-up has been arranged for 01/14/2022 at\n1:00 PM in our radiotherapy outpatient clinic in the Tumor Therapy\nCenter.\n\n**Lab results upon Discharge:**\n\n**Hematology**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- -----------------------\n WBC 6,900 /μL 4,500 - 11,000 /μL\n RBC 2.7M /μL 4.5M - 5.9M /μL\n Hemoglobin 8.2 g/dL 14 - 18 g/dL\n Hematocrit 25.1 % 40 - 48 %\n MCH 31.27 pg 27 - 33 pg\n MCV 94 fL 82 - 92 fL\n MCHC 32.7 g/dL 32 - 36 g/dL\n Platelets 638,000 /μL 150,000 - 450,000 /μL\n\n**Serum chemistry**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ -----------------\n Sodium 144 mEq/L 135 - 145 mEq/L\n Potassium 4.8 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.3 mg/dL 0.7 - 1.3 mg/dL\n ALT 21 U/L 10 - 50 U/L\n eGFR 55 mL/min \\> 90 mL/min\n CRP 2.9 mg/dL \\< 0.5 mg/dL\n\n**Coagulation**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ ---------------\n PT 93 % 70 - 120 %\n INR 1.1 0.8 - 1.2\n aPTT 31 sec 26 - 37 sec\n\n**Thyroid hormones**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- ------------------\n TSH 1.16 μIU/mL 0.4 - 4.2 μIU/mL\n fT3 2.38 pg/mL 2.3 - 4.2 pg/mL\n fT4 1.70 ng/dL 0.9 - 1.7 ng/dL\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who was admitted\nto our hospital from 01/10/2022 to 01/27/2022.\n\n**Diagnosis**: Metachronous pulmonary metastatic squamous cell carcinoma\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014 Odynophagia\n\n- 05/14/2014 Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014 Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Planned Surgical Procedure:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Medical History**: Mr. Paul Doe initially presented with a diagnosis\nof pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left midline\ntongue carcinoma. Panendoscopy with specimen collection on 04/14/2014\nand 04/26/2014 confirmed carcinoma.\n\nSurgical resection was performed via lateral pharyngotomy and neck\ndissection. Histology confirmed squamous cell carcinoma. He subsequently\nreceived radiotherapy.\n\nDuring a follow-up CT examination, a suspicious lesion was identified in\nthe lung, which raised concerns regarding the possibility of metastasis\noriginating from the previously diagnosed left midline tongue carcinoma\n(pT1, pN0, G2, RX).\n\n**Current Presentation:** Mr. Doe was admitted for further examination\nand treatment to assess the behavior and extent of the lesion.\nClinically, Mr. Doe was in stable general condition and had no symptoms\nsuggestive of B symptoms.\n\n**Therapy and Progression**: The above-mentioned procedure was performed\nwithout complications on 01/10/2022. Histologically, the final resection\nspecimen confirmed the presence of a 2.9 cm squamous cell carcinoma,\nconsistent with a metastatic recurrence of the previously known\nhypopharyngeal carcinoma. The dissected lymph nodes were free of tumor.\nThe postoperative course was uneventful. In the absence of any\ncomplications, surgical sutures were removed on day 10 after surgery. A\ncurrent chest X-ray showed a regular postoperative outcome with\nsufficient expansion of the left lobe. Further monitoring is recommended\nby the treating colleagues in this regard. Mr. Doe is also connected to\nthe radiation therapy team for ongoing follow-up.\n\nIf there are any complications or questions, please contact the relevant\nward or reach out to our Central Patient Management. Outside regular\nworking hours, you can contact the on-call colleague in the Abdominal\nSurgery department for assistance.\n\nFor further information on the patient\\'s discharge management, treating\nproviders are available for inquiries from Monday to Friday, 9 AM to 7\nPM, as well as on weekends and holidays from 10 AM to 2 PM.\n\nMr. Doe was discharged from the hospital on 01/27/2022.\n\n**Addition:**\n\n**Histology Report:** Resected left upper lobe specimen with a 2.9 cm\nsolid carcinoma. The histological picture is consistent with a\nmetastasis from the previously diagnosed non-keratinizing squamous cell\ncarcinoma. There were focal vascular invasions. No pleural invasion was\nobserved. The resection was complete, with all dissected lymph nodes\nshowing no tumor involvement.\n\n**Chest X-ray, anterior-posterior view from 01/21/2022**:\n\n[Clinical Information:]{.underline} History of VATS with wedge\nresection, yesterday\\'s drain removal\n\n[Question:]{.underline} Follow-up, pneumothorax after drain removal?\nInfiltrates? Atelectasis?\n\n[Findings:]{.underline} Left chest drainage tube has been removed. Left\napical pneumothorax line, measuring approximately 2.3 cm. Continued\nextensive shadowing of the left upper field, most likely postoperative,\ninfiltrate cannot be definitively ruled out. Slightly hypotransparent\nleft lung in comparison, most likely due to residual postoperative\nreduced ventilation. No effusion. Widened cardiac silhouette. Regression\nof dystelectasis in the right lower field. No acute signs of pulmonary\nvenous congestion. Trachea is mid-positioned and not stenosed.\nLeft-sided port catheter still in place.\n\n[Summary]{.underline}: Left apical corax with a width of 2.3 cm.\nContinued extensive shadowing of the left upper field, most likely\npostoperative, with infiltrate not definitively excluded. Residual\npostoperative reduced ventilation on the left side. Regression of\ndystelectasis in the right lower field. No effusion. No acute signs of\npulmonary venous congestion. Follow-up recommended.\n\n**Examinations Chest X-ray, anterior-posterior view from 01/23/2022:**\n\n[Question]{.underline}**:** Follow-up.\n\n[Findings]{.underline}: Left apical pneumothorax, measuring\napproximately 1.4 cm. Extensive shadowing in projection onto the left\nupper lobe, differentials include postoperative changes, incipient\ninfiltrate not excluded. Dystelectasis of the right lower field. No\nevidence of pleural effusion or acute pulmonary venous congestion.\nCardiomegaly. Indwelling chest drainage with the catheter tip projecting\nonto the left upper lobe. Well-positioned port catheter tip projecting\nonto the right atrial entrance plane. No evidence of pleural effusion.\nAssessment Left apical pneumothorax, measuring approximately 1.4 cm,\nwith indwelling left chest drainage. Extensive shadowing in projection\nonto the left upper lobe, differentials include postoperative changes,\nincipient infiltrate not excluded. Dystelectasis of the right lower\nfield. No significant pleural effusion. No acute pulmonary venous\ncongestion. Cardiomegaly.\n\n**Chest X-ray, anterior-posterior view from 01/25/2022**\n\n[Previous Examinations]{.underline}: Appearance of a diffuse\npostoperative shadow in the left upper field. No evidence of pleural\neffusion, inflammatory infiltrate, or pulmonary venous congestion.\n\n[Findings]{.underline}: Left-sided chest port with the tip projecting\nonto the superior vena cava. The upper mediastinum is narrow, the\ntrachea is mid-positioned and patent.\n\n[Assessment]{.underline}: The pneumothorax appears to be largely\nresolved.\n\n**Urinanalysis**:\n\nMaterial: Urine, midstream sample collected on 01/11/2022\n\n- Antimicrobial inhibitors negative\n\n- No evidence of growth-inhibiting substances in the sample material.\n\n- Colony Count (CFU) / mL \\<1,000, Assessment: A low colony count\n typically does not support a urinary tract infection.\n\n- Epithelial cells (microscopic) \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic) \\<20 leukocytes/μL\n\n- Microorganisms (microscopic) 20-100 microorganisms/μL Pathogen\n Enterococci\n\n**Lab values upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- --------------------- ---------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n Calcium 10.4 mg/dL 8.8 - 10.6 mg/dL\n eGFR (MDRD) \\> 60 mL/min/1.73m² \\> 60 mL/min/1.73m²\n eGFR (CKD-EPI) 85 mL/min/1.73m² \\> 90 mL/min/1.73m²\n C-Reactive Protein 5.0 mg/dL \\< 0.5 mg/dL\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgical Procedure from 01/11/2022:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015: radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n- OSAS with CPAP incompliance\n\n<!-- -->\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for postoperative follow-up\nafter his left-sided videothoracoscopic upper lobe resection due to\npreviously diagnosed pulmonary metastatic hypopharyngeal carcinoma.\n\n**Medical History:** The patient\\'s general condition is good. He is\ncurrently on intermittent as-needed analgesia with Acetaminophen. The\nfinal resection specimen histologically confirmed the presence of a 2.9\ncm squamous cell carcinoma, consistent with a metastatic recurrence of\nthe previously known hypopharyngeal carcinoma. The dissected lymph nodes\nwere free of tumor.\n\n**Therapy and Progression**: During the follow-up appointment, Mr. Doe\nunderwent a clinical examination and a chest X-ray to assess his\npostoperative condition. The examination revealed no new concerning\nfindings, and Mr. Doe continued to remain in stable general condition.\nHis surgical incision site was inspected, showing signs of satisfactory\nhealing without any signs of infection or complications.\n\nFurthermore, Mr. Doe\\'s lung function was evaluated through spirometry,\nwhich indicated adequate pulmonary function post-surgery. He was also\nprovided with personalized recommendations for respiratory exercises to\noptimize his lung function during the recovery period.\n\n**Current Recommendations:**\n\n- Mr. Doe is connected to the radiation therapy team for ongoing\n follow-up.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgery on 01/11/2022:**\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015 Radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n**Other Diagnoses:**\n\n- OSAS with CPAP incompliance\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for routine follow-up.\nClinically, he remains in stable general condition, with no signs of\nB-symptoms.\n\n**Medical History**: The surgical procedure performed on 01/11/2022\ninvolved perioperative bronchoscopy, left VATS, pleurolysis, anatomical\nupper lobe resection, systematic mediastinal, hilar, and interlobar\nlymph node dissection, as well as the placement of double chest drains.\nHistologically, the final resection specimen confirmed a 2.9 cm solid\ncarcinoma, consistent with metastasis from the previously diagnosed\nsquamous cell carcinoma. Lymph nodes dissected during the procedure were\ntumor-free. Mr. Doe\\'s postoperative course was uneventful, and surgical\nsutures were removed on day 10 after surgery.\n\n**Physical Examination:** Patient in good general condition. Weight loss\n0°, MUST score: 0, pain VAS 1-2/10, fatigue I°, dysphagia I° with solid\nfood (liquids occasionally flow out of the nose again when swallowing),\naspiration 0°, ulcer 0°, trismus 0°, taste disorder I° (present in\napprox. 80%), xerostomia I°, osteonecrosis 0°, hypothyroidism II°,\nhoarseness II°, hearing loss, I°, dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**Current Recommendations:** Mr. Doe is advised to continue his\nfollow-up appointments.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------- ---------------------\n Neutrophils 72.2 % 42.0-77.0 %\n Lymphocytes 8.6 % 20.0-44.0 %\n Monocytes 11.6 % 2.0-9.5 %\n Basophils 1.4 % 0.0-1.8 %\n Eosinophils 6.0 % 0.5-5.5 %\n Immature Granulocytes 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 9.24 mg/dL 8.8-10.2 mg/dL\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n CRP 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n GGT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5 % 37.0-49.0 %\n RBC 3.3 M/µL 4.0-5.6 M/µL\n WBC 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Absolute Neutrophils 3.59 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.010 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.43 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.58 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.30 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94 % 0.50-2.00 %\n Ret-Hb 33.9 pg 28.5-34.5 pg\n PT 112 % \\> 78 %\n INR 0.95 \\< 1.25\n aPTT 30.2 sec. 25.0-38.0 sec.\n\n\n\n\nHere is the query:\nIn relation to Mr. Doe's radiotherapy in 2015, how many Gy was each session?\n\nChoose the correct answer from the following options:\nA. 1 Gy\nB. 2 Gy\nC. 3 Gy\nD. 4 Gy\nE. 5 Gy\n\n\nYour response:\n", "role": "user" }, { "content": "2 Gy", "role": "assistant" } ]

[ { "content": "**Dear colleague, ****Dear colleague, **\n\n \n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who was treated in our clinic from 05/28/14 to 06/20/14.\n\n \n\n**Diagnoses: **\n\n- pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left\n midline tongue carcinoma\n\n- Arterial hypertension\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Idiopathic thrombocytopenia\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Hypothyroidism\n\n- Nicotine abuse\n\n<!-- -->\n\n- Panendoscopy with sampling on 04/14/2014 and 04/26/2014\n\n \n\n**Current Presentation**: With histologically confirmed carcinoma in the\nregion of the base of the tongue on the left side, Mr. Doe presents for\nsurgical treatment of the findings. In accordance with the tumor board\ndecision, resection is performed via a lateral pharyngotomy and neck\ndissection on both sides.\n\n \n\n**Physical Examination:** Patient in stable general condition (85 kg,\n188 cm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I° (L-thyroxine increased to 150 μg 1-0-0), hoarseness\n0°, hearing loss 0° (subjectively reduced), dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\nA tumorous mass can be inspected at the base of the left tongue. Tongue\nmobility is unremarkable.\n\n**CT chest, abdomen, pelvis on 05/28/14:**\n\nEmphasized mediastinal as well as abdominal lymph\nnodes.** **Vasosclerosis. Otherwise, there is no evidence for the\npresence of distant metastases with a suspected base of tongue\ncarcinoma. Liver cirrhosis.\n\n \n\n**CT neck on 06/11/14:**\n\nSuspected left tongue base carcinoma crossing midline with extension\ninto the left vallecula and compression of the left piriform sinus with\nsuspected lymph node metastases in levels I-III ipsilateral.\nContralateral prominent but not certainly suspicious lymph nodes. The\nprominent structure on the left supraclavicular side can also be\ninterpreted as circumscribed cystiform ectasia of the thoracic duct.\n\n \n\n**Ultrasound abdomen on 06/15/14:**\n\nImage of liver cirrhosis status post cholecystectomy.\nHepatosplenomegaly. Moderate aortic sclerosis.\n\n \n\n**X-ray pap swallow on 06/17/14:**\n\nClear tracheal aspiration in the absence of epiglottis envelope. The\ncough reflex is preserved. Otherwise, essentially unremarkable\nswallowing act. \n\n \n\n**Histology**: Invasive, moderately differentiated, squamous cell\ncarcinoma with keratinization of the medial left base of the tongue,\nmaximum extent 1.0 cm. Carcinoma- and dysplasia-free biopsies of the\nleft tonsil, the oropharyngeal tumor/tongue base on the left, deep\nresection of the tumor, lower tonsillar pole transition on the left\ntongue base, tongue base on the left and medial left tongue base, as\nwell as median tongue base.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** pT1. pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n \n\n**Therapy and Progression**: After the usual clinical and laboratory\npreparations, we performed the above-mentioned therapy on 05/29/14 in\nintubation anesthesia without complications. For perioperative infection\nprophylaxis, the patient received intravenous antibiotic therapy with\nAmpicillin and Sulbactam 3g three times daily for the duration of his\nhospital stay.\n\nDuring this procedure, the left lingual artery was interrupted\nprophylactically. No postoperative bleeding and no wound healing\ndisturbances occurred.\n\nA porridge swallow examination showed no evidence of a fistula. On the\nfollowing day, the patient was decannulated in consultation with the\ncolleagues of the speech therapy. After this, a food build-up was\ncarried out in cooperation with speech therapists. At the time of\ndischarge, the patient was receiving regular oral nutrition. The stoma\ncontinued to shrink. The patient was monitored, and if necessary, the\ntracheostoma was closed with local anesthesia. Histological findings\nwere pT1. Due to an RX status, adjuvant radiotherapy will be performed\nas decided by the tumor board. A prophylactic presentation at the\ncolleagues of the MKG as a preparatory measure for the upcoming\nradiotherapy. We asked for a control re-presentation in our outpatient\nclinic on 06/26/14 at 3:00 PM. Further controls take place at the half\nand at the end of the radiotherapy and further in 4-6 weeks rhythm. In\ncase of acute complaints, an immediate re-presentation is possible at\nany time.\n\n \n\n**Type of surgery**: Lateral pharyngotomy with resection of the base of\nthe tongue on the left as well as selective neck dissection on both\nsides level II-IV with ligature of the lingual artery on the left side,\ncreation of a stable tracheostoma and tonsillectomy on the left side.\n\n**Surgery report: **First, tracheotomy in a typical manner. A horizontal\nincision was made on the skin, positioned approximately two transverse\nfinger widths above the jugulum. Subsequently, the subcutaneous tissue\nand the platysma colli were incised. To facilitate access to the\ntrachea, the laryngeal muscles were carefully displaced to the side. The\nthyroid isthmus was undermined and clamped bilaterally. A precise\ntransection of the thyroid isthmus followed, with both halves of the\nthyroid gland being meticulously sutured using 0- Vicryl. The thyroid\nhalves were repositioned to expose the trachea. A visceral tracheotomy\nwas performed, and re-intubation was achieved utilizing a U-tube. The\nsurgical procedure then transitioned to a neck dissection on the left\nside. This phase began with an incision along the anterior edge of the\nsternocleidomastoid muscle. The subcutaneous tissue and platysma colli\nwere carefully cut, with due respect to the auricularis magnus nerve.\nDissection continued dorsally along the sternocleidomastoid muscle to\nreach the anterior border of the trapezius muscle. Further exposure\ninvolved the accessorius nerve in a cranialward direction, with\npreservation of this neural structure. Dissection proceeded along the\ncervical vascular sheath, revealing the common carotid artery, internal\njugular vein, and vagus nerve up to the digastric muscle. Below this\nlevel, exposure of the hypoglossal nerve was achieved.\n\nSuccessive dissection involved the lymph node fat package, progressing\nfrom level II to level IV in a cranial to caudal and ventral to dorsal\ndirection. Throughout this process, careful attention was paid to\nsparing the aforementioned neural and vascular structures. Subsequently,\naccess to the lateral pharyngectomy area was gained, allowing\nvisualization of the external carotid artery along with its branches,\nincluding the superior thyroid artery, superior laryngeal artery, and\nlingual artery. Notably, the lingual artery was interrupted during this\nstage.\n\nFurther exploration revealed the superior laryngeal nerve and\nhypoglossal nerve intersecting in a loop above the internal carotid\nartery and externally below the external jugular vein. Additional\ndissection in a ventral direction followed. The hypoglossal nerve was\nprepared meticulously. Exposure of the hyoid bone was achieved, with a\nposterior resection of half of the hyoid bone. Importantly, the\nhypoglossal nerve was spared during this procedure. Subsequent to these\nsteps, the lateral pharynx wall was opened, exposing the base of the\nhyoid. The next phase of the procedure involved enoral tumor\ntonsillectomy on the left side. Starting from the left side, the\nsurgical team identified the tonsil capsule at the anterior palatal arch\nusing a Henke spatula. The upper tonsillar pole was then dislodged and\ndissected with the Rosenblatt instrument, proceeding from cranial to\ncaudal. Hemostasis was meticulously achieved through swab pressure and\nelectrocautery. The excised tonsil tissue was sent for frozen section\nexamination for further analysis.\n\n**Frozen Section Report: **No evidence of malignancy was found. The\nresection was carried out at the junction of the caudal tonsillar pole\nand the base of the tongue. At this location, tissue from the base of\nthe tongue was resected and sent for a frozen section examination, which\nrevealed no indication of malignancy. Subsequently, a medial resection\nof the base of the tongue was performed, confirming the presence of\nsquamous cell carcinoma in the frozen section analysis. Mucosal suturing\nwith inverting sutures was then conducted. On the left side, a neck\ndissection procedure was performed. The dissection extended along the\nsternocleidomastoid muscle, reaching dorsally to the anterior border of\nthe trapezius muscle. This approach allowed for cranial exposure of the\naccessorius nerve while sparing the same. Dissection continued along the\ncervical vascular sheath, exposing the common carotid artery, internal\njugular vein, and the vagus nerve up to the digastric muscle. Below\nthis, the hypoglossal nerve was exposed. Subsequently, the lymph node\nfat package was dissected systematically from level II to level IV,\nprogressing from cranial to caudal and ventral to dorsal, while\ncarefully preserving the mentioned structures. The surgical procedure\nconcluded with the placement of a drain, subcutaneous suturing, and skin\nsuturing.\n\n**Frozen section report:** Invasive squamous cell carcinoma.\n\n \n\n**Microscopy:**\n\nEven after paraffin embedding, mucosal cross-sections show a covering of\nstratified, non-keratinizing squamous epithelium with occasional\nsignificant stratification disturbances extending into superficial cell\nlayers. This transitions into invasive growth with solid clusters of\npolygonal tumor cells, some of which exhibit identifiable intercellular\nbridges. The cell nuclei are enlarged, round to oval, with occasional\nsmall nucleoli and mild to moderate nuclear pleomorphism. Dyskeratosis\nis observed in some areas.\n\n**Lab results upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- ----------------------- -----------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.0 mg/dL 0.7 - 1.3 mg/dL\n Calcium 9.04 mg/dL 8.8 - 10.6 mg/dL\n GFR (MDRD) \\> 60 mL/min/1.73m\\^2 \\> 60 mL/min/1.73m\\^2\n GFR (CKD-EPI,CREA) 80 mL/min/1.73m\\^2 \\> 90 mL/min/1.73m\\^2\n C-reactive protein 1.0 mg/dL \\< 0.5 mg/dL\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who presented to our outpatient clinic on 09/14/2014.\n\n**Diagnosis: **Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21)\nL0 V0 Pn0 G2 RX\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n- Since 03/2014: Odynophagia\n\n<!-- -->\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Histology:**\n\nInvasive, moderately differentiated, squamous cell carcinoma with\nkeratinization of the medial left base of the tongue, maximum extent 1.0\ncm. Carcinoma- and dysplasia-free biopsies of the left tonsil, the\noropharyngeal tumor/tongue base on the left, deep resection of the\ntumor, lower tonsillar pole transition on the left tongue base, tongue\nbase on the left and medial left tongue base, as well as median tongue\nbase.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** min pT1, pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n**Current Radiotherapy:**\n\n**Indication**: According to the decision made by the interdisciplinary\ntumor board for head and neck tumors, it was determined by our medical\nteam that, in the postoperative condition following the resection of a\ntongue base carcinoma with an unclear resection status, there is an\nindication for radiation therapy of the former tumor site.\n\n**Technique:** Percutaneous radiotherapy of the former primary tumor\nregion with 6-MeVPhotons, in Rapid-Arc technique, with a single dose of\n2 Gy up to a total dose of 60 Gy.\n\n**Radiotherapy 07/27/2014 - 09/06/2014:**\n\nDuring the course of radiotherapy, the patient experienced enoral\nmucositis (grade II according to CTCAE) leading to subsequent\nodynophagia and dysphagia. We managed these symptoms with oral rinses\nand initiated pain management using Acetaminophen, resulting in an\nacceptable reduction of pain over time. At the end of the therapy, the\npatient\\'s general condition remained stable (ECOG performance status:\n70%). Second-degree mucositis enoral persisted, causing ongoing\ndysphagia and odynophagia. Additionally, the patient exhibited localized\nradiodermatitis (grade II according to CTCAE) within the radiation\nfield. The patient did not report xerostomia or dysgeusia.\n\n**Current Recommendations:**\n\nThe patient received comprehensive instructions on continued skincare\nand side-effect management. An initial follow-up appointment with the\nradio-oncology team has been scheduled in our outpatient clinic. We\nkindly request the patient to provide a renewed referral for\nradiotherapy on the day of the appointment.\n\nThe ongoing oncological treatment plan will be determined by the\npatient\\'s Ear, Nose, and Throat specialists. Regular follow-up\nexaminations are strongly recommended. Additionally, for patients who\nhave completed radiation therapy in the ENT region, we advise lifelong\nadherence to fluoride prophylaxis and antibiotic therapy during any\ndental procedures.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965, who presented\nto our outpatient clinic for phoniatrics and pedaudiology on 10/10/2014.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Medical History: **We may kindly assume the detailed history as known.\n\n**Phoniatrics: Fiberoptic endoscopic swallow examination:**\n\nTongue motor function is well preserved, sensitivity of lip and tongue\nlaterally equal,\n\nMucous membranes non-irritant on all sides. Tracheal mucosa\nnon-irritant, no evidence of saliva intratracheal. Neopharynx\ninconspicuous, air bubbles visible above Provox outlet on pressing\nattempt. Tongue retraction slightly limited. Velopharyngeal closure\ngood.\n\n**Therapy and Course:** After completion of the adjuvant radiotherapy\napproximately 6 weeks ago, phonation via the Provox voice prosthesis was\nno longer possible after this had initially worked after the operation.\nAdditionally, there were issues with regurgitation of ingested\nsubstances, regardless of their consistency. In some cases, nasal\npenetration with fluids occurred. There were no indications of\naspiration. A self-assessment, involving the use of blue-colored liquid,\nrevealed no signs of leakage from the Provox device.\n\n**Current Recommendations:** Oncological follow-up in 12 months.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965 who presented\nat our outpatient clinic for radio-oncological follow-up on 10/09/2020.\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n \n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for a radio-oncological follow-up on 10/09/2020 in the\npresence of his wife.\n\n**Physical Examination**: Patient in stable general condition (85 kg,188\ncm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I°, hoarseness 0°, hearing loss 0° (subjectively\nreduced), dyspnea: 0°, pneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\n**MRI scan of the neck from 10/09/2020:** \n\nClear post-therapeutic changes in the resection and radiation area after\nadjuvant RTx following tumor resection with laryngectomy for extensive\nrecurrence of oropharyngeal cancer. \n\nSize constant, but still clearly accentuated lymph nodes in level Ib/IIa\non the left. Regredience of seroma formation under the left\nsternocleidomastoid muscle.\n\n**Current Recommendations: **Primary oncological care and follow-up,\nincluding imaging, will be provided by the ENT clinic according to the\nguidelines. A re-appointment for a further radio-oncological follow-up\nat the follow-up appointment at the Radiation Therapy Tumor Therapy\nCenter has been scheduled. After head and neck radiation therapy,\nregular fluoridation of the teeth and guideline-based antibiotic\nprophylaxis is required prior to major dental procedures. We also\nrecommend temporomandibular joint opening exercises to prevent\ntemporomandibular joint fibrosis and consecutive temporomandibular joint\nopening obstruction. We also refer to regular control of thyroid\nfunction parameters and, if necessary, initiation of substitution\ntherapy after radiotherapy to the neck.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe hereby report on our patient Mr. Paul Doe, born 08/08/1965 for\nradio-oncological follow-up on 09/24/2021.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for radio-oncological follow-up on 09/24/2021. \n\n**Physical Examination: **Patient in reduced general condition (KPS 60%,\n86 kg,188 cm). Weight loss 0°, MUST score: 0, pain VAS 1-2/10, fatigue\nI°, dysphagia I° with solid food (liquids occasionally flow out of the\nnose again when swallowing), aspiration 0°, ulcer 0°, trismus 0°, taste\ndisorder I° (present in approx. 80%), xerostomia I°, osteonecrosis 0°,\nhypothyroidism II°, hoarseness II°, hearing loss, I°, dyspnea: 0°,\npneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**MR neck plain + contrast agent on 09/24/2021**:\n\n[Technique]{.underline}: STIR triplanar, T1 ax -/+ contrast agent, T1\nmDixon cor after\n\ncontrast agent.\n\n[Findings]{.underline}: Known status post tumor resection with\nlaryngectomy for extensive recurrence of oropharyngeal Carcinoma;\nFollow-up after RTx. Somewhat increasing swelling of nasopharynx to\noropharynx. From the uvula the swelling is stable. As far as can be\nassessed, no clear recurrence-specific tissue proliferation or contrast\nuptake. Unchanged accentuated lymph nodes in level Ib/IIa on the left\n(one exemplary measured lymph node borderline large, idem to preliminary\nexamination). Mastoid cells minimally displaced on the left. Moderate\ndegenerative changes of the cervical spine. Assessment. Increasing\nswelling of the naso- to oropharynx. Neopharynx unchanged swollen. No\nevidence of malignancy-suspicious lymph nodes.\n\n**CT scan of the thorax on 09/24/2021**:\n\nSize-constant visualization of interlobar oval compaction in the left\nupper lobe corresponding to an interlobar lymph node. New to the\nprevious examination, two small nodular condensations appear, basal in\nthe right and in the left lower lobe, differentially inflammatory;\nfollow-up is recommended. Unchanged the prominent mediastinal lymph\nnodes, constant in size and number.\n\n**Current Recommendations:**\n\nPrimary oncologic care and follow-up including imaging will take place\nvia the ENT clinic on 01/14/22 at 11:00 AM. A re-appointment for the\nnext radio-oncological follow-up has been arranged for 01/14/2022 at\n1:00 PM in our radiotherapy outpatient clinic in the Tumor Therapy\nCenter.\n\n**Lab results upon Discharge:**\n\n**Hematology**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- -----------------------\n WBC 6,900 /μL 4,500 - 11,000 /μL\n RBC 2.7M /μL 4.5M - 5.9M /μL\n Hemoglobin 8.2 g/dL 14 - 18 g/dL\n Hematocrit 25.1 % 40 - 48 %\n MCH 31.27 pg 27 - 33 pg\n MCV 94 fL 82 - 92 fL\n MCHC 32.7 g/dL 32 - 36 g/dL\n Platelets 638,000 /μL 150,000 - 450,000 /μL\n\n**Serum chemistry**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ -----------------\n Sodium 144 mEq/L 135 - 145 mEq/L\n Potassium 4.8 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.3 mg/dL 0.7 - 1.3 mg/dL\n ALT 21 U/L 10 - 50 U/L\n eGFR 55 mL/min \\> 90 mL/min\n CRP 2.9 mg/dL \\< 0.5 mg/dL\n\n**Coagulation**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ ---------------\n PT 93 % 70 - 120 %\n INR 1.1 0.8 - 1.2\n aPTT 31 sec 26 - 37 sec\n\n**Thyroid hormones**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- ------------------\n TSH 1.16 μIU/mL 0.4 - 4.2 μIU/mL\n fT3 2.38 pg/mL 2.3 - 4.2 pg/mL\n fT4 1.70 ng/dL 0.9 - 1.7 ng/dL\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who was admitted\nto our hospital from 01/10/2022 to 01/27/2022.\n\n**Diagnosis**: Metachronous pulmonary metastatic squamous cell carcinoma\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014 Odynophagia\n\n- 05/14/2014 Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014 Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Planned Surgical Procedure:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Medical History**: Mr. Paul Doe initially presented with a diagnosis\nof pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left midline\ntongue carcinoma. Panendoscopy with specimen collection on 04/14/2014\nand 04/26/2014 confirmed carcinoma.\n\nSurgical resection was performed via lateral pharyngotomy and neck\ndissection. Histology confirmed squamous cell carcinoma. He subsequently\nreceived radiotherapy.\n\nDuring a follow-up CT examination, a suspicious lesion was identified in\nthe lung, which raised concerns regarding the possibility of metastasis\noriginating from the previously diagnosed left midline tongue carcinoma\n(pT1, pN0, G2, RX).\n\n**Current Presentation:** Mr. Doe was admitted for further examination\nand treatment to assess the behavior and extent of the lesion.\nClinically, Mr. Doe was in stable general condition and had no symptoms\nsuggestive of B symptoms.\n\n**Therapy and Progression**: The above-mentioned procedure was performed\nwithout complications on 01/10/2022. Histologically, the final resection\nspecimen confirmed the presence of a 2.9 cm squamous cell carcinoma,\nconsistent with a metastatic recurrence of the previously known\nhypopharyngeal carcinoma. The dissected lymph nodes were free of tumor.\nThe postoperative course was uneventful. In the absence of any\ncomplications, surgical sutures were removed on day 10 after surgery. A\ncurrent chest X-ray showed a regular postoperative outcome with\nsufficient expansion of the left lobe. Further monitoring is recommended\nby the treating colleagues in this regard. Mr. Doe is also connected to\nthe radiation therapy team for ongoing follow-up.\n\nIf there are any complications or questions, please contact the relevant\nward or reach out to our Central Patient Management. Outside regular\nworking hours, you can contact the on-call colleague in the Abdominal\nSurgery department for assistance.\n\nFor further information on the patient\\'s discharge management, treating\nproviders are available for inquiries from Monday to Friday, 9 AM to 7\nPM, as well as on weekends and holidays from 10 AM to 2 PM.\n\nMr. Doe was discharged from the hospital on 01/27/2022.\n\n**Addition:**\n\n**Histology Report:** Resected left upper lobe specimen with a 2.9 cm\nsolid carcinoma. The histological picture is consistent with a\nmetastasis from the previously diagnosed non-keratinizing squamous cell\ncarcinoma. There were focal vascular invasions. No pleural invasion was\nobserved. The resection was complete, with all dissected lymph nodes\nshowing no tumor involvement.\n\n**Chest X-ray, anterior-posterior view from 01/21/2022**:\n\n[Clinical Information:]{.underline} History of VATS with wedge\nresection, yesterday\\'s drain removal\n\n[Question:]{.underline} Follow-up, pneumothorax after drain removal?\nInfiltrates? Atelectasis?\n\n[Findings:]{.underline} Left chest drainage tube has been removed. Left\napical pneumothorax line, measuring approximately 2.3 cm. Continued\nextensive shadowing of the left upper field, most likely postoperative,\ninfiltrate cannot be definitively ruled out. Slightly hypotransparent\nleft lung in comparison, most likely due to residual postoperative\nreduced ventilation. No effusion. Widened cardiac silhouette. Regression\nof dystelectasis in the right lower field. No acute signs of pulmonary\nvenous congestion. Trachea is mid-positioned and not stenosed.\nLeft-sided port catheter still in place.\n\n[Summary]{.underline}: Left apical corax with a width of 2.3 cm.\nContinued extensive shadowing of the left upper field, most likely\npostoperative, with infiltrate not definitively excluded. Residual\npostoperative reduced ventilation on the left side. Regression of\ndystelectasis in the right lower field. No effusion. No acute signs of\npulmonary venous congestion. Follow-up recommended.\n\n**Examinations Chest X-ray, anterior-posterior view from 01/23/2022:**\n\n[Question]{.underline}**:** Follow-up.\n\n[Findings]{.underline}: Left apical pneumothorax, measuring\napproximately 1.4 cm. Extensive shadowing in projection onto the left\nupper lobe, differentials include postoperative changes, incipient\ninfiltrate not excluded. Dystelectasis of the right lower field. No\nevidence of pleural effusion or acute pulmonary venous congestion.\nCardiomegaly. Indwelling chest drainage with the catheter tip projecting\nonto the left upper lobe. Well-positioned port catheter tip projecting\nonto the right atrial entrance plane. No evidence of pleural effusion.\nAssessment Left apical pneumothorax, measuring approximately 1.4 cm,\nwith indwelling left chest drainage. Extensive shadowing in projection\nonto the left upper lobe, differentials include postoperative changes,\nincipient infiltrate not excluded. Dystelectasis of the right lower\nfield. No significant pleural effusion. No acute pulmonary venous\ncongestion. Cardiomegaly.\n\n**Chest X-ray, anterior-posterior view from 01/25/2022**\n\n[Previous Examinations]{.underline}: Appearance of a diffuse\npostoperative shadow in the left upper field. No evidence of pleural\neffusion, inflammatory infiltrate, or pulmonary venous congestion.\n\n[Findings]{.underline}: Left-sided chest port with the tip projecting\nonto the superior vena cava. The upper mediastinum is narrow, the\ntrachea is mid-positioned and patent.\n\n[Assessment]{.underline}: The pneumothorax appears to be largely\nresolved.\n\n**Urinanalysis**:\n\nMaterial: Urine, midstream sample collected on 01/11/2022\n\n- Antimicrobial inhibitors negative\n\n- No evidence of growth-inhibiting substances in the sample material.\n\n- Colony Count (CFU) / mL \\<1,000, Assessment: A low colony count\n typically does not support a urinary tract infection.\n\n- Epithelial cells (microscopic) \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic) \\<20 leukocytes/μL\n\n- Microorganisms (microscopic) 20-100 microorganisms/μL Pathogen\n Enterococci\n\n**Lab values upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- --------------------- ---------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n Calcium 10.4 mg/dL 8.8 - 10.6 mg/dL\n eGFR (MDRD) \\> 60 mL/min/1.73m² \\> 60 mL/min/1.73m²\n eGFR (CKD-EPI) 85 mL/min/1.73m² \\> 90 mL/min/1.73m²\n C-Reactive Protein 5.0 mg/dL \\< 0.5 mg/dL\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgical Procedure from 01/11/2022:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015: radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n- OSAS with CPAP incompliance\n\n<!-- -->\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for postoperative follow-up\nafter his left-sided videothoracoscopic upper lobe resection due to\npreviously diagnosed pulmonary metastatic hypopharyngeal carcinoma.\n\n**Medical History:** The patient\\'s general condition is good. He is\ncurrently on intermittent as-needed analgesia with Acetaminophen. The\nfinal resection specimen histologically confirmed the presence of a 2.9\ncm squamous cell carcinoma, consistent with a metastatic recurrence of\nthe previously known hypopharyngeal carcinoma. The dissected lymph nodes\nwere free of tumor.\n\n**Therapy and Progression**: During the follow-up appointment, Mr. Doe\nunderwent a clinical examination and a chest X-ray to assess his\npostoperative condition. The examination revealed no new concerning\nfindings, and Mr. Doe continued to remain in stable general condition.\nHis surgical incision site was inspected, showing signs of satisfactory\nhealing without any signs of infection or complications.\n\nFurthermore, Mr. Doe\\'s lung function was evaluated through spirometry,\nwhich indicated adequate pulmonary function post-surgery. He was also\nprovided with personalized recommendations for respiratory exercises to\noptimize his lung function during the recovery period.\n\n**Current Recommendations:**\n\n- Mr. Doe is connected to the radiation therapy team for ongoing\n follow-up.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgery on 01/11/2022:**\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015 Radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n**Other Diagnoses:**\n\n- OSAS with CPAP incompliance\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for routine follow-up.\nClinically, he remains in stable general condition, with no signs of\nB-symptoms.\n\n**Medical History**: The surgical procedure performed on 01/11/2022\ninvolved perioperative bronchoscopy, left VATS, pleurolysis, anatomical\nupper lobe resection, systematic mediastinal, hilar, and interlobar\nlymph node dissection, as well as the placement of double chest drains.\nHistologically, the final resection specimen confirmed a 2.9 cm solid\ncarcinoma, consistent with metastasis from the previously diagnosed\nsquamous cell carcinoma. Lymph nodes dissected during the procedure were\ntumor-free. Mr. Doe\\'s postoperative course was uneventful, and surgical\nsutures were removed on day 10 after surgery.\n\n**Physical Examination:** Patient in good general condition. Weight loss\n0°, MUST score: 0, pain VAS 1-2/10, fatigue I°, dysphagia I° with solid\nfood (liquids occasionally flow out of the nose again when swallowing),\naspiration 0°, ulcer 0°, trismus 0°, taste disorder I° (present in\napprox. 80%), xerostomia I°, osteonecrosis 0°, hypothyroidism II°,\nhoarseness II°, hearing loss, I°, dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**Current Recommendations:** Mr. Doe is advised to continue his\nfollow-up appointments.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------- ---------------------\n Neutrophils 72.2 % 42.0-77.0 %\n Lymphocytes 8.6 % 20.0-44.0 %\n Monocytes 11.6 % 2.0-9.5 %\n Basophils 1.4 % 0.0-1.8 %\n Eosinophils 6.0 % 0.5-5.5 %\n Immature Granulocytes 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 9.24 mg/dL 8.8-10.2 mg/dL\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n CRP 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n GGT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5 % 37.0-49.0 %\n RBC 3.3 M/µL 4.0-5.6 M/µL\n WBC 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Absolute Neutrophils 3.59 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.010 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.43 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.58 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.30 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94 % 0.50-2.00 %\n Ret-Hb 33.9 pg 28.5-34.5 pg\n PT 112 % \\> 78 %\n INR 0.95 \\< 1.25\n aPTT 30.2 sec. 25.0-38.0 sec.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n\n\n\n\nHere is the query:\nWhich complication did Mr. Chapman NOT experience during his ICU stay?\n\nChoose the correct answer from the following options:\nA. Rhabdomyolysis\nB. Diabetes insipidus\nC. Malresorptive hydrocephalus\nD. Infarct areas in the MCA-ACA border zones\nE. Subarachnoid hemorrhage\n\n\nYour response:\n", "role": "user" }, { "content": "Diabetes insipidus", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953. He was under our inpatient care from 04/19/2009 to\n04/28/2009.\n\n**Diagnoses:**\n\n- Progressive deterioration of renal transplant function (creeping\n creatinine) without evidence of biopsy-proven rejection\n\n- Isovolumetric tubular epithelial vacuolization\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Mr. Fisher was admitted for a renal transplant\nbiopsy due to progressive deterioration of transplant function (creeping\ncreatinine). His recent creatinine values had increased to around 1.4 --\n1.6 mg/dL, while they had previously been around 1.1 mg/dL.\n\n**Therapy and Progression:** Following appropriate preparation and\ninformed consent, a complication-free transplant puncture was performed.\nThe biopsy showed isometric tubular epithelial vacuolization without\nsignificant findings. This was followed by adjustment of Cyclosporin-A\nlevels and the addition of a lymphocyte proliferation inhibitor to the\nexisting immunosuppressive dual therapy. There was a significant\nincrease in Cyclosporin-A levels at one point due to accidental double\ndosing by the patient, but levels returned to the target range. This\nmight explain the current rise in creatinine. Another explanation could\nbe recurrent hypotensive blood pressure dysregulations, leading to the\ndiscontinuation of Minoxidile medication. For chronic atrial\nfibrillation, anticoagulation therapy with Marcumar was restarted during\nhospitalization and should be continued as an outpatient according to\nthe target INR. Low molecular weight heparin administration could be\ndiscontinued.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No dyspnea. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable.\n\nLungs: Normal chest shape, moderately mobile, resonant percussion sound,\nvesicular breath sounds bilaterally, no wheezing or crackles heard.\n\nHeart: Irregular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, markedly obese, no tenderness, no palpable\nmasses, liver and spleen not palpable due to limited access, non-tender\nkidneys. Large reducible incisional hernia on the right side following\nnephrectomy.\n\nExtremities: Occluded fistula on the right forearm. Normal peripheral\npulses; joints freely movable. Strength, motor function, and sensation\nare unremarkable.\n\n**Kidney Biopsy on 04/19/2009:** Complication-free biopsy of the\ntransplant kidney.\n\nFindings: Erythematous macules.\n\nRecommendation: Follow-up in 3 months.\n\n**Ultrasound of Transplant Kidney on 04/20/2009:** Transplant kidney\nwell visualized, located in the left iliac fossa, measurable,\noval-shaped. Parenchymal echogenicity normal, normal corticomedullary\ndifferentiation. No evidence of arteriovenous fistula or hematoma after\nkidney biopsy.\n\n**Pathological-anatomical assessment on 04/19/2009:**\n\n**Macroscopic Findings:** Singular Nodule Identified: Dimensions\nmeasuring 8 mm.\n\n**Microscopic Examination:**\n\nSampled Tissue: Renal cortex\n\nIdentified Components:\n\n- Glomeruli: Nine observed\n\n- Interlobular Artery: One segment present\n\n- Absence of medullary tissue\n\n**Diagnostic Observations:** There were no signs of inflammation or\nscarring in the renal cortex. The glomeruli appeared normocellular, and\nno signs of inflammation or pathological changes were observed in them.\nThe peritubular capillaries were free of inflammation, and the specific\ntest for C4d staining yielded negative results. The arterioles within\nthe tissue had thin walls, and there was no evidence of inflammation in\nthis vascular component.\n\nThe interlobular artery was also thin-walled and showed no evidence of\ninflammation.\n\nA notable finding was extensive damage to the tubular epithelium. The\ndamage was characterized by isometric microvesicular cytoplasmic\ntransformation, which exceeded 80%. Importantly, there was no evidence\nof cell necrosis and only minimal flattening of cells was observed. In\naddition, no pathological imprints, microcalcifications, or nuclear\ninclusion bodies were observed in the tubular epithelium.\n\n**Summary:** The predominant pathological finding in this case is\nsubstantial tubular damage. Consequently, it is highly advisable to\nclosely monitor immunosuppression levels in the patient\\'s management.\nFurther comprehensive evaluation is strongly recommended to determine\nthe underlying cause of the observed tubular damage and to address the\nclinical question concerning the presence of Chronic Allograft\nNephropathy or the potential involvement of an infection in the clinical\npresentation.\n\n**Chest X-ray (2 views) on 04/22/2009:**\n\n[Findings]{.underline}: No pneumothorax, no effusion. No evidence of\npneumonia. No focal findings. Left-biased heart without decompensation.\nMediastinum centrally positioned, not widened. Unremarkable depiction of\ncentral hilar structures. Thoracic hyperkyphosis.\n\n**Current Recommenations:** We request regular outpatient monitoring of\nretention parameters (initially every 2-3 weeks) and are available for\nfurther questions at the provided telephone number.\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 144 mEq/L 134-145 mEq/L\n Potassium 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium 9.48 mg/dL 8.6-10.6 mg/dL\n Chloride 106 mEq/L 95-112 mEq/L\n Phosphorus 2.88 mg/dL 2.5-4.5 mg/dL\n Transferrin Saturation 20 % 16-45 %\n Magnesium 1.9 mg/dL 1.8-2.6 mg/dL\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n Glomerular Filtration Rate 36 mL/min \\>90 mL/min\n BUN (Blood Urea Nitrogen) 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n C-Reactive Protein 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 ng/mL 30-300 ng/mL\n ALT (Alanine Aminotransferase) 17 U/L \\<45 U/L\n AST (Aspartate Aminotransferase) 20 U/L \\<50 U/L\n Alkaline Phosphatase 119 U/L 40-129 U/L\n GGT (Gamma-Glutamyltransferase) 94 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n TSH (Thyroid-Stimulating Hormone) 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43% 40-52%\n Red Blood Cells 4.60 M/uL 4.6-6.2 M/uL\n White Blood Cells 8.78 K/uL 4.5-11.0 K/uL\n Platelets 205 K/uL 150-400 K/uL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/uL 1.8-7.7 K/uL\n Lymphocytes 2.37 K/uL 1.4-3.7 K/uL\n Monocytes 0.93 K/uL 0.2-1.0 K/uL\n Eosinophils 1.67 K/uL \\<0.7 K/uL\n Basophils 0.09 K/uL 0.01-0.10 K/uL\n Nucleated Red Blood Cells Negative \\<0.01 K/uL\n APTT (Activated Partial Thromboplastin Time) 45.1 sec 26-40 sec\n Antithrombin Activity 85 % 80-120 %\n\n**Medication upon discharge**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Cyclosporine (Neoral) 1 mg 1-0-1\n Mycophenolic Acid (Myfortic) 180 mg 1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0\n Aspirin 81 mg 1-0-0\n Candesartan (Atacand) 16 mg 0-0-1\n Metoprolol (Lopressor) 50 mg 1-1-1-1\n Isosorbide Dinitrate (Isordil) 60 mg 1-0-0\n Torsemide (Demadex) 10 mg As directed\n Ranitidine (Zantac) 300 mg 0-0-1\n Fluvastatin (Lescol) 20 mg 0-0-1\n Allopurinol (Zyloprim) 100 mg 0-1-0\n Tamsulosin (Flomax) 0.4 mg 1-0-0\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide an update on our patient, Mr. Alan Fisher,\nborn on 12/09/1953.\n\nHe was under our inpatient care from 10/02/2018 to 10/03/2018.\n\n**Diagnoses:**\n\n- Urosepsis\n\n- Acute postrenal kidney failure\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Previous Surgeries:** Previous prostate vesiculectomy with regional\nlymphadenectomy\n\n**Planned procedure:** Urethro-cystoscopy with catheter placement for\nurethral stricture\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by the outpatient urologist due to suspicion of\na urethral stricture. Mr. Fisher reports a worsening urinary retention\nfor approximately 6 months. Despite multiple unsuccessful attempts at\ncatheter placement, ureterocystoscopy with catheter insertion was\nperformed. Intraoperatively, purulent cystitis and a bladder outlet\nobstruction were observed.\n\nMr. Fisher regularly attends follow-up examinations for his history of\nkidney transplantation in 1995 and previous prostate vesiculectomy with\nregional lymphadenectomy in 01/2018.\n\n**Physical Examination:** Neurology: RASS 0, alert, CAM-ICU negative, no\nnew focal neurology\n\nLungs: Bilateral air entry, no rales or wheezing, sufficient gas\nexchange on 2L/O2 Cardiovascular: Normal sinus rhythm, normotensive on\n0.01 µg/kg/min NA\n\nAbdomen: Soft, no guarding, sparse peristalsis, advanced oral diet,\nregular bowel movements\n\nDiuresis: Normal urine output, retention values within normal range,\ngoal: balanced fluid status\n\nSkin/Wounds: Non-irritated, no peripheral edema\n\n**Therapy and Progression**: We received Mr. Fisher, who was awake and\nspontaneously breathing under a 2L O2 mask via nasal cannula, to our\nintensive care unit due to urosepsis. To maintain an adequate\ncirculation, low-dose catecholamine therapy was required but could be\ndiscontinued on the first postoperative day. Pulmonary function remained\nstable with intensive non-invasive ventilation and breathing training.\n\nGiven his immunosuppression, we escalated the intraoperatively initiated\nanti-infective therapy from Ceftriaxone to Piperacillin/Tazobactam.\nPneumococcal and Legionella rapid tests were negative. Following\nappropriate volume resuscitation and diuretic therapy with Furosemide,\ndiuresis became sufficient. Oral diet progression occurred without\ncomplications. Anticoagulation was initially in prophylactic dosing with\nHeparin and later switched to therapeutic dosing with Enoxaparin.\n\n**Current Recommendations:**\n\n- Switch unfractionated Heparin to Fragmin\n\n- baseline Crea 2mg/dL, target CyA level: 50-60ng/mL, Myfortic\n continued.\n\n- Urological care of the stricture in progress, leave catheter until\n then.\n\n- Mobilization\n\n**Medication upon Discharge:**\n\n **Medication (Brand)** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Torsemide (Demadex) 10 mg 1-1-0-0\n Prednisone (Deltasone) 5 mg 1-1-0-0\n Pantoprazole (Protonix) 20 mg 1-1-0-0\n Mycophenolate Mofetil (CellCept) 360 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 100 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Candesartan (Atacand) 16 mg 0-0.5-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Allopurinol (Zyloprim) 100 mg 1-0-0-0\n Aspirin 81 mg 1-0-0-0\n Paracetamol (Tylenol) 500 mg As needed\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. Alan Fisher, born on\n12/09/1953.\n\nHe was under our inpatient care from 11/04/2018 to 11/12/2018.\n\n**Current Symptoms:** Decreased diuresis, rising creatinine, frustrating\ncatheterization.\n\n**Diagnoses:**\n\n- Acute on chronic graft failure\n\n<!-- -->\n\n- Creatinine increased from 1.56 mg/dL to a maximum of 2.35 mg/dL.\n\n- Likely postrenal origin due to urethral stricture; sonographically,\n Grade II urinary stasis with urinary retention and residual urine\n formation.\n\n- Frustrating catheterization due to urethral stricture\n\n- Urethro-cystoscopy with bougie and catheter placement\n\n- Parainfectious component in purulent cystitis with urosepsis\n\n- Discharged with indwelling catheter\n\n- Inpatient readmission to the colleagues in Urology for internal\n urethrotomy\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by an outpatient urologist due to suspected\nurethral stricture. Mr. Fisher reports increasing difficulty urinating\nfor approximately 6 months. He has to \\\"squeeze out\\\" his bladder\ncompletely. Frustrating catheterization was performed due to urinary\nretention. Intraoperatively, purulent cystitis and bladder outlet\nstenosis were observed. Mr. Fisher regularly undergoes follow-up\nexaminations for a history of kidney transplantation in 1995 and a\nprostate vesiculectomy with regional lymphadenectomy in 01/2018.\n\n**Vegetative Findings:** The patient had a bowel movement 4 days ago,\nindwelling catheter irritation (3L of diuresis the previous day), no\nnausea/vomiting, no fever or night sweats, weight loss of 30kg from\nFebruary to April 2020.\n\n**Physical Capacity:** Limited, can still climb 2 stairs but needs to\ntake a break due to shortness of breath.\n\n**Physical Examination:** Temperature 37.4°C, Blood pressure 128/72\nmmHg; Pulse 72/min; Respiratory rate 15/min, O2 saturation under 2L O2:\n96%\n\nAwake, alert, cooperative, oriented to time, place, person, and\nsituation.\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; Clear paranasal\nsinuses; moist and pink mucous membranes; unremarkable dentition; moist\nand glossy tongue; non-palpable thyroid enlargement.\n\n[Chest]{.underline}: Normal configuration; Non-tender spine; free renal\nbeds bilaterally.\n\n[Heart]{.underline}: Rhythmic, clear heart sounds, normal rate, no\nsplitting; non-distended jugular veins. [Lungs]{.underline}: Vesicular\nbreath sounds; Resonant percussion note; no adventitious sounds; no\nstridor; normal chest expansion.\n\n[Abdomen]{.underline}: Protuberant, known incisional hernia, normal\nperistalsis in all quadrants; soft; no pathological resistance; no\ntenderness; liver palpable below the costal margin; spleen not palpable.\n\n[Lymph nodes:]{.underline} No pathologically enlarged cervical nodes\npalpable; axillary and inguinal nodes not palpable.\n\nSkin: No pathological skin findings.\n\n[Extremities:]{.underline} Warm; mild bilateral ankle edema.\n\n[Pulse status (right/left):]{.underline} A. carotis +/+, A. radialis\n+/+, A. femoralis +/+, A. tibialis post. +/+, A. dorsalis ped. +/+\n\n[Neurological]{.underline}: Oriented and unremarkable.\n\n**Therapy and Progression:** The patient was admitted through our\nemergency department upon referral by an outpatient urologist due to\nsuspected urethral stricture, which had been causing increasingly\ndifficult urination for approximately 6 months. Sonography showed Grade\nII urinary stasis with urinary retention and residual urine. Frustrating\ncatheterization was performed, followed by ureterocystoscopy with bougie\nand catheter placement. Intraoperatively, purulent cystitis and bladder\noutlet stenosis were observed. Laboratory tests revealed acute kidney\ntransplant failure, with creatinine increasing from 1.56 mg/dL to 2.35\nmg/dL, along with significantly elevated infection parameters: CRP up to\n186 mg/dL, PCT 12.82 µg/L, and leukocytosis of 21.6/nL. After obtaining\nblood cultures, empirical antibiotic therapy with Ceftriaxone was\ninitiated. Upon detecting Pseudomonas aeruginosa, therapy was switched\nto Piperacillin/Tazobactam on 12/06/20 and continued until 12/13/20.\nUnder this treatment, infection parameters significantly improved, and\nMr. Fisher remained afebrile. Kidney retention parameters also decreased\nto a discharge creatinine of 2.05 mg/dL. Regarding the urethral\nstricture, he was initially discharged with an indwelling catheter. A\nfollow-up appointment for internal urethrotomy and potentially Allium\nstent placement was scheduled for 4 weeks later. During the hospital\nstay, ciclosporin levels remained within the target range. Following\nprostate vesiculectomy earlier in the year, anticoagulation was switched\nfrom Enoxaparin to Apixaban 2.5 mg twice daily, and Aspirin therapy was\ndiscontinued.\n\n**Recommendations**: We recommend regular monitoring of kidney retention\nparameters and infection parameters. Regarding the urethral stricture,\nthe patient will be discharged with an indwelling catheter. We scheduled\na follow-up with colleagues in Urology for internal urethrotomy and\npotentially Allium stent placement. Pause oral anticoagulation with\nApixaban one day before inpatient admission.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Candesartan (Atacand) 8 mg 0-1-0-0\n Torsemide (Demadex) 10 mg 1-1-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU Pause\n Magnesium Oxide 400 mg 1-0-0-0\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under outpatient care on 07/01/2019.\n\n**Current Symptoms:** Pain on the left side at rib level**,** Dyspnea\n\n**Diagnoses:**\n\n- Infection of unclear origin\n\n - CT Thorax and Abdomen showed no focus\n\n - Urine dipstick and cultures were bland\n\n - Antibiotics: Meropenem from 06/11/2019 to 06/19/2019\n\n- Acute Transplant Dysfunction\n\n - Serum Creatinine: 2.4 -\\> 4.5 -\\> 2.6 mg/dl\n\n - Renal ultrasound: 123 x 54 x 24 mm, not dilated, some areas of\n increased echogenicity, no twinkling, no acoustic shadowing, no\n signs of urolithiasis.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Initial presentation was at the local emergency\ndepartment on referral from the primary care physician for suspected\nacute coronary syndrome. Mr. Fisher described left-sided rib pain, which\nwas related to breathing and pressure, as well as dyspnea for a few\ndays. Laboratory tests showed acute-on-chronic kidney failure and\nelevated infection parameters. A urine dipstick test was negative for\nnitrites and leukocytes. Chest CT ruled out pulmonary pathology, and\nacute coronary syndrome was also excluded. Mr. Fisher reported a urinary\ntract infection about 4 weeks ago, which was treated with antibiotics as\nan outpatient.\n\n**Physical Examination:** Alert, oriented, cooperative, and responsive\nto time, place, person, and situation\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; clear nasal\nsinuses; moist pink mucous membranes; unremarkable dental status; moist\ntongue\n\n[Chest]{.underline}: Normal configuration; no tenderness in the spine;\nboth renal beds free\n\n[Heart]{.underline}: Arrhythmic heart sounds, pure, tachycardic, not\nsplit\n\n[Lungs]{.underline}: Vesicular breath sounds; somewhat decreased breath\nsounds bilaterally; no adventitious sounds; no stridor\n\n[Abdomen]{.underline}: Regular peristalsis in all quadrants; soft; right\nlower abdomen notably distended with increased vascular markings, liver\nand spleen not palpable, transplant kidney non-tender\n\n[Lymph Nodes:]{.underline} No pathologically enlarged cervical lymph\nnodes palpable\n\n[Skin]{.underline}: No pathological skin findings\n\n[Extremities:]{.underline} Warm; no edema; cyanosis of toes bilaterally\nafter prolonged leg dependency\n\n- Pulse status (right/left): Carotid artery +/+, Radial artery +/+,\n Posterior tibial artery +/+\n\n- Neurology: Normal cranial nerves; round, moderately dilated pupils;\n prompt bilateral pupillary light reflex; no sensory or motor\n deficits; ubiquitous muscle strength 5/5\n\n**Therapy and Progression:** We admitted the patient for further\ndiagnosis and treatment. Initially suspected acute coronary syndrome was\nruled out. Laboratory results showed elevated retention and infection\nparameters. With volume substitution, we achieved baseline creatinine\nlevels again. The transplant kidney appeared non-dilated and\nwell-perfused. For the infection, the patient received the mentioned\nimaging studies, which did not reveal any definitive findings. Our urine\nanalyses and cultures also showed bland results. It should be noted that\nprior outpatient treatment for suspected urinary tract infection was\nlikely with cotrimoxazole. Ultimately, considering the recent\nantibiograms, we decided on a calculated antibiotic therapy with\nMeropenem. This led to a significant improvement in infection\nparameters. The last measured Ciclosporin level was slightly\nsubtherapeutic, so we adjusted the dosage accordingly. We recommend\nfollow-up with the primary care physician.\n\n**Chest CT on 06/10/2019:**\n\n[Clinical Information, Question, Justification]{.underline}: Patient\nwith a history of kidney transplantation. Bursting pain on both sides at\nthe ribcage. Cough. Elevated inflammatory markers. Question about\ninfiltrates, pleural effusion, congestion.\n\n[Technique]{.underline}: Digital overview radiographs. Plain 80-line CT\nof the chest. MPR (Multiplanar reconstruction). DLP (Dose-Length\nProduct) 120.6 mGy\\*cm.\n\n[Findings]{.underline}: No previous images available for comparison.\nSymmetric thyroid. Minimal pericardial effusion, accentuated at the\nbase, measuring up to 8 mm in width (Series 5, Image 293). Coronary\natherosclerosis. No pathologically enlarged lymph nodes in the\nmediastinum, axilla, or hilum on plain images. Multisegmental calcified\n(micro)nodules. No suspicious pulmonary nodules indicative of\nmalignancy. No pneumonic infiltrates. No pleural effusions. No\npneumothorax. No pulmonary venous congestion. Delicate scar tissue at\nthe bases bilaterally. Small axial hiatal hernia. Rounded soft tissue\nstructure in the right adrenal space (Series 5, measuring 411 x 10 mm).\nIncidentally captured at the image margins is a shrunken left kidney.\nSpondylosis deformans of the thoracic spine. Interpretation: No\npneumonic infiltrates. No pleural effusions. No pulmonary venous\ncongestion. Minimal pericardial effusion. Multisegmental calcified\n(micro)nodules, likely post-inflammatory.\n\n**Abdomen/Pelvis CT on 06/14/2019:**\n\n[Clinical Information, Question, Justification:]{.underline} Acute\nkidney failure. Question regarding kidney or ureteral stones.\n\n[Technique]{.underline}: Plain 80-line CT of the abdomen. MPR. DLP 947\nmGy\\*cm. Findings and [Interpretation:]{.underline}\n\nThe left transplant kidney shows pelvic dilation with an expanded renal\npelvis and ureter (hydronephrosis grade II) but no evidence of stones.\nStatus post-right nephrectomy. Shrunken left kidney. Known large,\nbroad-based right-sided abdominal wall weakness with prolapsed\nintestinal loops and mesenteric fat tissue without evidence of\nincarceration. No ileus. Diverticulosis of the sigmoid colon. Small\naxial hiatal hernia. No free or encapsulated fluid or free air in the\nabdomen with the right diaphragmatic dome not fully visualized.\n\nCholecystolithiasis. No cholestasis. Vascular sclerosis. No\nlymphadenopathy. Bilaterally aerated lung bases captured without change.\nUnchanged irregularly thickened and coarsely structured right iliac\nbone, consistent with Paget\\'s disease.\n\n**Recommendations:**\n\nCiclosporin level monitoring\n\n**Medication upon discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Candesartan Cilexetil (Atacand) 8 mg 0-1-0-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU 1 x/week\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 70-0-70-0\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under our inpatient care from 02/19/2020 to\n03/01/2020.\n\n**Current Symptoms:** Decreased general condition, weakness,\ndecompensation\n\n**Diagnosis**: Acute episode of recurrent urinary tract infection with\ndetection of E. faecalis, E. faecium, and Enterobacter cloacae in urine\n(blood cultures sterile).\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our internal\nmedicine emergency department. He presented with worsening general\ncondition and increasing weakness, following the recommendation of our\nlocal nephrological telemedicine. He particularly noticed the increasing\nweakness when getting up, describing his legs as feeling like rubber. He\nalso experienced shortness of breath. His walking distance was greater\nthan 100 meters. There was no fever, chills, nausea, vomiting, dysuria,\nor changes in bowel movements. Before the outpatient visit, the patient\nhad collected urine for 24 hours, totaling 1700 ml, with a fluid intake\nof approximately 2 liters. His blood pressure at home was approximately\n120/60 mmHg. In the emergency department, he had negative urinary\ndipstick results and a non-specific chest X-ray. Blood and urine\ncultures were obtained, and he was subsequently transferred to our\ngeneral ward. No angina pectoris symptoms. The patient had normal bowel\nmovements, specifically no melena, and no blood-tinged stools. Urine was\ndescribed as clear and light.\n\n**Physical Examination:** Alert, oriented, cooperative, oriented to\ntime, place, person, and situation. Height 179 cm; Weight 114 kg\n\n[Head/neck:]{.underline} No tender nerve exit points; Clear nasal\nsinuses; No tenderness over the skull; Mucous membranes pink and moist;\nDental status is rehabilitated; Tongue moist and glossy\n[Thorax]{.underline}: Normally shaped; Spine without tenderness; Renal\nregions free of tenderness\n\n[Heart]{.underline}: Heart sounds are faint, arrhythmic, clear, regular\nrate, no splitting of heart sounds; Jugular veins are not distended\n\n[Lungs]{.underline}: Faint vesicular breath sounds; Resonant percussion\nnote; Dullness on the left, no added sounds; No stridor; Normal breath\nexcursion\n\n[Abdomen]{.underline}: Large right abdominal wall hernia, normal\nperistalsis in all quadrants; Soft; No pathological resistances; No\ntenderness (especially not over the left lower abdomen)\n\n[Skin status:]{.underline} No pathological skin findings\n\nExtremities: Warm; Mild edema.\n\n[Neurology:]{.underline} Alert. No focal deficits\n\n**Treatment and Progression:** The patient was admitted through our\nemergency department due to a decrease in general condition and\nweakness, accompanied by significantly elevated laboratory infection\nparameters and slightly worsened retention parameters (Creatinine max\n3.4 mg/dL compared to the current baseline of 3 mg/dL). Upon admission,\napart from a known and persistent leukocyturia since 2020, there were no\nindications of any other infectious focus. We were able to detect\nEnterobacter cloacae and Enterococcus faecalis in the urine, and we\ninitially treated the patient with intravenous Tazobactam. Blood\ncultures remained sterile. The patient\\'s general condition improved\nwithin a few days, along with a regression of infection parameters.\n\nFor further investigation of recurrent urinary tract infections (UTIs)\nand in the context of a history of urethral stricture treatment in\nFebruary 2021 with bougienage of the urethra one year ago, a urological\nconsultation was arranged. During this consultation, there was suspicion\nof a recurrence of the urethral stricture due to a significant residual\nurine volume of 175 ml. A scheduled readmission for repeat surgical\nmanagement was set for May 16, 2022. Due to the lack of normalization of\nelevated infection parameters and significant residual urine, a urinary\ncatheter was inserted. Subsequently, Enterococcus faecium was detected,\nand we continued treatment with oral Linezolid after the completion of\nintravenous antibiotic therapy.\n\nThe antibiotic treatment was planned to continue on an outpatient basis\nfor a total of 10 days. We kindly request an outpatient follow-up to\nmonitor infection parameters next week. The urinary catheter will be\nmaintained until the urological follow-up appointment, and the patient\nhas been provided with a prescription for medication.\n\nFurthermore, the patient exhibited atrial tachyarrhythmia. We reduced\nthe heart rate using Digoxin, as the patient was already on maximum\nbeta-blocker therapy. The atrial tachyarrhythmia significantly improved\nunder this treatment.\n\nAdditionally, there was a non-puncture-worthy pleural effusion and a\nchronic pericardial effusion, which was not hemodynamically relevant.\nThere were no clinical indications of pericarditis.\n\n**Current Recommendations:**\n\n1. Inpatient admission to Urology Department.\n\n2. Outpatient laboratory monitoring and referral issuance by the\n primary care physician.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on mutual patient, Mr. Alan Fisher, born on 12/09/1953,\nwho was under our inpatient care from 03/14/2020 to 03/15/2020.\n\n**Diagnoses**: Anastomotic stricture following history of prostatectomy\nand history of urethrotomy interna.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Procedure**:\n\n- Urethrotomy interna according to Sachse\n\n- Calculated intravenous antibiotic therapy with Meropenem starting on\n 03/14/2020\n\n- Extension of therapy to include antifungal treatment with\n Fluconazole on 03/15/2020\n\n**Medical History:** The patient presents with a recurrence of\nsymptomatic urethral stricture at the anastomosis site following\nprostatectomy. The main symptoms are frequent urination, dysuria, and\nresidual urine formation up to 175 ml. In January 2019, urethrotomy\ninterna was already performed. Since the last hospitalization due to a\nurinary tract infection, the patient has had a continuous\ncatheterization.\n\n**Physical Examination:** Patient in a reduced general condition and\nobese nutritional status. The abdomen is soft, without signs of\nresistance or pain. Kidney beds on both sides are indolent.\n\n**Urine Diagnostics**: Urine dipstick: Leukocytes 500, Nitrite negative,\nErythrocytes 50\n\n**Microbiology**: Candida in urine, collected by the general\npractitioner on 03/11/2020.\n\n**Chest X-ray in two planes on 02/19/2020:**\n\n[Clinical Information, Question, Justification for the\nExamination]{.underline}: Deterioration of general condition. History of\nrecurrent sepsis. History of lung transplantation. Infiltrates?\n\n**Findings**: The heart is shifted to the left and has a mitral\nconfiguration. No signs of acute congestion. The mediastinum shows no\nsigns of emphysema, is centrally located, and of normal width. No active\npneumonia in the ventilated lung regions. Progressive costophrenic angle\neffusion on the left. No pleural effusion on the right, as far as can be\nassessed. No pneumothorax. Degenerative changes in the spine.\nHyperkyphosis of the thoracic spine.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complication. Scar tissue at the level of the bladder sphincter\nwas incised. The postoperative course was uneventful. The transurethral\nindwelling catheter was removed on the 19th postoperative day. At the\ntime of discharge, the patient could urinate without residual urine with\na good urinary stream. We discharged the patient on 03/19/2020 for\nfurther outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------------- ------------------- ------------------\n Magnesium Oxide 400 mg 1-0-0-0\n Atorvastatin (Lipitor) 43.3 mg 0-0-1-0\n Candesartan Cilexetil (Atacand) 16 mg 1-1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol, oily) 20,000 IU 1x every 2 weeks\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 385 mg 1-0-1-0\n Pantoprazole (Protonix) 22.6 mg 1-0-0-0\n Piperacillin/Tazobactam (Zosyn) 4.17 g and 0.54 g 1-1-1-0\n Cyclosporine, microemulsified (Neoral) 10 mg 1-0-1-0\n Cyclosporine, microemulsified (Neoral) 50 mg 1-0-1-0\n Torsemide (Demadex) 10 mg 2-1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------------ ---------------------\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 3.02 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 19 mL/min/1.73m² \\-\n Total Bilirubin 0.73 mg/dL \\< 1.20 mg/dL\n Direct Bilirubin 0.41 mg/dL \\< 0.30 mg/dL\n C-reactive Protein 78.3 mg/dL \\< 5.0 mg/dL\n Alanine Aminotransferase 35 U/L \\< 41 U/L\n Aspartate Aminotransferase 33 U/L \\< 50 U/L\n Alkaline Phosphatase 273 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 184 U/L 8-61 U/L\n Lipase 102 U/L 13-60 U/L\n Hemoglobin 12.3 g/dL 12.5-17.2 g/dL\n Hematocrit 39.0% 37.0-49.0%\n Red Blood Cells 4.2 M/uL 4.0-5.6 M/uL\n White Blood Cells 10.41 K/uL 3.90-10.50 K/uL\n Platelets 488 K/uL 150-370 K/uL\n Mean Corpuscular Volume 92.4 fL 80.0-101.0 fL\n Mean Corpuscular Hemoglobin 29.1 pg 27.0-34.0 pg\n Mean Corpuscular Hemoglobin Concentration 31.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.3 fL 7.0-12.0 fL\n Red Cell Distribution Width 13.5% 11.5-15.0%\n\n\n\n\nHere is the query:\nWhat was Mr. Fisher's history regarding liver issues?\n\nChoose the correct answer from the following options:\nA. Hepatic cirrhosis\nB. Fatty liver disease\nC. Hepatitis B infection\nD. Liver transplant\nE. Cholelithiasis\n\n\nYour response:\n", "role": "user" }, { "content": "Hepatitis B infection", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953. He was under our inpatient care from 04/19/2009 to\n04/28/2009.\n\n**Diagnoses:**\n\n- Progressive deterioration of renal transplant function (creeping\n creatinine) without evidence of biopsy-proven rejection\n\n- Isovolumetric tubular epithelial vacuolization\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Mr. Fisher was admitted for a renal transplant\nbiopsy due to progressive deterioration of transplant function (creeping\ncreatinine). His recent creatinine values had increased to around 1.4 --\n1.6 mg/dL, while they had previously been around 1.1 mg/dL.\n\n**Therapy and Progression:** Following appropriate preparation and\ninformed consent, a complication-free transplant puncture was performed.\nThe biopsy showed isometric tubular epithelial vacuolization without\nsignificant findings. This was followed by adjustment of Cyclosporin-A\nlevels and the addition of a lymphocyte proliferation inhibitor to the\nexisting immunosuppressive dual therapy. There was a significant\nincrease in Cyclosporin-A levels at one point due to accidental double\ndosing by the patient, but levels returned to the target range. This\nmight explain the current rise in creatinine. Another explanation could\nbe recurrent hypotensive blood pressure dysregulations, leading to the\ndiscontinuation of Minoxidile medication. For chronic atrial\nfibrillation, anticoagulation therapy with Marcumar was restarted during\nhospitalization and should be continued as an outpatient according to\nthe target INR. Low molecular weight heparin administration could be\ndiscontinued.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No dyspnea. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable.\n\nLungs: Normal chest shape, moderately mobile, resonant percussion sound,\nvesicular breath sounds bilaterally, no wheezing or crackles heard.\n\nHeart: Irregular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, markedly obese, no tenderness, no palpable\nmasses, liver and spleen not palpable due to limited access, non-tender\nkidneys. Large reducible incisional hernia on the right side following\nnephrectomy.\n\nExtremities: Occluded fistula on the right forearm. Normal peripheral\npulses; joints freely movable. Strength, motor function, and sensation\nare unremarkable.\n\n**Kidney Biopsy on 04/19/2009:** Complication-free biopsy of the\ntransplant kidney.\n\nFindings: Erythematous macules.\n\nRecommendation: Follow-up in 3 months.\n\n**Ultrasound of Transplant Kidney on 04/20/2009:** Transplant kidney\nwell visualized, located in the left iliac fossa, measurable,\noval-shaped. Parenchymal echogenicity normal, normal corticomedullary\ndifferentiation. No evidence of arteriovenous fistula or hematoma after\nkidney biopsy.\n\n**Pathological-anatomical assessment on 04/19/2009:**\n\n**Macroscopic Findings:** Singular Nodule Identified: Dimensions\nmeasuring 8 mm.\n\n**Microscopic Examination:**\n\nSampled Tissue: Renal cortex\n\nIdentified Components:\n\n- Glomeruli: Nine observed\n\n- Interlobular Artery: One segment present\n\n- Absence of medullary tissue\n\n**Diagnostic Observations:** There were no signs of inflammation or\nscarring in the renal cortex. The glomeruli appeared normocellular, and\nno signs of inflammation or pathological changes were observed in them.\nThe peritubular capillaries were free of inflammation, and the specific\ntest for C4d staining yielded negative results. The arterioles within\nthe tissue had thin walls, and there was no evidence of inflammation in\nthis vascular component.\n\nThe interlobular artery was also thin-walled and showed no evidence of\ninflammation.\n\nA notable finding was extensive damage to the tubular epithelium. The\ndamage was characterized by isometric microvesicular cytoplasmic\ntransformation, which exceeded 80%. Importantly, there was no evidence\nof cell necrosis and only minimal flattening of cells was observed. In\naddition, no pathological imprints, microcalcifications, or nuclear\ninclusion bodies were observed in the tubular epithelium.\n\n**Summary:** The predominant pathological finding in this case is\nsubstantial tubular damage. Consequently, it is highly advisable to\nclosely monitor immunosuppression levels in the patient\\'s management.\nFurther comprehensive evaluation is strongly recommended to determine\nthe underlying cause of the observed tubular damage and to address the\nclinical question concerning the presence of Chronic Allograft\nNephropathy or the potential involvement of an infection in the clinical\npresentation.\n\n**Chest X-ray (2 views) on 04/22/2009:**\n\n[Findings]{.underline}: No pneumothorax, no effusion. No evidence of\npneumonia. No focal findings. Left-biased heart without decompensation.\nMediastinum centrally positioned, not widened. Unremarkable depiction of\ncentral hilar structures. Thoracic hyperkyphosis.\n\n**Current Recommenations:** We request regular outpatient monitoring of\nretention parameters (initially every 2-3 weeks) and are available for\nfurther questions at the provided telephone number.\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 144 mEq/L 134-145 mEq/L\n Potassium 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium 9.48 mg/dL 8.6-10.6 mg/dL\n Chloride 106 mEq/L 95-112 mEq/L\n Phosphorus 2.88 mg/dL 2.5-4.5 mg/dL\n Transferrin Saturation 20 % 16-45 %\n Magnesium 1.9 mg/dL 1.8-2.6 mg/dL\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n Glomerular Filtration Rate 36 mL/min \\>90 mL/min\n BUN (Blood Urea Nitrogen) 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n C-Reactive Protein 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 ng/mL 30-300 ng/mL\n ALT (Alanine Aminotransferase) 17 U/L \\<45 U/L\n AST (Aspartate Aminotransferase) 20 U/L \\<50 U/L\n Alkaline Phosphatase 119 U/L 40-129 U/L\n GGT (Gamma-Glutamyltransferase) 94 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n TSH (Thyroid-Stimulating Hormone) 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43% 40-52%\n Red Blood Cells 4.60 M/uL 4.6-6.2 M/uL\n White Blood Cells 8.78 K/uL 4.5-11.0 K/uL\n Platelets 205 K/uL 150-400 K/uL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/uL 1.8-7.7 K/uL\n Lymphocytes 2.37 K/uL 1.4-3.7 K/uL\n Monocytes 0.93 K/uL 0.2-1.0 K/uL\n Eosinophils 1.67 K/uL \\<0.7 K/uL\n Basophils 0.09 K/uL 0.01-0.10 K/uL\n Nucleated Red Blood Cells Negative \\<0.01 K/uL\n APTT (Activated Partial Thromboplastin Time) 45.1 sec 26-40 sec\n Antithrombin Activity 85 % 80-120 %\n\n**Medication upon discharge**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Cyclosporine (Neoral) 1 mg 1-0-1\n Mycophenolic Acid (Myfortic) 180 mg 1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0\n Aspirin 81 mg 1-0-0\n Candesartan (Atacand) 16 mg 0-0-1\n Metoprolol (Lopressor) 50 mg 1-1-1-1\n Isosorbide Dinitrate (Isordil) 60 mg 1-0-0\n Torsemide (Demadex) 10 mg As directed\n Ranitidine (Zantac) 300 mg 0-0-1\n Fluvastatin (Lescol) 20 mg 0-0-1\n Allopurinol (Zyloprim) 100 mg 0-1-0\n Tamsulosin (Flomax) 0.4 mg 1-0-0\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient, Mr. Alan Fisher,\nborn on 12/09/1953.\n\nHe was under our inpatient care from 10/02/2018 to 10/03/2018.\n\n**Diagnoses:**\n\n- Urosepsis\n\n- Acute postrenal kidney failure\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Previous Surgeries:** Previous prostate vesiculectomy with regional\nlymphadenectomy\n\n**Planned procedure:** Urethro-cystoscopy with catheter placement for\nurethral stricture\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by the outpatient urologist due to suspicion of\na urethral stricture. Mr. Fisher reports a worsening urinary retention\nfor approximately 6 months. Despite multiple unsuccessful attempts at\ncatheter placement, ureterocystoscopy with catheter insertion was\nperformed. Intraoperatively, purulent cystitis and a bladder outlet\nobstruction were observed.\n\nMr. Fisher regularly attends follow-up examinations for his history of\nkidney transplantation in 1995 and previous prostate vesiculectomy with\nregional lymphadenectomy in 01/2018.\n\n**Physical Examination:** Neurology: RASS 0, alert, CAM-ICU negative, no\nnew focal neurology\n\nLungs: Bilateral air entry, no rales or wheezing, sufficient gas\nexchange on 2L/O2 Cardiovascular: Normal sinus rhythm, normotensive on\n0.01 µg/kg/min NA\n\nAbdomen: Soft, no guarding, sparse peristalsis, advanced oral diet,\nregular bowel movements\n\nDiuresis: Normal urine output, retention values within normal range,\ngoal: balanced fluid status\n\nSkin/Wounds: Non-irritated, no peripheral edema\n\n**Therapy and Progression**: We received Mr. Fisher, who was awake and\nspontaneously breathing under a 2L O2 mask via nasal cannula, to our\nintensive care unit due to urosepsis. To maintain an adequate\ncirculation, low-dose catecholamine therapy was required but could be\ndiscontinued on the first postoperative day. Pulmonary function remained\nstable with intensive non-invasive ventilation and breathing training.\n\nGiven his immunosuppression, we escalated the intraoperatively initiated\nanti-infective therapy from Ceftriaxone to Piperacillin/Tazobactam.\nPneumococcal and Legionella rapid tests were negative. Following\nappropriate volume resuscitation and diuretic therapy with Furosemide,\ndiuresis became sufficient. Oral diet progression occurred without\ncomplications. Anticoagulation was initially in prophylactic dosing with\nHeparin and later switched to therapeutic dosing with Enoxaparin.\n\n**Current Recommendations:**\n\n- Switch unfractionated Heparin to Fragmin\n\n- baseline Crea 2mg/dL, target CyA level: 50-60ng/mL, Myfortic\n continued.\n\n- Urological care of the stricture in progress, leave catheter until\n then.\n\n- Mobilization\n\n**Medication upon Discharge:**\n\n **Medication (Brand)** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Torsemide (Demadex) 10 mg 1-1-0-0\n Prednisone (Deltasone) 5 mg 1-1-0-0\n Pantoprazole (Protonix) 20 mg 1-1-0-0\n Mycophenolate Mofetil (CellCept) 360 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 100 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Candesartan (Atacand) 16 mg 0-0.5-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Allopurinol (Zyloprim) 100 mg 1-0-0-0\n Aspirin 81 mg 1-0-0-0\n Paracetamol (Tylenol) 500 mg As needed\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. Alan Fisher, born on\n12/09/1953.\n\nHe was under our inpatient care from 11/04/2018 to 11/12/2018.\n\n**Current Symptoms:** Decreased diuresis, rising creatinine, frustrating\ncatheterization.\n\n**Diagnoses:**\n\n- Acute on chronic graft failure\n\n<!-- -->\n\n- Creatinine increased from 1.56 mg/dL to a maximum of 2.35 mg/dL.\n\n- Likely postrenal origin due to urethral stricture; sonographically,\n Grade II urinary stasis with urinary retention and residual urine\n formation.\n\n- Frustrating catheterization due to urethral stricture\n\n- Urethro-cystoscopy with bougie and catheter placement\n\n- Parainfectious component in purulent cystitis with urosepsis\n\n- Discharged with indwelling catheter\n\n- Inpatient readmission to the colleagues in Urology for internal\n urethrotomy\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by an outpatient urologist due to suspected\nurethral stricture. Mr. Fisher reports increasing difficulty urinating\nfor approximately 6 months. He has to \\\"squeeze out\\\" his bladder\ncompletely. Frustrating catheterization was performed due to urinary\nretention. Intraoperatively, purulent cystitis and bladder outlet\nstenosis were observed. Mr. Fisher regularly undergoes follow-up\nexaminations for a history of kidney transplantation in 1995 and a\nprostate vesiculectomy with regional lymphadenectomy in 01/2018.\n\n**Vegetative Findings:** The patient had a bowel movement 4 days ago,\nindwelling catheter irritation (3L of diuresis the previous day), no\nnausea/vomiting, no fever or night sweats, weight loss of 30kg from\nFebruary to April 2020.\n\n**Physical Capacity:** Limited, can still climb 2 stairs but needs to\ntake a break due to shortness of breath.\n\n**Physical Examination:** Temperature 37.4°C, Blood pressure 128/72\nmmHg; Pulse 72/min; Respiratory rate 15/min, O2 saturation under 2L O2:\n96%\n\nAwake, alert, cooperative, oriented to time, place, person, and\nsituation.\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; Clear paranasal\nsinuses; moist and pink mucous membranes; unremarkable dentition; moist\nand glossy tongue; non-palpable thyroid enlargement.\n\n[Chest]{.underline}: Normal configuration; Non-tender spine; free renal\nbeds bilaterally.\n\n[Heart]{.underline}: Rhythmic, clear heart sounds, normal rate, no\nsplitting; non-distended jugular veins. [Lungs]{.underline}: Vesicular\nbreath sounds; Resonant percussion note; no adventitious sounds; no\nstridor; normal chest expansion.\n\n[Abdomen]{.underline}: Protuberant, known incisional hernia, normal\nperistalsis in all quadrants; soft; no pathological resistance; no\ntenderness; liver palpable below the costal margin; spleen not palpable.\n\n[Lymph nodes:]{.underline} No pathologically enlarged cervical nodes\npalpable; axillary and inguinal nodes not palpable.\n\nSkin: No pathological skin findings.\n\n[Extremities:]{.underline} Warm; mild bilateral ankle edema.\n\n[Pulse status (right/left):]{.underline} A. carotis +/+, A. radialis\n+/+, A. femoralis +/+, A. tibialis post. +/+, A. dorsalis ped. +/+\n\n[Neurological]{.underline}: Oriented and unremarkable.\n\n**Therapy and Progression:** The patient was admitted through our\nemergency department upon referral by an outpatient urologist due to\nsuspected urethral stricture, which had been causing increasingly\ndifficult urination for approximately 6 months. Sonography showed Grade\nII urinary stasis with urinary retention and residual urine. Frustrating\ncatheterization was performed, followed by ureterocystoscopy with bougie\nand catheter placement. Intraoperatively, purulent cystitis and bladder\noutlet stenosis were observed. Laboratory tests revealed acute kidney\ntransplant failure, with creatinine increasing from 1.56 mg/dL to 2.35\nmg/dL, along with significantly elevated infection parameters: CRP up to\n186 mg/dL, PCT 12.82 µg/L, and leukocytosis of 21.6/nL. After obtaining\nblood cultures, empirical antibiotic therapy with Ceftriaxone was\ninitiated. Upon detecting Pseudomonas aeruginosa, therapy was switched\nto Piperacillin/Tazobactam on 12/06/20 and continued until 12/13/20.\nUnder this treatment, infection parameters significantly improved, and\nMr. Fisher remained afebrile. Kidney retention parameters also decreased\nto a discharge creatinine of 2.05 mg/dL. Regarding the urethral\nstricture, he was initially discharged with an indwelling catheter. A\nfollow-up appointment for internal urethrotomy and potentially Allium\nstent placement was scheduled for 4 weeks later. During the hospital\nstay, ciclosporin levels remained within the target range. Following\nprostate vesiculectomy earlier in the year, anticoagulation was switched\nfrom Enoxaparin to Apixaban 2.5 mg twice daily, and Aspirin therapy was\ndiscontinued.\n\n**Recommendations**: We recommend regular monitoring of kidney retention\nparameters and infection parameters. Regarding the urethral stricture,\nthe patient will be discharged with an indwelling catheter. We scheduled\na follow-up with colleagues in Urology for internal urethrotomy and\npotentially Allium stent placement. Pause oral anticoagulation with\nApixaban one day before inpatient admission.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Candesartan (Atacand) 8 mg 0-1-0-0\n Torsemide (Demadex) 10 mg 1-1-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU Pause\n Magnesium Oxide 400 mg 1-0-0-0\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under outpatient care on 07/01/2019.\n\n**Current Symptoms:** Pain on the left side at rib level**,** Dyspnea\n\n**Diagnoses:**\n\n- Infection of unclear origin\n\n - CT Thorax and Abdomen showed no focus\n\n - Urine dipstick and cultures were bland\n\n - Antibiotics: Meropenem from 06/11/2019 to 06/19/2019\n\n- Acute Transplant Dysfunction\n\n - Serum Creatinine: 2.4 -\\> 4.5 -\\> 2.6 mg/dl\n\n - Renal ultrasound: 123 x 54 x 24 mm, not dilated, some areas of\n increased echogenicity, no twinkling, no acoustic shadowing, no\n signs of urolithiasis.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Initial presentation was at the local emergency\ndepartment on referral from the primary care physician for suspected\nacute coronary syndrome. Mr. Fisher described left-sided rib pain, which\nwas related to breathing and pressure, as well as dyspnea for a few\ndays. Laboratory tests showed acute-on-chronic kidney failure and\nelevated infection parameters. A urine dipstick test was negative for\nnitrites and leukocytes. Chest CT ruled out pulmonary pathology, and\nacute coronary syndrome was also excluded. Mr. Fisher reported a urinary\ntract infection about 4 weeks ago, which was treated with antibiotics as\nan outpatient.\n\n**Physical Examination:** Alert, oriented, cooperative, and responsive\nto time, place, person, and situation\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; clear nasal\nsinuses; moist pink mucous membranes; unremarkable dental status; moist\ntongue\n\n[Chest]{.underline}: Normal configuration; no tenderness in the spine;\nboth renal beds free\n\n[Heart]{.underline}: Arrhythmic heart sounds, pure, tachycardic, not\nsplit\n\n[Lungs]{.underline}: Vesicular breath sounds; somewhat decreased breath\nsounds bilaterally; no adventitious sounds; no stridor\n\n[Abdomen]{.underline}: Regular peristalsis in all quadrants; soft; right\nlower abdomen notably distended with increased vascular markings, liver\nand spleen not palpable, transplant kidney non-tender\n\n[Lymph Nodes:]{.underline} No pathologically enlarged cervical lymph\nnodes palpable\n\n[Skin]{.underline}: No pathological skin findings\n\n[Extremities:]{.underline} Warm; no edema; cyanosis of toes bilaterally\nafter prolonged leg dependency\n\n- Pulse status (right/left): Carotid artery +/+, Radial artery +/+,\n Posterior tibial artery +/+\n\n- Neurology: Normal cranial nerves; round, moderately dilated pupils;\n prompt bilateral pupillary light reflex; no sensory or motor\n deficits; ubiquitous muscle strength 5/5\n\n**Therapy and Progression:** We admitted the patient for further\ndiagnosis and treatment. Initially suspected acute coronary syndrome was\nruled out. Laboratory results showed elevated retention and infection\nparameters. With volume substitution, we achieved baseline creatinine\nlevels again. The transplant kidney appeared non-dilated and\nwell-perfused. For the infection, the patient received the mentioned\nimaging studies, which did not reveal any definitive findings. Our urine\nanalyses and cultures also showed bland results. It should be noted that\nprior outpatient treatment for suspected urinary tract infection was\nlikely with cotrimoxazole. Ultimately, considering the recent\nantibiograms, we decided on a calculated antibiotic therapy with\nMeropenem. This led to a significant improvement in infection\nparameters. The last measured Ciclosporin level was slightly\nsubtherapeutic, so we adjusted the dosage accordingly. We recommend\nfollow-up with the primary care physician.\n\n**Chest CT on 06/10/2019:**\n\n[Clinical Information, Question, Justification]{.underline}: Patient\nwith a history of kidney transplantation. Bursting pain on both sides at\nthe ribcage. Cough. Elevated inflammatory markers. Question about\ninfiltrates, pleural effusion, congestion.\n\n[Technique]{.underline}: Digital overview radiographs. Plain 80-line CT\nof the chest. MPR (Multiplanar reconstruction). DLP (Dose-Length\nProduct) 120.6 mGy\\*cm.\n\n[Findings]{.underline}: No previous images available for comparison.\nSymmetric thyroid. Minimal pericardial effusion, accentuated at the\nbase, measuring up to 8 mm in width (Series 5, Image 293). Coronary\natherosclerosis. No pathologically enlarged lymph nodes in the\nmediastinum, axilla, or hilum on plain images. Multisegmental calcified\n(micro)nodules. No suspicious pulmonary nodules indicative of\nmalignancy. No pneumonic infiltrates. No pleural effusions. No\npneumothorax. No pulmonary venous congestion. Delicate scar tissue at\nthe bases bilaterally. Small axial hiatal hernia. Rounded soft tissue\nstructure in the right adrenal space (Series 5, measuring 411 x 10 mm).\nIncidentally captured at the image margins is a shrunken left kidney.\nSpondylosis deformans of the thoracic spine. Interpretation: No\npneumonic infiltrates. No pleural effusions. No pulmonary venous\ncongestion. Minimal pericardial effusion. Multisegmental calcified\n(micro)nodules, likely post-inflammatory.\n\n**Abdomen/Pelvis CT on 06/14/2019:**\n\n[Clinical Information, Question, Justification:]{.underline} Acute\nkidney failure. Question regarding kidney or ureteral stones.\n\n[Technique]{.underline}: Plain 80-line CT of the abdomen. MPR. DLP 947\nmGy\\*cm. Findings and [Interpretation:]{.underline}\n\nThe left transplant kidney shows pelvic dilation with an expanded renal\npelvis and ureter (hydronephrosis grade II) but no evidence of stones.\nStatus post-right nephrectomy. Shrunken left kidney. Known large,\nbroad-based right-sided abdominal wall weakness with prolapsed\nintestinal loops and mesenteric fat tissue without evidence of\nincarceration. No ileus. Diverticulosis of the sigmoid colon. Small\naxial hiatal hernia. No free or encapsulated fluid or free air in the\nabdomen with the right diaphragmatic dome not fully visualized.\n\nCholecystolithiasis. No cholestasis. Vascular sclerosis. No\nlymphadenopathy. Bilaterally aerated lung bases captured without change.\nUnchanged irregularly thickened and coarsely structured right iliac\nbone, consistent with Paget\\'s disease.\n\n**Recommendations:**\n\nCiclosporin level monitoring\n\n**Medication upon discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Candesartan Cilexetil (Atacand) 8 mg 0-1-0-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU 1 x/week\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 70-0-70-0\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under our inpatient care from 02/19/2020 to\n03/01/2020.\n\n**Current Symptoms:** Decreased general condition, weakness,\ndecompensation\n\n**Diagnosis**: Acute episode of recurrent urinary tract infection with\ndetection of E. faecalis, E. faecium, and Enterobacter cloacae in urine\n(blood cultures sterile).\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our internal\nmedicine emergency department. He presented with worsening general\ncondition and increasing weakness, following the recommendation of our\nlocal nephrological telemedicine. He particularly noticed the increasing\nweakness when getting up, describing his legs as feeling like rubber. He\nalso experienced shortness of breath. His walking distance was greater\nthan 100 meters. There was no fever, chills, nausea, vomiting, dysuria,\nor changes in bowel movements. Before the outpatient visit, the patient\nhad collected urine for 24 hours, totaling 1700 ml, with a fluid intake\nof approximately 2 liters. His blood pressure at home was approximately\n120/60 mmHg. In the emergency department, he had negative urinary\ndipstick results and a non-specific chest X-ray. Blood and urine\ncultures were obtained, and he was subsequently transferred to our\ngeneral ward. No angina pectoris symptoms. The patient had normal bowel\nmovements, specifically no melena, and no blood-tinged stools. Urine was\ndescribed as clear and light.\n\n**Physical Examination:** Alert, oriented, cooperative, oriented to\ntime, place, person, and situation. Height 179 cm; Weight 114 kg\n\n[Head/neck:]{.underline} No tender nerve exit points; Clear nasal\nsinuses; No tenderness over the skull; Mucous membranes pink and moist;\nDental status is rehabilitated; Tongue moist and glossy\n[Thorax]{.underline}: Normally shaped; Spine without tenderness; Renal\nregions free of tenderness\n\n[Heart]{.underline}: Heart sounds are faint, arrhythmic, clear, regular\nrate, no splitting of heart sounds; Jugular veins are not distended\n\n[Lungs]{.underline}: Faint vesicular breath sounds; Resonant percussion\nnote; Dullness on the left, no added sounds; No stridor; Normal breath\nexcursion\n\n[Abdomen]{.underline}: Large right abdominal wall hernia, normal\nperistalsis in all quadrants; Soft; No pathological resistances; No\ntenderness (especially not over the left lower abdomen)\n\n[Skin status:]{.underline} No pathological skin findings\n\nExtremities: Warm; Mild edema.\n\n[Neurology:]{.underline} Alert. No focal deficits\n\n**Treatment and Progression:** The patient was admitted through our\nemergency department due to a decrease in general condition and\nweakness, accompanied by significantly elevated laboratory infection\nparameters and slightly worsened retention parameters (Creatinine max\n3.4 mg/dL compared to the current baseline of 3 mg/dL). Upon admission,\napart from a known and persistent leukocyturia since 2020, there were no\nindications of any other infectious focus. We were able to detect\nEnterobacter cloacae and Enterococcus faecalis in the urine, and we\ninitially treated the patient with intravenous Tazobactam. Blood\ncultures remained sterile. The patient\\'s general condition improved\nwithin a few days, along with a regression of infection parameters.\n\nFor further investigation of recurrent urinary tract infections (UTIs)\nand in the context of a history of urethral stricture treatment in\nFebruary 2021 with bougienage of the urethra one year ago, a urological\nconsultation was arranged. During this consultation, there was suspicion\nof a recurrence of the urethral stricture due to a significant residual\nurine volume of 175 ml. A scheduled readmission for repeat surgical\nmanagement was set for May 16, 2022. Due to the lack of normalization of\nelevated infection parameters and significant residual urine, a urinary\ncatheter was inserted. Subsequently, Enterococcus faecium was detected,\nand we continued treatment with oral Linezolid after the completion of\nintravenous antibiotic therapy.\n\nThe antibiotic treatment was planned to continue on an outpatient basis\nfor a total of 10 days. We kindly request an outpatient follow-up to\nmonitor infection parameters next week. The urinary catheter will be\nmaintained until the urological follow-up appointment, and the patient\nhas been provided with a prescription for medication.\n\nFurthermore, the patient exhibited atrial tachyarrhythmia. We reduced\nthe heart rate using Digoxin, as the patient was already on maximum\nbeta-blocker therapy. The atrial tachyarrhythmia significantly improved\nunder this treatment.\n\nAdditionally, there was a non-puncture-worthy pleural effusion and a\nchronic pericardial effusion, which was not hemodynamically relevant.\nThere were no clinical indications of pericarditis.\n\n**Current Recommendations:**\n\n1. Inpatient admission to Urology Department.\n\n2. Outpatient laboratory monitoring and referral issuance by the\n primary care physician.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on mutual patient, Mr. Alan Fisher, born on 12/09/1953,\nwho was under our inpatient care from 03/14/2020 to 03/15/2020.\n\n**Diagnoses**: Anastomotic stricture following history of prostatectomy\nand history of urethrotomy interna.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Procedure**:\n\n- Urethrotomy interna according to Sachse\n\n- Calculated intravenous antibiotic therapy with Meropenem starting on\n 03/14/2020\n\n- Extension of therapy to include antifungal treatment with\n Fluconazole on 03/15/2020\n\n**Medical History:** The patient presents with a recurrence of\nsymptomatic urethral stricture at the anastomosis site following\nprostatectomy. The main symptoms are frequent urination, dysuria, and\nresidual urine formation up to 175 ml. In January 2019, urethrotomy\ninterna was already performed. Since the last hospitalization due to a\nurinary tract infection, the patient has had a continuous\ncatheterization.\n\n**Physical Examination:** Patient in a reduced general condition and\nobese nutritional status. The abdomen is soft, without signs of\nresistance or pain. Kidney beds on both sides are indolent.\n\n**Urine Diagnostics**: Urine dipstick: Leukocytes 500, Nitrite negative,\nErythrocytes 50\n\n**Microbiology**: Candida in urine, collected by the general\npractitioner on 03/11/2020.\n\n**Chest X-ray in two planes on 02/19/2020:**\n\n[Clinical Information, Question, Justification for the\nExamination]{.underline}: Deterioration of general condition. History of\nrecurrent sepsis. History of lung transplantation. Infiltrates?\n\n**Findings**: The heart is shifted to the left and has a mitral\nconfiguration. No signs of acute congestion. The mediastinum shows no\nsigns of emphysema, is centrally located, and of normal width. No active\npneumonia in the ventilated lung regions. Progressive costophrenic angle\neffusion on the left. No pleural effusion on the right, as far as can be\nassessed. No pneumothorax. Degenerative changes in the spine.\nHyperkyphosis of the thoracic spine.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complication. Scar tissue at the level of the bladder sphincter\nwas incised. The postoperative course was uneventful. The transurethral\nindwelling catheter was removed on the 19th postoperative day. At the\ntime of discharge, the patient could urinate without residual urine with\na good urinary stream. We discharged the patient on 03/19/2020 for\nfurther outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------------- ------------------- ------------------\n Magnesium Oxide 400 mg 1-0-0-0\n Atorvastatin (Lipitor) 43.3 mg 0-0-1-0\n Candesartan Cilexetil (Atacand) 16 mg 1-1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol, oily) 20,000 IU 1x every 2 weeks\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 385 mg 1-0-1-0\n Pantoprazole (Protonix) 22.6 mg 1-0-0-0\n Piperacillin/Tazobactam (Zosyn) 4.17 g and 0.54 g 1-1-1-0\n Cyclosporine, microemulsified (Neoral) 10 mg 1-0-1-0\n Cyclosporine, microemulsified (Neoral) 50 mg 1-0-1-0\n Torsemide (Demadex) 10 mg 2-1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------------ ---------------------\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 3.02 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 19 mL/min/1.73m² \\-\n Total Bilirubin 0.73 mg/dL \\< 1.20 mg/dL\n Direct Bilirubin 0.41 mg/dL \\< 0.30 mg/dL\n C-reactive Protein 78.3 mg/dL \\< 5.0 mg/dL\n Alanine Aminotransferase 35 U/L \\< 41 U/L\n Aspartate Aminotransferase 33 U/L \\< 50 U/L\n Alkaline Phosphatase 273 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 184 U/L 8-61 U/L\n Lipase 102 U/L 13-60 U/L\n Hemoglobin 12.3 g/dL 12.5-17.2 g/dL\n Hematocrit 39.0% 37.0-49.0%\n Red Blood Cells 4.2 M/uL 4.0-5.6 M/uL\n White Blood Cells 10.41 K/uL 3.90-10.50 K/uL\n Platelets 488 K/uL 150-370 K/uL\n Mean Corpuscular Volume 92.4 fL 80.0-101.0 fL\n Mean Corpuscular Hemoglobin 29.1 pg 27.0-34.0 pg\n Mean Corpuscular Hemoglobin Concentration 31.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.3 fL 7.0-12.0 fL\n Red Cell Distribution Width 13.5% 11.5-15.0%\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on Mr. Ben Harder, born on 08/02/1940, who was admitted\nto our hospital from 12/17/2015 to 12/27/2015.\n\n**Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Status post excision on the nose with suspicion of basal cell\n carcinoma\n\n- Status post laparoscopic cholecystectomy\n\n- Retropubic radical prostatectomy without nerve preservation and with\n bilateral pelvic lymphadenectomy was performed on 12/17/2015.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------- ---------------------------------------------------\n Valsartan (Diovan) 160 mg 1-0-1\n Aspirin 100 mg 1-0-1\n Simvastatin (Zocor) 15 mg 0-0-1\n Doxazosin (Cardura) 1 mg 0-0-1\n Enoxaparin (Lovenox) 0.6 mL s.c. Administer subcutaneously for a total of 4 weeks.\n Acetaminophen (Tylenol) 500 mg 1-1-1 (for 4 days)\n\n**Histopathology:**\n\n1. 2 adenocarcinoma metastases in 2 out of 4 lymph nodes, left external\n iliac region.\n\n2. 3 adenocarcinoma metastases in 3 out of 6 lymph nodes, right pelvic\n region.\n\n3. 7 adenocarcinoma metastases in 7 out of 7 lymph nodes, right lumbar\n para-aortic region.\n\n4. Acinar adenocarcinoma of the prostate is observed bilaterally, with\n a Gleason score of 4 (70%) + 5 (25%) = 9 and a tertiary Gleason\n grade of 3 (5%) according to the modified Gleason grading of the\n ISUP 2005. The tumor is multifocal and encompasses the entire\n prostate with a maximum extrapolated tumor extension of 60 mm. There\n is extracapsular tumor growth, with focal involvement at the dorsal\n right base. Vascular invasion is not noted, but perineural invasion\n is extensive. Both seminal vesicles are heavily infiltrated, and the\n resection margin of the left seminal vesicle is involved. Before\n tissue embedding, the margins of the specimen show focal\n infiltration by the tumor, in the right anterior region near the\n base (section 7) with a total contact area of 2 mm wide, and the\n primary Gleason grade at the positive margin is 4. In addition to\n the carcinoma, other prostatic tissue shows features of myoglandular\n hyperplasia and high-grade prostatic intraepithelial neoplasia\n (HGPIN). The prostatic urethra is free of tumors or dysplasia.\n\n5. **Tumor classification:** pT3bpN1(12/17), R1L0V0, Gleason: 4 + 5 = 9\n\n**Medical History:** Mr. Harder was admitted for open prostatectomy due\nto biopsy-confirmed prostate carcinoma.\n\nInitial PSA value: 5.42 ng/ml. Gleason score of biopsy: 4+5=9 in 11 out\nof 12 biopsy samples. Clinical tumor stage: cT2c PSMA PET-CT + MRI from\n12/23/2015: Left capsular penetration without rectal infiltration.\nSeminal vesicles are infiltrated on both sides. Evidence of multiple\nlymph nodes; intrapelvic locoregional and two lymph nodes on the right\nparailiacal and lumbar interaortocaval region.\n\nTRUS: 88 cc Digital Rectal Examination: Abnormal findings on the left\nside\n\n**Physical Examination:** The patient is in good general condition, has\na lean nutritional status, and reports feeling well. The abdomen is\nsoft, with no tenderness, masses, resistance, or guarding, and the\nexternal genitalia are unremarkable.\n\n**Ultrasound upon admission:** Both kidneys are not dilated and show no\nspace-occupying lesions. The bladder is minimally filled and appears\nunremarkable to the extent assessable.\n\n**Pretherapeutic Tumor Conference:** The findings were discussed\ninterdisciplinary, and the possible treatment options were explained.\nThe patient opted for radical prostatectomy.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complications. The postoperative course was uneventful. Blood\ntransfusions were not required. Unfortunately, a cystogram on revealed\nextravasation, requiring the indwelling catheter to be retained. The\nwound drain was lifted once with serum-identical creatinine values and\nretained with persistent output (approximately 400 ml daily). Both\nkidneys were not dilated, and there were no signs of lymphocele or\nhematoma in the pelvic region on ultrasound. A follow-up rehabilitation\ntreatment has been organized through our social services. We discharged\nthe patient with absorbable intracutaneous sutures for further\noutpatient care.\n\n**Current Recommendations:** The patient was discharged with a permanent\ncatheter and will present on 01/03/2016 for cystogram and possibly\ncatheter removal. If catheter removal is indicated, we recommend\nconsidering a trial of voiding with subsequent admission if the\ncystogram is normal. The wound drain was also retained, and we request\ndocumentation of output. If output regresses and remains persistently \\<\n30-40 ml, and there is no ultrasound evidence of lymphocele, it could be\nremoved on an outpatient basis or during the follow-up appointment.\n\nWe recommend the first PSA check 6 -- 8 weeks postoperatively, followed\nby quarterly intervals. If the PSA level does not reach the zero range\nor rises again from the zero range, the patient can be offered\nradiotherapy of the prostatic bed and lymphatic drainage pathways in\ncombination with a 2-year hormonal ablative therapy as an individual\ntherapeutic trial. Alternatively, primary hormonal ablative therapy is\nan option. If the PSA level reaches the zero range, the patient may be\noffered adjuvant hormonal ablative therapy for 2 years, possibly\ncombined with radiotherapy. Additional findings will be discussed in our\npost-therapeutic conference. In case of changes in the recommended\nprocedure mentioned above, we will inform you again.\n\n**Course of the lab results:**\n\n **Parameter** **12/18/15** **12/19/15** **12/20/15** **12/23/15** **Reference Range**\n --------------------------- --------------- ---------------- --------------- -------------- ---------------------\n Sodium 135 mEq/L 138 mEq/L 136-145 mEq/L\n Potassium 5.1 mEq/L 4.4 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffe method) 0.93 mg/dL 1.05 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 83 65 \n Hemoglobin 11.4 g/dL 12.4 g/dL 12.5-17.2 g/dL\n Hematocrit 0.323 L/L 0.361 L/L 0.370-0.490 L/L\n Red Blood Cells 3.8 x10\\^12/L 4.3 x10\\^12/L 4.2 x10\\^12/L 4.0-5.7 x10\\^12/L\n White Blood Cells 9.57 x10\\^9/L 11.51 x10\\^9/L 9.65 x10\\^9/L 3.90-10.50 x10\\^9/L\n Platelets 216 x10\\^9/L 239 x10\\^9/L 285 x10\\^9/L 150-370 x10\\^9/L\n MCV 88.1 fL 86.0 fL 88.3 fL 80.0-101.0 fL\n MCH 30.2 pg 30.1 pg 29.5 pg 27.0-34.0 pg\n MCHC 34.5 g/dL 35.3 g/dL 33.8 g/dL 31.5-36.0 g/dL\n MPV 10.2 fL 10.4 fL 10.3 fL 7.0-12.0 fL\n RDW-CV 12.1% 12.2% 12.8% 11.6-14.4%\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about Mr. Ben Harder, born on 08/02/1940 who received\ninpatient treatment from 01/13/2016 to 01/19/2016.\n\n**Diagnosis:** Urinary Tract Infection in Patient with indwelling\ncatheter\n\n**Other Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n- Arterial hypertension\n\n- History of excision on the nose with suspicion of basal cell\n carcinoma\n\n- History of laparoscopic cholecystectomy\n\n**Medication upon Admission: **\n\n **Medication (Brand)** **Dosage** **Frequency**\n ------------------------------ ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan (Atacand) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multivitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Selenium 999 mcg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Thiamine 200 mg 1x/Week\n Pyridoxine 25 mg 2-3x/Week\n\n**Current presentation:** Mr. Harder returned to our clinic on\n01/13/2016, complaining of new-onset symptoms including increased\nurgency and frequency of urination, discomfort, lower abdominal pain,\nand fever. Given his recent surgery and indwelling catheter, concerns\nwere raised about a possible urinary tract infection.\n\n**Clinical Examination:** On physical examination, Mr. Harder appeared\nunwell. He had a temperature of 38.8°C, elevated heart rate\n(tachycardia), and mild lower abdominal tenderness on palpation. The\nindwelling urinary catheter was in situ, and no signs of catheter\ndislodgment or leakage were observed.\n\n**Ultrasound of the Abdomen upon admission:** Bilateral, no urinary\ntransport obstruction, approximately 4x2 cm-sized fluid collection noted\nin the right inguinal area, suggestive of possible lymphocele.\n\n**CT Scan Abdomen/Pelvic from 01/13/2016:** The liver displays a smooth\ncontour, with homogeneous parenchymal contrast enhancement, and no\nevidence of focal intrahepatic lesions. There is no indication of\nintrahepatic or extrahepatic cholestasis. History of previous\ncholecystectomy with an accentuated common hepatic duct. Spleen,\npancreas, and adrenal glands appear unremarkable. Both orthotopically\nlocated kidneys exhibit simultaneous and equal contrast enhancement. No\nintrarenal structural abnormalities or signs of urinary obstruction are\nobserved. The colonic frame and small intestine show adequate perfusion,\nwithout focal wall thickening. The stomach is distended. The urinary\nbladder contains a catheter. Two intraluminal air pockets are seen.\nKnown circumferential, uniform bladder wall thickening from previous\nexaminations. No free intrabdominal air is detected. No evidence of\nascites. Bilateral iliac and inguinal operative clips from prior\nlymphadenectomy. Right iliac region shows a serous fluid collection\nmeasuring approximately 3 x 2 cm. Para-aortic lymph nodes, up to 14 mm\nin size, are consistent with findings from previous evaluations. No\nsuspicious malignancy-related bone destruction is noted. A drainage tube\nhas been placed through the right lower abdominal wall, with its tip\nlocated in the left pelvic area.\n\n**Assessment:** No evidence of abscess formation. A lymphocele measuring\napproximately 3 x 2 cm is noted in the right iliac region, without signs\nof acute inflammation.\n\n**Microbiological Examination**\n\n**Material**: Catheter Urine Examination Request: Identification of\nPathogens and Resistance Results: Organism 1: Growth of 100,000 CFU/mL\nEnterococcus faecalis Possible ICD-10 Coding Suggestion: Enterococci as\nPathogen.\n\n- Acute Cystitis\n\n- Pyelonephritis\n\n- Urinary Tract Infection related to Catheter/Implant\n\n- Urinary Tract Infection, Unspecified Location\n\n**Antibiogram**\n\n- Gentamicin HL: S\n\n- Levofloxacin: R 1\n\n- Teicoplanin: S \\<=0.5\n\n- Ampicillin: S \\<=2\n\n- Piperacillin: S\n\n- Ampicillin/Sulbactam: S \\<=2\n\n- Piperacillin/Tazobactam: S\n\n- Imipenem: S \\<=1\n\n- Cefuroxim: R \\>=64\n\n- Gentamicin: R\n\n- Cotrimoxazole: R \\<=10\n\n- Ciprofloxacin: R \\<=0.5\n\n- Vancomycin: S 2\n\n- Linezolid: S 2\n\n- Tigecyclin: S \\<=0.12\n\n**Therapy and Progression:** After CT morphological exclusion of an\nabscess formation or retention, the wound drainage was removed under\nantibiotic coverage. Initially, empirical antibiotic therapy with\nCefuroxim was administered, followed by targeted treatment with oral\nUnacid based on resistance testing. The drainage insertion site healed\nprimarily. The bladder catheter was removed, after which urination was\nfree of residual urine. The patient has primary continence. We\ndischarged the patient to further outpatient treatment, with the patient\nreporting subjective well-being.\n\nMr. Harder showed gradual clinical improvement after initiating\nantibiotic therapy. His fever subsided, and lower abdominal tenderness\ndiminished. The IV fluids were discontinued, and he remained on oral\nantibiotics.\n\n**Urine Culture Results:** The urine culture results returned positive\nfor Escherichia coli (E. coli), a common uropathogen. The sensitivity\nprofile indicated susceptibility to ciprofloxacin.\n\n**Follow-Up:** Mr. Harder was closely monitored for the duration of his\nantibiotic course. He was advised to complete the full course of\nantibiotics and maintain adequate hydration. The urinary catheter was\nremoved on the fifth day of hospitalization after demonstrating improved\nurine output and resolution of symptoms. No further complications\nrelated to the catheter removal were observed.\n\n**Current Recommendations:**\n\n1. Please refer to the previous discharge letter for the procedure\n regarding prostate cancer.\n\n2. He was educated on the signs and symptoms of UTIs and instructed to\n seek prompt medical attention if symptoms recurred.\n\n**\\\n**\n\n\n\n### text_2\n**Dear colleague, **\n\nThank you for assigning Mr. Ben Harder, born on 08/02/1940 to the PET/CT\ncombination scanner examination on 12/11/2022.\n\n**Diagnoses:**\n\n- Initial diagnosis of prostate cancer in December 2015, confirmed by\n prostate biopsy.\n\n- Tumor detected in 11 out of 12 biopsy samples\n\n- Maximum Gleason score of 9\n\n- Preoperative PSA level: 5.42 ng/ml\n\n- In the initial PET/CT examination (preoperative) on 12/23/2015\n evidence of prostate cancer extending beyond the capsule in both\n prostatic lobes was found.\n\n- Infiltration of the left seminal vesicles and beginning infiltration\n of the right seminal vesicles\n\n- Multiple retroperitoneal lymph node metastases and bilateral pelvic\n lymph nodes.\n\n- Radical prostatectomy\n\n- Current PSA level: 1.23 ng/ml\n\n- Radiation therapy planned at our facility\n\n**Technique**: To expedite renal-urinary activity elimination, the\npatient was adequately hydrated. The examination was conducted using the\nPET/CT combination scanner BIOGRAPH 64 with CT parameters set at 120 kV\nand 1 mm slice thickness. PET emission data were acquired with 5 bed\npositions on a radiation therapy-compatible table for whole-body\nexamination in the caudocranial direction with transverse slices at 3.0\nmm intervals over the same axial range as the CT scan. Iterative\nreconstruction was performed. A whole-body scan was conducted 90 minutes\nafter the administration of 278 MBq Ga-68-PSMA (prostate-specific\nmembrane antigen). Transmissions-corrected and non-corrected PET scans,\nCT scans, fusion images, and the determination of the SUV value\n(standard uptake value, a measure of activity uptake per volume) were\nused for evaluation.\n\n**PET Findings:** The 3D whole-body images documented in 3 planes using\nPET and PET/CT technology showed the following changes compared to the\nprior examination on 12/23/2015:\n\n- Post-radical prostatectomy, there is diffuse activity accumulation\n in the region dorsal to the bladder, on the left side.\n\n- Regarding the known retroperitoneal lymph node metastases, the\n following changes were observed: New retrocrural nodule on the\n right. SUV 6.6, diameter: 6 mm.\n\n- Known interaortocaval lymph node, dorsally at the level of L3/4,\n showed increased metabolic activity from SUV 4.7 to 11.5. Slightly\n increased in size, measuring 7 to 8 mm. Additionally, two new\n metabolically active nodules cranially, up to the level of L2/3.\n\n- Slightly increased metabolic activity in the known right iliaca\n communis lymph node, located between the fifth lumbar vertebra and\n the psoas muscle, from 4.0 to 4.6, with the same size of 5 mm.\n\n- Progressive enlargement of the known confluent lymph nodes on the\n right parailiacal externa proximal side, now having a combined size\n of 10 x 26 mm (width x height), previously individual nodules of 10\n and 12 mm. SUV 18.2, previously max 11.5.\n\n- New paraaortic lymph nodes on the left, mostly small, SUV 11.2.\n\n- Newly added lymph nodes in both biiliac communal areas. Maximum size\n on the left is 15 mm, SUV 17.2.\n\n- New retrocrural lymph node on the right, measuring 6 mm, SUV 6.6.\n\n- Known lymph node on the right perirectal, slightly progressive from\n 8 to 10 mm. SUV 6.9, previously 6.4.\n\n- Known lymph node on the left iliaca externa not currently\n verifiable, possibly postoperative scarring.\n\n- Newly added focus in the bone at the level of the spinous\n process/dorsal arch of the fifth lumbar vertebra. In CT, a 7 mm\n focal sclerosis is noted. Normal activity accumulation in the soft\n tissues of the neck, axillae, and chest. Physiological accumulation\n in the parenchymal upper abdominal organs. Kidneys and urinary tract\n appear functionally normal. Whole-body CT following bolus-like\n peripheral venous machine injection of 100 ml of Optiray 350: No\n suspicious lymph nodes in the cervical, axillary, or mediastinal\n regions. Normal-sized thyroid gland. No pleuropulmonary infiltrates\n or round lesions. Scarred changes in the left lower lobe.\n Normal-sized liver without focal lesions. Spleen, pancreas, adrenal\n glands, and kidneys appear regular. No urinary obstruction..\n\n**Results**: In the postoperative PET/CT compared to the preoperative\nexamination on, there is now malignancy-typical PSMA receptor binding in\nthe former prostate lodge, indicating a local recurrence. Progression of\nretroperitoneal lymph node metastases, with further extension cranially,\nextending to the interaortocaval region up to the level of L2/3. Newly\nadded metastases on the left paraaortic and biiliac communal areas.\nProgression of known right iliaca externa lymph node metastases. The\nleft iliaca externa nodule is not verifiable, likely removed. New small\nretrocrural nodule on the right. New osteosclerotic metastasis in the\ndorsal arch of LWK 5. Minimal activity accumulation in the 8th rib on\nthe right lateral aspect. A developing metastasis cannot be conclusively\nruled out here. We kindly request information on the patient\\'s further\nclinical course (submission of medical reports, etc.).\n\n**Lab results**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Glucose (Plasma) 91 mg/dL 55-100 mg/dL\n Alkaline Phosphatase 93 U/L \\< 130 U/L\n Total Cholesterol 152 mg/dL \\< 200 mg/dL\n LDL-Cholesterol 89 mg/dL \\< 130 mg/dL\n HDL-Cholesterol 50 mg/dL 40-60 mg/dL\n Non-HDL Cholesterol 101.8 mg/dL \\< 200 mg/dL\n Triglycerides 64 mg/dL \\< 150 mg/dL\n White Blood Cells 4.1 K/uL 4.5-11 K/uL\n Red Blood Cells 4.68 M/uL 4.0-5.5 M/uL\n Hemoglobin 13.6 g/dL 12.5-17.2 g/dL\n Hematocrit 39.5% 37.0-49.0%\n MCH 29.1 pg 27.0-34.0 pg\n MCHC 34.4 g/dL 31.5-36.0 g/dL\n MCV 84.4 fL 80.0-101.0 fL\n RDW 13.0% 11.6-14.4%\n Platelets 238 K/uL 150-370 K/uL\n\n**\\\n**\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to provide an update on Mr. Ben Harder, born on\n08/02/1940, who received inpatient treatment at our facility from\n06/23/2023 to 06/26/2023.\n\n**Diagnosis:**\n\nProstate Cancer pT3b pN1 R1 L0 V0 Gleason Score: 4 + 5 = 9 (Initial\ndiagnosis in December 2015)\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015. Currently, lymph node and bone metastasis\n\n**Other Diagnoses:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015.\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n (thora 11 and 12) with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT in 06/2023 scan indicated new extensive metastasis in\n the sacrum and diffuse lung metastases, accompanied by a PSA level\n of 1.35 ng/ml.\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n**Medications on Admission:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Candesartan (Atacand) 16 mg 1-0-1-0\n Aspirin 100 mg 1-0-0-0\n Chlorthalidone (Thalitone) 25 mg 1-0-0-0\n\n**Physical Examination:** The patient was in good general condition and\nhad normal orientation to all qualities. There were no edemas, dyspnea,\nfever, or cough.\n\n**Medical History:** Mr. Hader presents himself for the 1st cycle of RLT\nwith Ac-225-PSMA/Lu-177-I&T-PSMA for lymph node and bone metastatic\nprostate cancer on an inpatient basis. In the presence of progressive\nimaging findings under guideline-compliant therapy, the indication for\nRLT tandem therapy was confirmed according to the tumor conference on.\nUpon admission, the patient reports feeling well, denies any B-symptoms.\nThere is no fever or nausea, and the weight is currently stable. There\nhas been a tendency to fall for some time. The rest of the medical\nhistory is assumed to be known.\n\n**Neurological Consultation on 06/25/2023: **\n\nClinically neurological examination revealed a polyneuropathy syndrome\nof the lower extremities, predominantly on the right side, as well as a\nknown right-sided foot drop. In summary, we consider the falls to be\nmultifactorial due to foot weakness as well as polyneuropathy syndrome\nwith impaired proprioception as the cause of the balance disorder.\nRecommended further procedure: In the presence of a known PNP syndrome\nthat has occurred during chemotherapy, consider outpatient neurological\nevaluation and objectification by means of Electromyography and\npolyneuropathy laboratory tests.\n\n**Salivary Gland Scintigraphy on 06/26/2023**\n\n**Assessment**: Normal function of the submandibular and parotid glands\nbilaterally.\n\nPost-therapeutic imaging with Lu-177-PSMA imaging using\nSPECT/low-dose-CT\n\n**Assessment:** Consistent with the PET-CT, there is no tracer uptake in\nthe area of the prostate. Intensive accumulation of the therapeutic\nagent in the area of lymph node metastases, especially mediastinal.\nCorresponding to the PET/CT, there are clear focal tracer accumulations\nin the left upper lobe of the lung in the area of nodular or diffuse\ntissue condensations, possibly metastases or, secondarily,\npost-inflammatory. Intensive tracer uptake in the area of known bone\nmetastases from the previous examination. No newly appearing\ntracer-enhancing lesions. In addition, physiological accumulation in the\norgan systems involved in tracer metabolism and excretion. NB: Small\npleural effusions on both sides. Known pronounced peribronchial cuffs in\nthe upper lobes on both sides, possibly scarred, or indicative of\npulmonary venous congestion. Known atrophic kidney on the right.\n\n**Current Recommendations:**\n\n- Blood count checks and determination of kidney and liver parameters\n 1, 2, 4, and 8 weeks after therapy\n\n- Outpatient neurologic assessment for the evaluation of\n polyneuropathy\n\n- PSA determination 6-8 weeks after therapy\n\n- Appointment for a 2nd cycle of radioligand therapy\n (Ac-225-/Lu-177-PSMA)\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Neutrophils (%) 72.2 % 42.0-77.0 %\n Lymphocytes (%) 8.6 % 20.0-44.0 %\n Monocytes (%) 11.6 % 2.0-9.5 %\n Basophils (%) 1.4 % 0.0-1.8 %\n Eosinophils (%) 6.0 % 0.5-5.5 %\n Immature Granulocytes (%) 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 2.31 mEq/L 2.20-2.55 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n C-reactive Protein 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 µg/L \\< 4.40 µg/L\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 µg/L 1.32-8.92 µg/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 0.285 L/L 0.370-0.490 L/L\n RBC 3.3 /pL 4.0-5.6 /pL\n WBC 4.98 /nL 3.90-10.50 /nL\n Platelets 281 /nL 150-370 /nL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Neutrophils (Absolute) 3.59 /nL 1.50-7.70 /nL\n Immature Granulocytes (Absolute) 0.010 /nL \\< 0.050 /nL\n Lymphocytes (Absolute) 0.43 /nL 1.10-4.50 /nL\n Monocytes (Absolute) 0.58 /nL 0.10-0.90 /nL\n Eosinophils (Absolute) 0.30 /nL 0.02-0.50 /nL\n Basophils (Absolute) 0.07 /nL 0.00-0.20 /nL\n Reticulocytes 31.3 /nL 25.0-105.0 /nL\n Reticulocyte (%) 0.94 % 0.50-2.00 %\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to report on our mutual patient, Mr. Ben Harder, born on\n08/02/1940, who presented himself to our outpatient clinic on 1/8/2023.\n\n**Diagnoses:**\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9 (initial\n diagnosis in 11/2015)\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally on\n 11/16/2015\n\n- Currently, there are lymph node and bone metastases\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Initial PSA level was 4.8 ng/ml\n\n- History of Docetaxel therapy\n\n- History of Cabazitaxel therapy\n\n- History of 4 cycles of Lutetium-Radioligand therapy\n\n- Subsequently, radiation therapy was initiated for the lymph node\n metastasis but discontinued after 11 sessions due to dyspnea and G3\n esophagitis.\n\n- Arterial hypertension\n\n- Chronic renal insufficiency\n\n- Type 2 diabetes mellitus\n\n**Treatment and Progression:** The patient presents for a second opinion\non his prostate cancer, which has metastasized to the bones and lymph\nnodes and has become castration-resistant. He recently received\nLutetium-Radioligand therapy. Genetic sequencing from the tissue biopsy\ndid not reveal any significant gene mutations. The patient wishes to\nundergo further evaluation for the diagnosis of relevant genetic\nmutations. A previously punctured subdiaphragmatic lymph node metastasis\nhas not yet undergone genetic testing, which may be justified based on\nthe available data and publications in specific cases. A chemotherapy\nsession with Cabazitaxel is planned for the end of January in the\ntreating urological practice. In cases of DNA repair gene alterations, a\nplatinum combination could also be considered. Further possible\ndiagnostic and therapeutic steps were discussed with the patient. An\napplication for a repeat genetic sequencing will be submitted by our\ncolleagues from the genetics department.\n\n**Current Recommendations:**\n\n- Application for genetic sequencing for the punctured lymph node\n metastasis through the genetics department and DNA-med\n\n- Subsequent re-genetic sequencing of the subdiaphragmatic lymph node\n metastasis for relevant mutations\n\n- After receiving the results, a follow-up appointment can be\n scheduled in our uro-oncology outpatient clinic.\n\n.\n\n**\\\n**\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting to you regarding the inpatient stay of our patient Mr.\nBen Harder, born on 08/02/1940. He was under our care from 09/16/2023 to\n09/23/2023.\n\n**Diagnosis**: Prostate Cancer pT3b pN1 R1 L0 V0\n\n- Gleason Score: 4 + 5 = 9\n\n- Postoperative status following retropubic radical prostatectomy\n without nerve preservation and with pelvic lymphadenectomy.\n\n- Currently presenting with lymph node and bone metastases, mCRPC\n (metastatic castration-resistant prostate cancer)\n\n- Initial PSA level: 4.8 ng/ml\n\n**Previous Treatment and Course:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects in 01/2023.\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT scan indicated new extensive metastasis in the sacrum\n and diffuse lung metastases, accompanied by a PSA level of 1.35\n ng/ml.\n\n- Current PET-CT not available. Recommendations for further treatment\n options are as follows, based on externally described\n image-morphological progression in the recent CT:\n\n 1. Actinium-225-PSMA Therapy (Lu-177 Tandem Therapy), provided that\n all vital metastases are PSMA-positive (mandatory exclusion of\n post-renal urinary flow obstruction)\n\n 2. Alternatively, consider initiating therapy with Abiraterone +\n Prednisolone or a Cabazitaxel re-challenge (if there was a\n favorable response to the last 2 cycles of Cabazitaxel\n\n 3. Evaluation of pre-screening for CAR-T cell studies in oncology\n at CBF (contact will be made)\n\n**Other Diagnoses:**\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n- Type 2 Diabetes Mellitus\n\n**Current Presentation:** Mr. Ben Harder is presenting for his 2nd cycle\nof Radioligand Therapy (RLT) with Ac-225-PSMA/Lu-177-I&T-PSMA for lymph\nnode and bone metastatic prostate cancer. In light of progressive\nimage-morphological findings despite guideline-compliant treatment, the\nindication for RLT tandem therapy was determined in the tumor\nconference.\n\n**Medical History:** Mr. Harder reports that after the last treatment\ncycle, he experienced pronounced fatigue symptoms. He particularly\nstruggled with climbing stairs and walking longer distances. However, he\nmanaged to fully recover from these symptoms through targeted training.\nAdditionally, he developed pain in the area of the right ribcage\nfollowing the last treatment cycle. The pain occurs intermittently and\nis accompanied by increased salivation and nausea, sometimes leading to\nvomiting. Mr. Ben Harder also reports newly developed swallowing\ndifficulties. He feels that food gets stuck in his throat after\nswallowing.\n\n**Therapy and Progression:**\n\nIn the case of Mr. Ben Harder, due to metastatic prostate cancer with\nradiographic progression despite previous guideline-recommended therapy,\naccording to the recommendations, there was an indication for the 2nd\nradioligand therapy with Ac-225-PSMA/Lu-177-I&T-PSMA. The\npost-therapeutic imaging showed targeted accumulation of the therapeutic\nagent within the tumor. The therapy was administered due to elevated\nrenal retention parameters with reduced activity of Lu-177-PSMA. The\ncourse of therapy and the entire hospital stay were uncomplicated, so we\ncan now transition the patient to your outpatient care. We recommend\nclose laboratory monitoring (blood count, liver and kidney parameters)\nat 1, 2, 4, and 8 weeks, as well as a PSA determination 6-8 weeks after\ntherapy.\n\nIn the case of significant fatigue symptoms after the 1st cycle of\ntandem RLT, if there are blood count changes indicating a decrease in\nhemoglobin levels and recurrent fatigue symptoms, the administration of\nerythropoietin or the indication for blood product transfusion should be\nconsidered. Depending on the PSA value 6 weeks post-therapy and the\nfindings of the PSMA-PET/CT, the further course of action will be\ndetermined in the interdisciplinary Tumor Conference.\n\nIf the patient desires, they can seek a second opinion on further\ntherapeutic procedures in the specialized clinic of the Uro-Oncology\ncolleagues. In case of pronounced rib pain, if requested by the patient,\nthe possibility of undergoing radiation therapy can be evaluated. To do\nso, Mr. Harder can schedule an appointment at the Radio-Oncology clinic.\nPsycho-oncological counseling has been offered to the patient.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan Cilexetil (Atacan) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multi-Vitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Sodium Selenite 999 µg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B Complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Vitamin B1 200 mg 1x/Week\n Vitamin B6 25 mg 2-3x/Week\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------------- ---------------------\n Neutrophils % 80.3 % 42.0-77.0 %\n Lymphocytes % 6.7 % 20.0-44.0 %\n Monocytes % 8.9 % 2.0-9.5 %\n Basophils % 1.3 % 0.0-1.8 %\n Eosinophils % 2.4 % 0.5-5.5 %\n Immature Granulocytes % 0.4 % 0.0-1.0 %\n I:T Ratio 0.005 \n HFLC Absolute 0.0 /µL \n Sodium 140 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Calcium 9.36 mg/dL 8.8-10.2 mg/dL\n Chloride 102 mEq/L 98-107 mEq/L\n Creatinine 1.25 P+ mg/dL 0.70-1.20 mg/dL\n Estimated GFR 52 mL/min/1.73m\\^2 \n BUN (Urea) 44 mg/dL 17-48 mg/dL\n Uric Acid 3.8 mg/dL 3.6-8.2 mg/dL\n CRP 1.3 mg/L \\< 5.0 mg/L\n PSA 2.98 ng/mL \\< 4.4 ng/mL\n ALT (GPT) 22 U/L \\< 41 U/L\n AST (GOT) 49 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 19 U/L 8-61 U/L\n LDH 404 P+ U/L 135-250 U/L\n Testosterone \\<0.03 P- ng/mL 1.32-8.92 ng/mL\n TSH 1.14 mIU/L 0.27-4.20 mIU/L\n Complete Blood Count \n Differential Count \n Hemoglobin 10.6 g/dL 12.5-17.2 g/dL\n Hematocrit 30.5 % 37.0-49.0 %\n RBC 3.4 M/µL 4.0-5.6 M/µL\n WBC 5.49 K/µL 3.90-10.50 K/µL\n Platelets 279 K/µL 150-370 K/µL\n MCV 88.7 fL 80.0-101.0 fL\n MCH 30.8 pg 27.0-34.0 pg\n MCHC 34.8 g/dL 31.5-36.0 g/dL\n MPV 10.1 fL 7.0-12.0 fL\n RDW-CV 14.1 % 11.5-15.0 %\n Absolute Neutrophils 4.41 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.020 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.37 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.49 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.13 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 37.8 K/µL 25.0-105.0 K/µL\n Reticulocyte Percentage 1.10 % 0.50-2.00 %\n Reticulocyte Production Index 0.4 \n Ret-Hb 35.0 pg 28.5-34.5 pg\n Prothrombin Time 117 % \\> 78 %\n INR 0.94 \\< 1.25\n aPTT 30.2 sec 25.0-38.0 sec\n\n\n\n\nHere is the query:\nRegarding Mr. Harder, what was the correct chronological order of radiological and nuclear medicine imaging studies?\n\nChoose the correct answer from the following options:\nA. PSMA PET-CT + MRI < Cystogram < Ultrasound < Cystogram < CT scan abdomen/pelvis < PSMA PET scan < CT scan chest/abdomen < PSMA PET scan\nB. PSMA PET-CT + MRI < Cystogram < Ultrasound < Cystogram < CT scan abdomen/pelvis < PSMA PET scan < CT scan chest/abdomen < PSMA PET scan\nC. CT Scan Abdomen/Pelvis < PSMA PET-CT Scan < Abdominal MRI < CT Scan of Chest and Abdomen < PSMA PET-CT Scan.\nD. PSMA PET-CT + MRI < MRI lumbar spine < Cystogram < Ultrasound < Cystogram < Ultrasound < CT scan abdomen/pelvis < MRI lumbar spine < PSMA PET scan < PSMA PET-CT + MRI < Cystogram < Ultrasound < Cystogram < Ultrasound < CT scan abdomen/pelvis < PSMA PET scan < CT scan chest/abdomen < PSMA PET scan < CT scan chest/abdomen < PSMA PET scan\nE. PSMA PET-CT + MRI < Cystogram < Ultrasound < Cystogram < Ultrasound of the abdomen < CT scan abdomen/pelvis < MRI lumbar spine < CT scan < PSMA PET-CT < CT scan chest/abdomen < PSMA PET scan < CT scan chest/abdomen < PSMA PET scan\n\n\nYour response:\n", "role": "user" }, { "content": "PSMA PET-CT + MRI < Cystogram < Ultrasound < Cystogram < Ultrasound of the abdomen < CT scan abdomen/pelvis < MRI lumbar spine < CT scan < PSMA PET-CT < CT scan chest/abdomen < PSMA PET scan < CT scan chest/abdomen < PSMA PET scan", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Ben Harder, born on 08/02/1940, who was admitted\nto our hospital from 12/17/2015 to 12/27/2015.\n\n**Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Status post excision on the nose with suspicion of basal cell\n carcinoma\n\n- Status post laparoscopic cholecystectomy\n\n- Retropubic radical prostatectomy without nerve preservation and with\n bilateral pelvic lymphadenectomy was performed on 12/17/2015.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------- ---------------------------------------------------\n Valsartan (Diovan) 160 mg 1-0-1\n Aspirin 100 mg 1-0-1\n Simvastatin (Zocor) 15 mg 0-0-1\n Doxazosin (Cardura) 1 mg 0-0-1\n Enoxaparin (Lovenox) 0.6 mL s.c. Administer subcutaneously for a total of 4 weeks.\n Acetaminophen (Tylenol) 500 mg 1-1-1 (for 4 days)\n\n**Histopathology:**\n\n1. 2 adenocarcinoma metastases in 2 out of 4 lymph nodes, left external\n iliac region.\n\n2. 3 adenocarcinoma metastases in 3 out of 6 lymph nodes, right pelvic\n region.\n\n3. 7 adenocarcinoma metastases in 7 out of 7 lymph nodes, right lumbar\n para-aortic region.\n\n4. Acinar adenocarcinoma of the prostate is observed bilaterally, with\n a Gleason score of 4 (70%) + 5 (25%) = 9 and a tertiary Gleason\n grade of 3 (5%) according to the modified Gleason grading of the\n ISUP 2005. The tumor is multifocal and encompasses the entire\n prostate with a maximum extrapolated tumor extension of 60 mm. There\n is extracapsular tumor growth, with focal involvement at the dorsal\n right base. Vascular invasion is not noted, but perineural invasion\n is extensive. Both seminal vesicles are heavily infiltrated, and the\n resection margin of the left seminal vesicle is involved. Before\n tissue embedding, the margins of the specimen show focal\n infiltration by the tumor, in the right anterior region near the\n base (section 7) with a total contact area of 2 mm wide, and the\n primary Gleason grade at the positive margin is 4. In addition to\n the carcinoma, other prostatic tissue shows features of myoglandular\n hyperplasia and high-grade prostatic intraepithelial neoplasia\n (HGPIN). The prostatic urethra is free of tumors or dysplasia.\n\n5. **Tumor classification:** pT3bpN1(12/17), R1L0V0, Gleason: 4 + 5 = 9\n\n**Medical History:** Mr. Harder was admitted for open prostatectomy due\nto biopsy-confirmed prostate carcinoma.\n\nInitial PSA value: 5.42 ng/ml. Gleason score of biopsy: 4+5=9 in 11 out\nof 12 biopsy samples. Clinical tumor stage: cT2c PSMA PET-CT + MRI from\n12/23/2015: Left capsular penetration without rectal infiltration.\nSeminal vesicles are infiltrated on both sides. Evidence of multiple\nlymph nodes; intrapelvic locoregional and two lymph nodes on the right\nparailiacal and lumbar interaortocaval region.\n\nTRUS: 88 cc Digital Rectal Examination: Abnormal findings on the left\nside\n\n**Physical Examination:** The patient is in good general condition, has\na lean nutritional status, and reports feeling well. The abdomen is\nsoft, with no tenderness, masses, resistance, or guarding, and the\nexternal genitalia are unremarkable.\n\n**Ultrasound upon admission:** Both kidneys are not dilated and show no\nspace-occupying lesions. The bladder is minimally filled and appears\nunremarkable to the extent assessable.\n\n**Pretherapeutic Tumor Conference:** The findings were discussed\ninterdisciplinary, and the possible treatment options were explained.\nThe patient opted for radical prostatectomy.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complications. The postoperative course was uneventful. Blood\ntransfusions were not required. Unfortunately, a cystogram on revealed\nextravasation, requiring the indwelling catheter to be retained. The\nwound drain was lifted once with serum-identical creatinine values and\nretained with persistent output (approximately 400 ml daily). Both\nkidneys were not dilated, and there were no signs of lymphocele or\nhematoma in the pelvic region on ultrasound. A follow-up rehabilitation\ntreatment has been organized through our social services. We discharged\nthe patient with absorbable intracutaneous sutures for further\noutpatient care.\n\n**Current Recommendations:** The patient was discharged with a permanent\ncatheter and will present on 01/03/2016 for cystogram and possibly\ncatheter removal. If catheter removal is indicated, we recommend\nconsidering a trial of voiding with subsequent admission if the\ncystogram is normal. The wound drain was also retained, and we request\ndocumentation of output. If output regresses and remains persistently \\<\n30-40 ml, and there is no ultrasound evidence of lymphocele, it could be\nremoved on an outpatient basis or during the follow-up appointment.\n\nWe recommend the first PSA check 6 -- 8 weeks postoperatively, followed\nby quarterly intervals. If the PSA level does not reach the zero range\nor rises again from the zero range, the patient can be offered\nradiotherapy of the prostatic bed and lymphatic drainage pathways in\ncombination with a 2-year hormonal ablative therapy as an individual\ntherapeutic trial. Alternatively, primary hormonal ablative therapy is\nan option. If the PSA level reaches the zero range, the patient may be\noffered adjuvant hormonal ablative therapy for 2 years, possibly\ncombined with radiotherapy. Additional findings will be discussed in our\npost-therapeutic conference. In case of changes in the recommended\nprocedure mentioned above, we will inform you again.\n\n**Course of the lab results:**\n\n **Parameter** **12/18/15** **12/19/15** **12/20/15** **12/23/15** **Reference Range**\n --------------------------- --------------- ---------------- --------------- -------------- ---------------------\n Sodium 135 mEq/L 138 mEq/L 136-145 mEq/L\n Potassium 5.1 mEq/L 4.4 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffe method) 0.93 mg/dL 1.05 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 83 65 \n Hemoglobin 11.4 g/dL 12.4 g/dL 12.5-17.2 g/dL\n Hematocrit 0.323 L/L 0.361 L/L 0.370-0.490 L/L\n Red Blood Cells 3.8 x10\\^12/L 4.3 x10\\^12/L 4.2 x10\\^12/L 4.0-5.7 x10\\^12/L\n White Blood Cells 9.57 x10\\^9/L 11.51 x10\\^9/L 9.65 x10\\^9/L 3.90-10.50 x10\\^9/L\n Platelets 216 x10\\^9/L 239 x10\\^9/L 285 x10\\^9/L 150-370 x10\\^9/L\n MCV 88.1 fL 86.0 fL 88.3 fL 80.0-101.0 fL\n MCH 30.2 pg 30.1 pg 29.5 pg 27.0-34.0 pg\n MCHC 34.5 g/dL 35.3 g/dL 33.8 g/dL 31.5-36.0 g/dL\n MPV 10.2 fL 10.4 fL 10.3 fL 7.0-12.0 fL\n RDW-CV 12.1% 12.2% 12.8% 11.6-14.4%\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Ben Harder, born on 08/02/1940 who received\ninpatient treatment from 01/13/2016 to 01/19/2016.\n\n**Diagnosis:** Urinary Tract Infection in Patient with indwelling\ncatheter\n\n**Other Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n- Arterial hypertension\n\n- History of excision on the nose with suspicion of basal cell\n carcinoma\n\n- History of laparoscopic cholecystectomy\n\n**Medication upon Admission: **\n\n **Medication (Brand)** **Dosage** **Frequency**\n ------------------------------ ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan (Atacand) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multivitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Selenium 999 mcg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Thiamine 200 mg 1x/Week\n Pyridoxine 25 mg 2-3x/Week\n\n**Current presentation:** Mr. Harder returned to our clinic on\n01/13/2016, complaining of new-onset symptoms including increased\nurgency and frequency of urination, discomfort, lower abdominal pain,\nand fever. Given his recent surgery and indwelling catheter, concerns\nwere raised about a possible urinary tract infection.\n\n**Clinical Examination:** On physical examination, Mr. Harder appeared\nunwell. He had a temperature of 38.8°C, elevated heart rate\n(tachycardia), and mild lower abdominal tenderness on palpation. The\nindwelling urinary catheter was in situ, and no signs of catheter\ndislodgment or leakage were observed.\n\n**Ultrasound of the Abdomen upon admission:** Bilateral, no urinary\ntransport obstruction, approximately 4x2 cm-sized fluid collection noted\nin the right inguinal area, suggestive of possible lymphocele.\n\n**CT Scan Abdomen/Pelvic from 01/13/2016:** The liver displays a smooth\ncontour, with homogeneous parenchymal contrast enhancement, and no\nevidence of focal intrahepatic lesions. There is no indication of\nintrahepatic or extrahepatic cholestasis. History of previous\ncholecystectomy with an accentuated common hepatic duct. Spleen,\npancreas, and adrenal glands appear unremarkable. Both orthotopically\nlocated kidneys exhibit simultaneous and equal contrast enhancement. No\nintrarenal structural abnormalities or signs of urinary obstruction are\nobserved. The colonic frame and small intestine show adequate perfusion,\nwithout focal wall thickening. The stomach is distended. The urinary\nbladder contains a catheter. Two intraluminal air pockets are seen.\nKnown circumferential, uniform bladder wall thickening from previous\nexaminations. No free intrabdominal air is detected. No evidence of\nascites. Bilateral iliac and inguinal operative clips from prior\nlymphadenectomy. Right iliac region shows a serous fluid collection\nmeasuring approximately 3 x 2 cm. Para-aortic lymph nodes, up to 14 mm\nin size, are consistent with findings from previous evaluations. No\nsuspicious malignancy-related bone destruction is noted. A drainage tube\nhas been placed through the right lower abdominal wall, with its tip\nlocated in the left pelvic area.\n\n**Assessment:** No evidence of abscess formation. A lymphocele measuring\napproximately 3 x 2 cm is noted in the right iliac region, without signs\nof acute inflammation.\n\n**Microbiological Examination**\n\n**Material**: Catheter Urine Examination Request: Identification of\nPathogens and Resistance Results: Organism 1: Growth of 100,000 CFU/mL\nEnterococcus faecalis Possible ICD-10 Coding Suggestion: Enterococci as\nPathogen.\n\n- Acute Cystitis\n\n- Pyelonephritis\n\n- Urinary Tract Infection related to Catheter/Implant\n\n- Urinary Tract Infection, Unspecified Location\n\n**Antibiogram**\n\n- Gentamicin HL: S\n\n- Levofloxacin: R 1\n\n- Teicoplanin: S \\<=0.5\n\n- Ampicillin: S \\<=2\n\n- Piperacillin: S\n\n- Ampicillin/Sulbactam: S \\<=2\n\n- Piperacillin/Tazobactam: S\n\n- Imipenem: S \\<=1\n\n- Cefuroxim: R \\>=64\n\n- Gentamicin: R\n\n- Cotrimoxazole: R \\<=10\n\n- Ciprofloxacin: R \\<=0.5\n\n- Vancomycin: S 2\n\n- Linezolid: S 2\n\n- Tigecyclin: S \\<=0.12\n\n**Therapy and Progression:** After CT morphological exclusion of an\nabscess formation or retention, the wound drainage was removed under\nantibiotic coverage. Initially, empirical antibiotic therapy with\nCefuroxim was administered, followed by targeted treatment with oral\nUnacid based on resistance testing. The drainage insertion site healed\nprimarily. The bladder catheter was removed, after which urination was\nfree of residual urine. The patient has primary continence. We\ndischarged the patient to further outpatient treatment, with the patient\nreporting subjective well-being.\n\nMr. Harder showed gradual clinical improvement after initiating\nantibiotic therapy. His fever subsided, and lower abdominal tenderness\ndiminished. The IV fluids were discontinued, and he remained on oral\nantibiotics.\n\n**Urine Culture Results:** The urine culture results returned positive\nfor Escherichia coli (E. coli), a common uropathogen. The sensitivity\nprofile indicated susceptibility to ciprofloxacin.\n\n**Follow-Up:** Mr. Harder was closely monitored for the duration of his\nantibiotic course. He was advised to complete the full course of\nantibiotics and maintain adequate hydration. The urinary catheter was\nremoved on the fifth day of hospitalization after demonstrating improved\nurine output and resolution of symptoms. No further complications\nrelated to the catheter removal were observed.\n\n**Current Recommendations:**\n\n1. Please refer to the previous discharge letter for the procedure\n regarding prostate cancer.\n\n2. He was educated on the signs and symptoms of UTIs and instructed to\n seek prompt medical attention if symptoms recurred.\n\n**\\\n**\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nThank you for assigning Mr. Ben Harder, born on 08/02/1940 to the PET/CT\ncombination scanner examination on 12/11/2022.\n\n**Diagnoses:**\n\n- Initial diagnosis of prostate cancer in December 2015, confirmed by\n prostate biopsy.\n\n- Tumor detected in 11 out of 12 biopsy samples\n\n- Maximum Gleason score of 9\n\n- Preoperative PSA level: 5.42 ng/ml\n\n- In the initial PET/CT examination (preoperative) on 12/23/2015\n evidence of prostate cancer extending beyond the capsule in both\n prostatic lobes was found.\n\n- Infiltration of the left seminal vesicles and beginning infiltration\n of the right seminal vesicles\n\n- Multiple retroperitoneal lymph node metastases and bilateral pelvic\n lymph nodes.\n\n- Radical prostatectomy\n\n- Current PSA level: 1.23 ng/ml\n\n- Radiation therapy planned at our facility\n\n**Technique**: To expedite renal-urinary activity elimination, the\npatient was adequately hydrated. The examination was conducted using the\nPET/CT combination scanner BIOGRAPH 64 with CT parameters set at 120 kV\nand 1 mm slice thickness. PET emission data were acquired with 5 bed\npositions on a radiation therapy-compatible table for whole-body\nexamination in the caudocranial direction with transverse slices at 3.0\nmm intervals over the same axial range as the CT scan. Iterative\nreconstruction was performed. A whole-body scan was conducted 90 minutes\nafter the administration of 278 MBq Ga-68-PSMA (prostate-specific\nmembrane antigen). Transmissions-corrected and non-corrected PET scans,\nCT scans, fusion images, and the determination of the SUV value\n(standard uptake value, a measure of activity uptake per volume) were\nused for evaluation.\n\n**PET Findings:** The 3D whole-body images documented in 3 planes using\nPET and PET/CT technology showed the following changes compared to the\nprior examination on 12/23/2015:\n\n- Post-radical prostatectomy, there is diffuse activity accumulation\n in the region dorsal to the bladder, on the left side.\n\n- Regarding the known retroperitoneal lymph node metastases, the\n following changes were observed: New retrocrural nodule on the\n right. SUV 6.6, diameter: 6 mm.\n\n- Known interaortocaval lymph node, dorsally at the level of L3/4,\n showed increased metabolic activity from SUV 4.7 to 11.5. Slightly\n increased in size, measuring 7 to 8 mm. Additionally, two new\n metabolically active nodules cranially, up to the level of L2/3.\n\n- Slightly increased metabolic activity in the known right iliaca\n communis lymph node, located between the fifth lumbar vertebra and\n the psoas muscle, from 4.0 to 4.6, with the same size of 5 mm.\n\n- Progressive enlargement of the known confluent lymph nodes on the\n right parailiacal externa proximal side, now having a combined size\n of 10 x 26 mm (width x height), previously individual nodules of 10\n and 12 mm. SUV 18.2, previously max 11.5.\n\n- New paraaortic lymph nodes on the left, mostly small, SUV 11.2.\n\n- Newly added lymph nodes in both biiliac communal areas. Maximum size\n on the left is 15 mm, SUV 17.2.\n\n- New retrocrural lymph node on the right, measuring 6 mm, SUV 6.6.\n\n- Known lymph node on the right perirectal, slightly progressive from\n 8 to 10 mm. SUV 6.9, previously 6.4.\n\n- Known lymph node on the left iliaca externa not currently\n verifiable, possibly postoperative scarring.\n\n- Newly added focus in the bone at the level of the spinous\n process/dorsal arch of the fifth lumbar vertebra. In CT, a 7 mm\n focal sclerosis is noted. Normal activity accumulation in the soft\n tissues of the neck, axillae, and chest. Physiological accumulation\n in the parenchymal upper abdominal organs. Kidneys and urinary tract\n appear functionally normal. Whole-body CT following bolus-like\n peripheral venous machine injection of 100 ml of Optiray 350: No\n suspicious lymph nodes in the cervical, axillary, or mediastinal\n regions. Normal-sized thyroid gland. No pleuropulmonary infiltrates\n or round lesions. Scarred changes in the left lower lobe.\n Normal-sized liver without focal lesions. Spleen, pancreas, adrenal\n glands, and kidneys appear regular. No urinary obstruction..\n\n**Results**: In the postoperative PET/CT compared to the preoperative\nexamination on, there is now malignancy-typical PSMA receptor binding in\nthe former prostate lodge, indicating a local recurrence. Progression of\nretroperitoneal lymph node metastases, with further extension cranially,\nextending to the interaortocaval region up to the level of L2/3. Newly\nadded metastases on the left paraaortic and biiliac communal areas.\nProgression of known right iliaca externa lymph node metastases. The\nleft iliaca externa nodule is not verifiable, likely removed. New small\nretrocrural nodule on the right. New osteosclerotic metastasis in the\ndorsal arch of LWK 5. Minimal activity accumulation in the 8th rib on\nthe right lateral aspect. A developing metastasis cannot be conclusively\nruled out here. We kindly request information on the patient\\'s further\nclinical course (submission of medical reports, etc.).\n\n**Lab results**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Glucose (Plasma) 91 mg/dL 55-100 mg/dL\n Alkaline Phosphatase 93 U/L \\< 130 U/L\n Total Cholesterol 152 mg/dL \\< 200 mg/dL\n LDL-Cholesterol 89 mg/dL \\< 130 mg/dL\n HDL-Cholesterol 50 mg/dL 40-60 mg/dL\n Non-HDL Cholesterol 101.8 mg/dL \\< 200 mg/dL\n Triglycerides 64 mg/dL \\< 150 mg/dL\n White Blood Cells 4.1 K/uL 4.5-11 K/uL\n Red Blood Cells 4.68 M/uL 4.0-5.5 M/uL\n Hemoglobin 13.6 g/dL 12.5-17.2 g/dL\n Hematocrit 39.5% 37.0-49.0%\n MCH 29.1 pg 27.0-34.0 pg\n MCHC 34.4 g/dL 31.5-36.0 g/dL\n MCV 84.4 fL 80.0-101.0 fL\n RDW 13.0% 11.6-14.4%\n Platelets 238 K/uL 150-370 K/uL\n\n**\\\n**\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mr. Ben Harder, born on\n08/02/1940, who received inpatient treatment at our facility from\n06/23/2023 to 06/26/2023.\n\n**Diagnosis:**\n\nProstate Cancer pT3b pN1 R1 L0 V0 Gleason Score: 4 + 5 = 9 (Initial\ndiagnosis in December 2015)\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015. Currently, lymph node and bone metastasis\n\n**Other Diagnoses:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015.\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n (thora 11 and 12) with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT in 06/2023 scan indicated new extensive metastasis in\n the sacrum and diffuse lung metastases, accompanied by a PSA level\n of 1.35 ng/ml.\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n**Medications on Admission:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Candesartan (Atacand) 16 mg 1-0-1-0\n Aspirin 100 mg 1-0-0-0\n Chlorthalidone (Thalitone) 25 mg 1-0-0-0\n\n**Physical Examination:** The patient was in good general condition and\nhad normal orientation to all qualities. There were no edemas, dyspnea,\nfever, or cough.\n\n**Medical History:** Mr. Hader presents himself for the 1st cycle of RLT\nwith Ac-225-PSMA/Lu-177-I&T-PSMA for lymph node and bone metastatic\nprostate cancer on an inpatient basis. In the presence of progressive\nimaging findings under guideline-compliant therapy, the indication for\nRLT tandem therapy was confirmed according to the tumor conference on.\nUpon admission, the patient reports feeling well, denies any B-symptoms.\nThere is no fever or nausea, and the weight is currently stable. There\nhas been a tendency to fall for some time. The rest of the medical\nhistory is assumed to be known.\n\n**Neurological Consultation on 06/25/2023: **\n\nClinically neurological examination revealed a polyneuropathy syndrome\nof the lower extremities, predominantly on the right side, as well as a\nknown right-sided foot drop. In summary, we consider the falls to be\nmultifactorial due to foot weakness as well as polyneuropathy syndrome\nwith impaired proprioception as the cause of the balance disorder.\nRecommended further procedure: In the presence of a known PNP syndrome\nthat has occurred during chemotherapy, consider outpatient neurological\nevaluation and objectification by means of Electromyography and\npolyneuropathy laboratory tests.\n\n**Salivary Gland Scintigraphy on 06/26/2023**\n\n**Assessment**: Normal function of the submandibular and parotid glands\nbilaterally.\n\nPost-therapeutic imaging with Lu-177-PSMA imaging using\nSPECT/low-dose-CT\n\n**Assessment:** Consistent with the PET-CT, there is no tracer uptake in\nthe area of the prostate. Intensive accumulation of the therapeutic\nagent in the area of lymph node metastases, especially mediastinal.\nCorresponding to the PET/CT, there are clear focal tracer accumulations\nin the left upper lobe of the lung in the area of nodular or diffuse\ntissue condensations, possibly metastases or, secondarily,\npost-inflammatory. Intensive tracer uptake in the area of known bone\nmetastases from the previous examination. No newly appearing\ntracer-enhancing lesions. In addition, physiological accumulation in the\norgan systems involved in tracer metabolism and excretion. NB: Small\npleural effusions on both sides. Known pronounced peribronchial cuffs in\nthe upper lobes on both sides, possibly scarred, or indicative of\npulmonary venous congestion. Known atrophic kidney on the right.\n\n**Current Recommendations:**\n\n- Blood count checks and determination of kidney and liver parameters\n 1, 2, 4, and 8 weeks after therapy\n\n- Outpatient neurologic assessment for the evaluation of\n polyneuropathy\n\n- PSA determination 6-8 weeks after therapy\n\n- Appointment for a 2nd cycle of radioligand therapy\n (Ac-225-/Lu-177-PSMA)\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Neutrophils (%) 72.2 % 42.0-77.0 %\n Lymphocytes (%) 8.6 % 20.0-44.0 %\n Monocytes (%) 11.6 % 2.0-9.5 %\n Basophils (%) 1.4 % 0.0-1.8 %\n Eosinophils (%) 6.0 % 0.5-5.5 %\n Immature Granulocytes (%) 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 2.31 mEq/L 2.20-2.55 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n C-reactive Protein 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 µg/L \\< 4.40 µg/L\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 µg/L 1.32-8.92 µg/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 0.285 L/L 0.370-0.490 L/L\n RBC 3.3 /pL 4.0-5.6 /pL\n WBC 4.98 /nL 3.90-10.50 /nL\n Platelets 281 /nL 150-370 /nL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Neutrophils (Absolute) 3.59 /nL 1.50-7.70 /nL\n Immature Granulocytes (Absolute) 0.010 /nL \\< 0.050 /nL\n Lymphocytes (Absolute) 0.43 /nL 1.10-4.50 /nL\n Monocytes (Absolute) 0.58 /nL 0.10-0.90 /nL\n Eosinophils (Absolute) 0.30 /nL 0.02-0.50 /nL\n Basophils (Absolute) 0.07 /nL 0.00-0.20 /nL\n Reticulocytes 31.3 /nL 25.0-105.0 /nL\n Reticulocyte (%) 0.94 % 0.50-2.00 %\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to report on our mutual patient, Mr. Ben Harder, born on\n08/02/1940, who presented himself to our outpatient clinic on 1/8/2023.\n\n**Diagnoses:**\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9 (initial\n diagnosis in 11/2015)\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally on\n 11/16/2015\n\n- Currently, there are lymph node and bone metastases\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Initial PSA level was 4.8 ng/ml\n\n- History of Docetaxel therapy\n\n- History of Cabazitaxel therapy\n\n- History of 4 cycles of Lutetium-Radioligand therapy\n\n- Subsequently, radiation therapy was initiated for the lymph node\n metastasis but discontinued after 11 sessions due to dyspnea and G3\n esophagitis.\n\n- Arterial hypertension\n\n- Chronic renal insufficiency\n\n- Type 2 diabetes mellitus\n\n**Treatment and Progression:** The patient presents for a second opinion\non his prostate cancer, which has metastasized to the bones and lymph\nnodes and has become castration-resistant. He recently received\nLutetium-Radioligand therapy. Genetic sequencing from the tissue biopsy\ndid not reveal any significant gene mutations. The patient wishes to\nundergo further evaluation for the diagnosis of relevant genetic\nmutations. A previously punctured subdiaphragmatic lymph node metastasis\nhas not yet undergone genetic testing, which may be justified based on\nthe available data and publications in specific cases. A chemotherapy\nsession with Cabazitaxel is planned for the end of January in the\ntreating urological practice. In cases of DNA repair gene alterations, a\nplatinum combination could also be considered. Further possible\ndiagnostic and therapeutic steps were discussed with the patient. An\napplication for a repeat genetic sequencing will be submitted by our\ncolleagues from the genetics department.\n\n**Current Recommendations:**\n\n- Application for genetic sequencing for the punctured lymph node\n metastasis through the genetics department and DNA-med\n\n- Subsequent re-genetic sequencing of the subdiaphragmatic lymph node\n metastasis for relevant mutations\n\n- After receiving the results, a follow-up appointment can be\n scheduled in our uro-oncology outpatient clinic.\n\n.\n\n**\\\n**\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting to you regarding the inpatient stay of our patient Mr.\nBen Harder, born on 08/02/1940. He was under our care from 09/16/2023 to\n09/23/2023.\n\n**Diagnosis**: Prostate Cancer pT3b pN1 R1 L0 V0\n\n- Gleason Score: 4 + 5 = 9\n\n- Postoperative status following retropubic radical prostatectomy\n without nerve preservation and with pelvic lymphadenectomy.\n\n- Currently presenting with lymph node and bone metastases, mCRPC\n (metastatic castration-resistant prostate cancer)\n\n- Initial PSA level: 4.8 ng/ml\n\n**Previous Treatment and Course:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects in 01/2023.\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT scan indicated new extensive metastasis in the sacrum\n and diffuse lung metastases, accompanied by a PSA level of 1.35\n ng/ml.\n\n- Current PET-CT not available. Recommendations for further treatment\n options are as follows, based on externally described\n image-morphological progression in the recent CT:\n\n 1. Actinium-225-PSMA Therapy (Lu-177 Tandem Therapy), provided that\n all vital metastases are PSMA-positive (mandatory exclusion of\n post-renal urinary flow obstruction)\n\n 2. Alternatively, consider initiating therapy with Abiraterone +\n Prednisolone or a Cabazitaxel re-challenge (if there was a\n favorable response to the last 2 cycles of Cabazitaxel\n\n 3. Evaluation of pre-screening for CAR-T cell studies in oncology\n at CBF (contact will be made)\n\n**Other Diagnoses:**\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n- Type 2 Diabetes Mellitus\n\n**Current Presentation:** Mr. Ben Harder is presenting for his 2nd cycle\nof Radioligand Therapy (RLT) with Ac-225-PSMA/Lu-177-I&T-PSMA for lymph\nnode and bone metastatic prostate cancer. In light of progressive\nimage-morphological findings despite guideline-compliant treatment, the\nindication for RLT tandem therapy was determined in the tumor\nconference.\n\n**Medical History:** Mr. Harder reports that after the last treatment\ncycle, he experienced pronounced fatigue symptoms. He particularly\nstruggled with climbing stairs and walking longer distances. However, he\nmanaged to fully recover from these symptoms through targeted training.\nAdditionally, he developed pain in the area of the right ribcage\nfollowing the last treatment cycle. The pain occurs intermittently and\nis accompanied by increased salivation and nausea, sometimes leading to\nvomiting. Mr. Ben Harder also reports newly developed swallowing\ndifficulties. He feels that food gets stuck in his throat after\nswallowing.\n\n**Therapy and Progression:**\n\nIn the case of Mr. Ben Harder, due to metastatic prostate cancer with\nradiographic progression despite previous guideline-recommended therapy,\naccording to the recommendations, there was an indication for the 2nd\nradioligand therapy with Ac-225-PSMA/Lu-177-I&T-PSMA. The\npost-therapeutic imaging showed targeted accumulation of the therapeutic\nagent within the tumor. The therapy was administered due to elevated\nrenal retention parameters with reduced activity of Lu-177-PSMA. The\ncourse of therapy and the entire hospital stay were uncomplicated, so we\ncan now transition the patient to your outpatient care. We recommend\nclose laboratory monitoring (blood count, liver and kidney parameters)\nat 1, 2, 4, and 8 weeks, as well as a PSA determination 6-8 weeks after\ntherapy.\n\nIn the case of significant fatigue symptoms after the 1st cycle of\ntandem RLT, if there are blood count changes indicating a decrease in\nhemoglobin levels and recurrent fatigue symptoms, the administration of\nerythropoietin or the indication for blood product transfusion should be\nconsidered. Depending on the PSA value 6 weeks post-therapy and the\nfindings of the PSMA-PET/CT, the further course of action will be\ndetermined in the interdisciplinary Tumor Conference.\n\nIf the patient desires, they can seek a second opinion on further\ntherapeutic procedures in the specialized clinic of the Uro-Oncology\ncolleagues. In case of pronounced rib pain, if requested by the patient,\nthe possibility of undergoing radiation therapy can be evaluated. To do\nso, Mr. Harder can schedule an appointment at the Radio-Oncology clinic.\nPsycho-oncological counseling has been offered to the patient.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan Cilexetil (Atacan) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multi-Vitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Sodium Selenite 999 µg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B Complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Vitamin B1 200 mg 1x/Week\n Vitamin B6 25 mg 2-3x/Week\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------------- ---------------------\n Neutrophils % 80.3 % 42.0-77.0 %\n Lymphocytes % 6.7 % 20.0-44.0 %\n Monocytes % 8.9 % 2.0-9.5 %\n Basophils % 1.3 % 0.0-1.8 %\n Eosinophils % 2.4 % 0.5-5.5 %\n Immature Granulocytes % 0.4 % 0.0-1.0 %\n I:T Ratio 0.005 \n HFLC Absolute 0.0 /µL \n Sodium 140 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Calcium 9.36 mg/dL 8.8-10.2 mg/dL\n Chloride 102 mEq/L 98-107 mEq/L\n Creatinine 1.25 P+ mg/dL 0.70-1.20 mg/dL\n Estimated GFR 52 mL/min/1.73m\\^2 \n BUN (Urea) 44 mg/dL 17-48 mg/dL\n Uric Acid 3.8 mg/dL 3.6-8.2 mg/dL\n CRP 1.3 mg/L \\< 5.0 mg/L\n PSA 2.98 ng/mL \\< 4.4 ng/mL\n ALT (GPT) 22 U/L \\< 41 U/L\n AST (GOT) 49 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 19 U/L 8-61 U/L\n LDH 404 P+ U/L 135-250 U/L\n Testosterone \\<0.03 P- ng/mL 1.32-8.92 ng/mL\n TSH 1.14 mIU/L 0.27-4.20 mIU/L\n Complete Blood Count \n Differential Count \n Hemoglobin 10.6 g/dL 12.5-17.2 g/dL\n Hematocrit 30.5 % 37.0-49.0 %\n RBC 3.4 M/µL 4.0-5.6 M/µL\n WBC 5.49 K/µL 3.90-10.50 K/µL\n Platelets 279 K/µL 150-370 K/µL\n MCV 88.7 fL 80.0-101.0 fL\n MCH 30.8 pg 27.0-34.0 pg\n MCHC 34.8 g/dL 31.5-36.0 g/dL\n MPV 10.1 fL 7.0-12.0 fL\n RDW-CV 14.1 % 11.5-15.0 %\n Absolute Neutrophils 4.41 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.020 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.37 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.49 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.13 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 37.8 K/µL 25.0-105.0 K/µL\n Reticulocyte Percentage 1.10 % 0.50-2.00 %\n Reticulocyte Production Index 0.4 \n Ret-Hb 35.0 pg 28.5-34.5 pg\n Prothrombin Time 117 % \\> 78 %\n INR 0.94 \\< 1.25\n aPTT 30.2 sec 25.0-38.0 sec\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n\n\n\n\nHere is the query:\nWhat was identified in Mr. Chapman's blood cultures during his stay from 04/03/2017 to 05/01/2017?\n\nChoose the correct answer from the following options:\nA. E. coli\nB. Pseudomonas aeruginosa\nC. Staphylococcus capitis\nD. Streptococcus pneumoniae\nE. Klebsiella pneumoniae\n\n\nYour response:\n", "role": "user" }, { "content": "Staphylococcus capitis", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_3\n**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n\nHere is the query:\nIn which area did Mr. Davies show below-average performance in the Wechsler Memory Scale?\n\nChoose the correct answer from the following options:\nA. Forward Digit Span\nB. Backward Digit Span\nC. Immediate Reproduction\nD. 30-minute retention\nE. Recognition performance\n\n\nYour response:\n", "role": "user" }, { "content": "Backward Digit Span", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are writing to provide an update on the examination results of our\npatient Mrs. Hilary Sanders, born on 08/24/1976, who presented to our\noutpatient clinic on 10/09/2016.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n human immunoglobulin\n\n**Medical History:** Mrs. Sanders presented with suspected previously\nundiagnosed immunodeficiency. There were no reports of frequent\ninfections during childhood and adolescence. No increased herpes\ninfections. No history of pneumonia, meningitis, or other serious\ninfections.\n\n**Current Presentation:** Mrs. Sanders has experienced recurrent\nrespiratory infections (bronchitis, pharyngitis) for about 3 years.\n\n**Physical Examination:** She reported joint pain in the left knee and\nnumbness below the shoulder blade. A tendency to bruise easily. No\nmucosal lesions, recurrent axillary lymph node swelling. No recurrent\nfevers. No B-symptoms. No resting dyspnea, no subjective heart rhythm\ndisturbances, no syncope, no peripheral edema, or other signs of\ncardiopulmonary decompensation.\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all IgG\n subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and NK-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B-cells.\n\n- Monocytic HLA-DR expression (immune competence marker) within the\n normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n- T-cell function after 24h polyvalent ConA stimulation: TNF-alpha,\n IFN-gamma, IL-2, IL-4 unremarkable\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells.\n\nFurther cellular immune status, including the complement system and\nsoluble mediators, showed no significant abnormalities except for an\nelevated soluble IL-2 receptor. Given the unremarkable monocytic\nTNF-alpha secretion after LPS stimulation, a significant Toll-like\nReceptor 4 defect is unlikely. An antibody response to Tetanus Toxoid\nwas demonstrated in a vaccine titer test. Protective\npneumococcal-specific antibodies could not be detected. There were no\nabnormalities in autoimmune diagnostics.\n\nImmunofixation showed no evidence of monoclonal gammopathy.\nHypogammaglobulinemia due to enteral or renal protein loss is unlikely\nin the presence of normal albumin.\n\nOverall, the picture is consistent with Common Variable\nImmunodeficiency. Formally, CVID is defined by a reduction in the major\nimmunoglobulin class IgG, with accompanying reduction in IgA and/or IgM,\nin the absence of normal or impaired vaccine response. Due to very low\nimmunoglobulin levels and planned travel, determination of vaccine\nresponse was currently omitted in the absence of therapeutic\nconsequence. After stable substitution, specific vaccine antibody levels\ncan be determined before or after vaccination, with the assumption that\nstable antibody concentrations exist due to continuous immunoglobulin\nsubstitution.\n\nAccording to B-cell differentiation, it corresponds to Type Ib according\nto the Freiburg Classification and Type B+smB-CD21lo according to the\nEuro Classification. The classification is clinically relevant, as Type\nIa is associated with increased immunocytopenias (especially ITP and\nAIH) and splenomegaly. In CVID with a high proportion (\\>10%) of CD-21\nlow B-cells, increased granulomatous diseases and splenomegaly have also\nbeen observed.\n\nThe indication for immunoglobulin substitution therapy exists because of\nrecurrent infections. The form of substitution therapy (intravenous. vs.\nsubcutaneous) is primarily based on patient preferences, but also on\nmedical conditions (concomitant diseases such as thrombocytopenia,\nconvenience, insurance, etc.).\n\n**Current Recommendations:**\n\nWe propose to initiate immunoglobulin substitution therapy with Hizentra\n20% (subcutaneous) at a dose of 200 ml once a week on Tuesdays. Further\ninformation and training on subcutaneous immunoglobulin substitution\ntherapy will be provided by a home care nursing service.\n\nMrs. Sanders will remain under regular medical supervision with close\nmonitoring of clinical symptoms, laboratory parameters, and the\neffectiveness of immunoglobulin substitution therapy. Any unexpected\nside effects or changes in her condition should be reported immediately.\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n --------------------------------------- --------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Calcium 2.41 mg/dL 2.15-2.50 mg/dL\n Inorganic Phosphate 1.00 mg/dL 0.87-1.45 mg/dL\n Selenium 0.79 µmol/L 0.60-1.50 µmol/L\n Zinc 10.1 µmol/L 9.0-22.0 µmol/L\n Creatinine 0.75 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 mL/min \\>90 mL/min\n Total Bilirubin 0.37 mg/dL \\< 1.20 mg/dL\n Albumin 4.55 g/dL 3.50-5.20 g/dL\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n A2-Globulin in Serum 10.7% 7.1-11.8%\n ß-Globulin in Serum 9.2% 8.4-13.1%\n Gamma-Globulin in Serum 3.2% 11.1-18.8%\n Immunoglobulin G 514 mg/dL 700-1600 mg/dL\n Immunoglobulin A 14 mg/dL 70-400 mg/dL\n Immunoglobulin M 19 mg/dL 40-230 mg/dL\n Immunoglobulin E 90 kU/L 0.0-100.0 kU/L\n IgG 1 299.5 mg/dL 280-800 mg/dL\n IgG 2 162.7 mg/dL 115-570 mg/dL\n IgG 3 49.1 mg/dL 24-125 mg/dL\n IgG 4 4.0 mg/dL 5.2-125 mg/dL\n Serum Immunofixation \n CRP 4.8 mg/L \\< 5.0 mg/L\n C3 Complement 980 mg/L 900-1800 mg/L\n C4 Complement 120 mg/L 100-400 mg/L\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n HBs Antigen Negative \n HBc Antibody Negative \n HBs Antibody Negative \n Ferritin 56 µg/L 13-140 µg/L\n ALT (GPT) 33 U/L \\< 31 U/L\n AST (GOT) 29 U/L \\< 35 U/L\n Alkaline Phosphatase 84 U/L 35-105 U/L\n Creatine Kinase 90 U/L \\< 167 U/L\n CK-MB 8.3 U/L \\< 24.0 U/L\n Gamma-GT 40 U/L 5-36 U/L\n LDH 204 U/L 135-214 U/L\n Lipase 50 U/L 13-60 U/L\n Cortisol 306.6 nmol/L 64.0-327.0 nmol/L\n 25-OH-Vitamin D3 65.3 nmol/L 50.0-150.0 nmol/L\n 1.25-OH-Vitamin D3 134 pmol/L 18.0-155.0 pmol/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Vitamin B12 770 pg/mL 191-663 pg/mL\n Folic Acid 14.6 ng/mL 4.6-18.7 ng/mL\n Hemoglobin 13.9 g/dL 12.0-15.6 g/dL\n Hematocrit 41.0% 35.5-45.5%\n Erythrocytes 5.2 M/uL 3.9-5.2 M/uL\n Leukocytes 4.13 K/uL 3.90-10.50 K/uL\n Platelets 174 K/uL 150-370 K/uL\n MCV 80.0 fL 80.0-99.0 fL\n MCH 26.7 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n RDW-CV 13.7% 11.5-15.0%\n Absolute Neutrophils 2.87 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.010 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.71 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.42 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.03 K/uL 0.00-0.20 K/uL\n HbA1c 4.9% \\< 6.0%\n HbA1c (IFCC) 30.1 mmol/mol \\< 42.0\n HBV Serology Result Negative \n HIV1/2 Antibodies, P24 Antigen Negative \n Hepatitis C Virus Antibodies in Serum Negative \n\n**Dear colleague,**\n\nWe report the examination results of Mrs. Hilary Sanders, born on\n08/24/1976 who presented at our outpatient clinic on 03/04/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all\n IgG-Subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and natural killer-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B cells.\n\n- Monocytic HLA-DR expression within the normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells. The further cellular immune\nstatus, including the complement system and soluble mediators, showed no\nsignificant abnormalities except for an elevated soluble IL-2 receptor.\n\n**Current Presentation:** Mrs. Sanders was again provided with detailed\ninformation about her condition and the planned course of action. We\nscheduled an appointment to initiate regular subcutaneous immunoglobulin\ntherapy.\n\n**Medical History:** Mrs. Sanders received her first dose of Hizentra\n20% subcutaneously as immunoglobulin substitution therapy for CVID. The\nadministration was well-tolerated initially, with no evidence of\nsignificant local or systemic side effects. Mrs. Sanders was once again\ninformed about possible risks (especially hypersensitivity reactions)\nand advised to contact us immediately in case of questions,\nuncertainties, or any abnormalities. The dosing for the first four weeks\nwas 3x20mL Hizentra 20% subcutaneously, and from the fifth week onward,\nit was changed to either 1x40mL or 2x20mL Hizentra 20% subcutaneously\nper week.\n\nIn the past days, Mrs. Sanders has been experiencing a cold: runny nose,\ncough (green-yellow), difficulty clearing mucus, slight fever, sinus\ninflammation, sore throat, difficulty speaking, and swallowing problems.\nThere was no improvement.\n\n**Physical Examination:** Reddened throat, no exudates, non-swollen\ncervical lymph nodes, lung examination showed bronchitis-like breathing\nsounds, no rales.\n\n**Therapy and Progression**: Today\\'s CRP is not elevated. IgGs are\nstill below normal. We recommended increasing immunoglobulin\nsubstitution during the infection. The patient had difficulty finding a\nsuitable injection site on her abdomen. However, she reported that the\nsecretions were gradually becoming lighter, so she decided to wait with\nthe antibiotic and only use it if there was no improvement.\n\nThe patient has been receiving 3x20mL Hizentra 20% per week since her\nlast visit. She complained of developing skin hardening at the injection\nsites, so a slower infusion time was discussed. She has been\nexperiencing a strong cough for several weeks without fever. No rales or\nsigns of pleuritis were detected on auscultation. No abnormalities were\nobserved on the chest X-ray. Laboratory results now show normal IgG\nlevels, so the dose was reduced to 2x20mL per week. A CT scan of the\nthorax and abdominal ultrasound were requested.\n\n**Chest X-ray in two planes from 03/04/2017:**\n\n[Findings/Assessment:]{.underline} No previous images are available for\ncomparison. Upper mediastinum and heart appear normal, with no central\ncongestion. No pneumothorax, effusions, confluent infiltrates, or\nsignificant focal lesions.\n\n**Abdominal ultrasound on 03/04/2017:**\n\nHepatosplenomegaly and retroperitoneal lymphadenopathy up to 26mm.\n\n**CT Chest/Abdomen/ from 03/04/2017:**\n\n[Methodology]{.underline}: Digital overview radiographs. After\nintravenous injection of contrast agent a 16-row CT scan of the thorax\nand entire abdomen was performed in the venous contrast phase, with\nprimary data set reconstruction at a thickness of 1.25 mm. Multiplanar\nreconstructions were created.\n\n[Findings]{.underline}: A conventional radiographic pre-image from\n11/18/2014 is available for comparison.\n\n[Thorax]{.underline}: Normal lung parenchyma with normal vascular\nmarkings. Small, sometimes hazy, sometimes nodular densities measuring\nup to 4mm in both lower lobes and the left upper lobe. Small\npleura-adjacent density in the right lower lobe. No evidence of\nconfluent infiltrates. No pleural effusion or pneumothorax. Normal heart\nsize and configuration. Normal diameter of the thoracic aorta and\npulmonary trunk. Increased number and enlarged retroclavicular lymph\nnodes on the right and left, axillary on both sides measuring up to 30mm\nin diameter. Trachea and esophagus displayed normally. No hiatus hernia.\nThyroid and neck soft tissues were unremarkable, as far as depicted.\nNormal thoracic soft tissue mantle. No soft tissue emphysema.\n\n[Abdomen]{.underline}: Hepatomegaly with morphologically normal liver\nparenchyma. No portal vein thrombosis. Gallbladder is unremarkable with\nno calculi. Intrahepatic and extrahepatic bile ducts are not dilated.\nPancreas is normally lobulated and structured, with no dilation of the\npancreatic duct. Splenomegaly. Accessory spleen measuring approximately\n20 mm in diameter. Splenic parenchyma is homogeneously contrasted in the\nvenous phase. Kidneys are orthotopically positioned, normal size with no\nside differences, and contrasted equally on both sides. Two regularly\nconfigured hypodense lesions in the left kidney, suggestive of\nuncomplicated renal cysts. No dilation of the urinary tract, and no\nevidence of stones. Adrenal glands are not visualized. Increased and\nenlarged mesenteric, pararaortic, parailiacal, and inguinal lymph nodes\nup to 30 mm in size. Gastrointestinal tract is displayed normally, as\nfar as assessable. Normal representation of major abdominal vessels. No\nfree intraperitoneal fluid or air.\n\n[Osseous structures:]{.underline} No evidence of suspicious osseous\ndestruction. Normal soft tissue mantle.\n\n[Assessment:]{.underline} Intrapulmonary multifocal, sometimes hazy,\nsometimes nodular densities, differential diagnosis includes atypical\npneumonia. Thoracoabdominal lymphadenopathy. Hepatosplenomegaly without\nsuspicious lesions.\n\n**Current Recommendations:**\n\n- Outpatient follow-up for discussion of findings\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% 2x20mL/week\n\n- Lung function test\n\n- Gastroscopy\n\n- In case of acute infection: increase immunoglobulin administration\n\n- Abdominal ultrasound: annually\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually Seasonal influenza vaccination: annually\n\n**Lab results upon discharge:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n Gamma-Globulin 3.2% 11.1-18.8%\n Immunoglobulin G 188 mg/dL 700-1600 mg/dL\n Immunoglobulin A 11 mg/dL 70-400 mg/dL\n Immunoglobulin M 12 mg/dL 40-230 mg/dL\n IgG Subclass 1 113 mg/dL 280-800 mg/dL\n IgG Subclass 2 49.1 mg/dL 115-570 mg/dL\n IgG Subclass 4 \\<0.0 mg/dL 5.2-125 mg/dL\n aPCP-IgG 7.32 mg/dL 10.00-191.20 mg/dL\n aPCP-IgG2 2.74 mg/dL 4.70-89.40 mg/dL\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n LDH 224 U/L 135-214 U/L\n Vitamin B12 708 pg/mL 191-663 pg/mL\n Erythrocytes 5.3 M/uL 3.9-5.2 M/uL\n Platelets 129 K/uL 150-370 K/uL\n MCV 78.0 fL 80.0-99.0 fL\n MCH 25.1 pg 27.0-33.5 pg\n Absolute Lymphocytes 0.91 K/uL 1.10-4.50 K/uL\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on Mrs. Hilary Sanders, born on 08/24/1976, who\npresented to our Immunodeficiency Clinic on 10/06/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Hepatosplenomegaly\n\n- Thoracoabdominal, inguinal, and axillary lymphadenopathy\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** Mrs. Sanders first presented herself to our clinic,\nwith suspected undiagnosed immunodeficiency. Regular subcutaneous\nimmunoglobulin therapy with Hizentra 20% (2x20mL/week) has been\nwell-tolerated. Initially, there were frequent upper respiratory tract\ninfections with sore throat and cough. In the absence of fever, a\none-time course of Cotrim was prescribed for 7 days due to sinusitis. We\ndiscussed Mrs. Sanders' medical history in detail, including the recent\nCT findings. She has been informed about the necessity of vigilance in\ncase of unclear and especially persistent lymph node swellings.\nRegarding the inguinal and axillary lymph nodes measuring up to 30mm in\ndiameter found on CT, we recommend an observational approach with\nregular sonographic monitoring. There have been no significant changes\nin laboratory parameters, with good IgG levels during ongoing\nsubstitution therapy and known moderate leukopenia and lymphopenia.\nDuring the next appointment, an additional lung function test, including\ndiffusion measurement, will be conducted\n\n**Current Recommendations:**\n\n- Outpatient follow-up, including lung function test\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% (2x20mL/week).\n\n- Current gastroscopy.\n\n<!-- -->\n\n- In case of acute infection: increase immunoglobulin administration.\n\n- Administer targeted, sufficiently long, and high-dose antibiotic\n therapy if bacterial infections require treatment.\n\n- Ideally, obtain material for microbiological diagnostics.\n\n- In case of increasing diarrhea, consider outpatient stool\n examinations, including Giardia lamblia and Cryptosporidium.\n\n- Abdominal ultrasound: annually.\n\n- Lung function test, including diffusion measurement: annually.\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually.\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings or H. pylori testing\n\n- Chest X-ray or CT thorax: if clinical symptoms or lung function\n abnormalities are observed.\n\n- Seasonal influenza vaccination: annually.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.1 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffé) 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n Immunoglobulin G 1025 mg/dL 700-1600 mg/dL\n Immunoglobulin A 16 mg/dL 70-400 mg/dL\n Immunoglobulin M 28 mg/dL 40-230 mg/dL\n Free Lambda Light Chains 5.86 5.70-26.30\n Free Kappa Light Chains 6.05 3.30-19.40\n Kappa/Lambda Ratio 1.03 0.26-1.65\n IgG Subclass 1 580.9 mg/dL 280-800 mg/dL\n IgG Subclass 2 340.7 mg/dL 115-570 mg/dL\n IgG Subclass 3 50.9 mg/dL 24-125 mg/dL\n IgG Subclass 4 5.7 mg/dL 5.2-125 mg/dL\n CRP 7.3 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 13.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 5.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n**Abdominal Ultrasound on 10/06/2017:**\n\n[Liver]{.underline}: Measures 19 cm in the MCL, homogeneous parenchyma,\nno focal lesions.\n\n[Gallbladder/Biliary Tract:]{.underline} No evidence of calculi, no\nsigns of inflammation, no congestion.\n\n[Spleen]{.underline}: Measures 14 cm in diameter, homogeneous. Accessory\nspleen measures 16 mm at the hilus.\n\n[Pancreas]{.underline}: Morphologically unremarkable, as far as visible\ndue to intestinal gas overlay, no evidence of space-occupying processes.\n\nRetroperitoneum: No signs of aneurysms. Enlarged retroperitoneal and\niliac lymph nodes, measuring up to approximately 2.5 cm in diameter.\n\n[Kidneys]{.underline}: Both kidneys are of normal size (right 4.3 x 11.8\ncm, left 4.6 cm x 11.9 cm). No congestion, no evidence of calculi\n(stones), no evidence of space-occupying processes.\n\n[Bladder]{.underline}: Smoothly defined and normally configured.\nMinimally filled.\n\n[Uterus]{.underline}: Size within the normal range, homogeneous.\n\nNo ascites.\n\n[Assessment:]{.underline} Evidence of enlarged lymph nodes up to 2.5 cm\nretroperitoneal and iliac. Compared to previous findings, a slight\ndecrease in splenomegaly.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on the examination results of our patient, Mrs. Hilary\nSanders, born on 08/24/1976, who presented herself in our\nImmunodeficiency Clinic on 02/10/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Ongoing diarrhea in the morning, often\nrecurring in the afternoon. No melena, no fresh blood. Resolving\nrespiratory infection, positive influenza.\n\nCurrently, IgG levels remain within the target range. An increased need\nfor immunoglobulins is expected, especially in the third trimester of\npregnancy. Therefore, we recommend close monitoring with us during\npregnancy. Ferritin levels have further declined, indicating the need\nfor iron substitution. Anamnestically, there is an intolerance to oral\niron preparations.\n\n**Recommendations:**\n\n- Outpatient follow-up\n\n- Early follow-up in case of infections or persistent diarrhea\n\n- Continue regular subcutaneous immunoglobulin therapy, currently with\n Hizentra 20% 2x20mL/week\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n04/12/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infection with symptoms for 3-4\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance.\n\nIgG levels remain within the target range; therefore, we recommend\ncontinuing the current treatment unchanged.\n\nSince the last visit, mild upper respiratory tract infections. No fever\n(except for one episode of sinusitis), no antibiotics. SCIG treatment\nunchanged with 3x20mL/week of Hizentra ®.\n\nMrs. Sanders continues to experience watery diarrhea about 5-7 times\ndaily. No blood in stools, no pain, no vomiting, no nausea. There has\nbeen no clear association with specific foods observed. Current weight:\n69kg.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori testing: e.g., breath test or Helicobacter\n pylori antigen in stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and Helicobacter pylori testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n02/18/2019.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infections with symptoms for 7\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance. Continued diarrhea, approximately 6 times a\nday, without weight loss. IgG levels remain within the target range;\ntherefore, we recommend continuing the current treatment unchanged.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue treatment as is\n\n- External upper gastrointestinal endoscopy (and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are writing to provide summary on the clinical course of Mrs. Hilary\nSanders, born on 08/24/1976, who presented at our outpatient\nImmunodeficiency Clinic.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n- Iron-deficiency anemia\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Overall stable condition. No longer\nexperiencing cough. Persistent fatigue. Upcoming appointment with the\nGastroenterology department next week. There is again an indication for\niron substitution.\n\n**Update on 11/15/2019: Laboratory results from 11/15/2019:**\nTransaminase elevation, Protein 18, markedly elevated BNP. However, IgA\nis at 0.5 (otherwise not detectable), IgG subclasses within normal\nrange. Findings do not align. Patient informed by phone, returning for\nfurther evaluation today; also screening for Hepatitis A, B, C, and E,\nEBV, CMV, TSH, coagulation. No shortness of breath, no edema, no\nabdominal enlargement, stable weight at 69 kg. In case of worsening\nsymptoms, shortness of breath, or fever, immediate referral to the\nemergency department recommended.\n\n**02/12/2020:** The patient is doing reasonably well. She has had a mild\ncold for about 2 weeks, no fever, but nasal congestion and\nyellowish-green sputum. No other infections. No antibiotics prescribed.\nShe has adapted to her gastrointestinal issues. An appointment with the\nGastroenterology department. She is currently working from home.\nMedication: no new medications, only Cuvitru 20mL 3x weekly. Weight\nremains stable at 67 kg. The last lung function test was in the summer\nof this year and was within normal limits. Imaging has not been\nperformed recently. Gastroscopy and colonoscopy have not been conducted\nfor some time.\n\n**04/14/2020:** Referral to Gastroenterology at is recommended for\npersistent abdominal symptoms.\n\n**10/24/2020:** The patient has mostly avoided social contacts due to\nthe pandemic. She continues to experience digestive problems (food\nintolerances, diarrhea, flatulence). She has less stamina. Few\ninfections in the past year, at most a minor cold. No significant\ninfections. Hizentra injections remain unchanged at 20 mL 3 times a\nweek.\n\n**03/22/2021:** Constant colds since December 2020. One-time antibiotic\ntreatment in October 2019. Subcutaneous Immunoglobulin therapy remains\nunchanged at 20 mL 3 times weekly.\n\n**09/19/2021:** She feels disoriented and very tired, more so than\nusual. Difficulty maintaining a steady gaze. No steroid therapy was\nadministered. CT showed enlarged lymph nodes. Diarrhea, especially in\nthe morning, 3-4 times a day, additional bowel movements with meals,\nsometimes watery. No fever, no infections. Hizentra injections continued\nunchanged.\n\n**Summary**: IgG levels are currently within the target range, so we\nrecommend continuing immunoglobulin substitution therapy without\nchanges. The antibody response (SARS-CoV-2 (S-Ag) IgG ELISA) to the\nCovid-19 vaccination is, as expected, negative. However, there is a\npositive detection of SARS-CoV-2 (N-Ag) IgG ELISA, as expected in the\ncase of viral contact (not vaccination). We consider this to be an\nunspecific reaction and recommend further monitoring at the next\nfollow-up appointment. With a platelet count currently at 55 K/uL, we\nrecommend a short-term blood count check with us or your primary care\nphysician.\n\nDue to the immunodeficiency, a lack of antibody response to vaccination\nwas expected. In the medium term, passive protection through\nimmunoglobulin substitution therapy will play a role. This is contingent\non a significant portion of plasma donors having antibodies against\nSARS-CoV2. There is a multi-month delay from the time of donation to the\nrelease of the preparations, so we anticipate that meaningful protection\nthrough immunoglobulin products will not be expected. An exact prognosis\nin this regard is not possible.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Consultation with Gastroenterology\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are providing you with an update regarding our patient Mrs. Hilary\nSanders, born on 08/24/1976. She was under our inpatient care from\n03/29/2023 to 04/05/2023.\n\n**Diagnoses:**\n\n- Suspected CVID-Associated enteropathy\n\n- Known hepatosplenomegaly with a borderline enlarged portal vein, no\n significant portocaval shunts. Multiple liver lesions, possibly\n hemangiomas further evaluation if not already done.\n\n- Known retroperitoneal and iliac lymphadenopathy, likely related to\n the underlying condition.\n\n- Known changes in the lower lung bases, likely associated with the\n underlying condition, e.g., ILD. Refer to previous examinations.\n\n- Capsule endoscopy: Incomplete capsule enteroscopy with no evidence\n of inflammatory changes. Some hyperemia and blurry vascular pattern\n observed in the visible colon.\n\n- CVID-Associated Hepatopathy in the Form of Nodular Regenerative\n Hyperplasia\n\n**Other Diagnoses:** Common Variable Immunodeficiency Syndrome (CVID)\nwith:\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n Hizentra 20%\n\n- Infectious manifestations: Frequent respiratory tract infections\n\n- Non-Infectious manifestations:\n\n - ITP (Immune Thrombocytopenia)\n\n - Hepatosplenomegaly\n\n - Lymphadenopathy in supraclavicular, infraclavicular,\n thoracoabdominal, inguinal, and axillary regions\n\n - Suspected Granulomatous-Lymphocytic Interstitial Lung Disease in\n CVID\n\n<!-- -->\n\n- Iron-deficiency anemia\n\n**Pysical Examination:** Patient in normal general condition and\nnutritional status (175 cm, 65.8 kg. No resting dyspnea.\n\n[Neuro (grossly orienting):]{.underline} awake, oriented to\ntime/place/person/situation, No evidence of focal neurological deficit.\nNo meningism.\n\n[Head/neck]{.underline}: pharynx non-irritable. Moist, rosy mucous\nmembranes. Tongue occupied.\n\n[Skin]{.underline}: intact, turgor normal, no icterus, no cyanosis.\n\n[Thorax]{.underline}: normal configuration, no spinal palpitation, renal\nbed clear.\n\n[Lung]{.underline}: vesicular breath sound bds, no accessory sounds,\nsonorous tapping sound bds.\n\n[Cor]{.underline}: Cardiac action pure, rhythmic, no vitia typical\nmurmurs.\n\n[Abdomen]{.underline}: regular bowel sounds, soft abdominal wall, no\ntenderness, no resistances, no hepatosplenomegaly.\n\n[Extremities]{.underline}: no edema. Feet warm. Dorsalis pedis +/+ and\nposterior tibial artery +/+.\n\n**Current Presentation:** The patient was admitted for further\nevaluation of suspected CVID-associated enteropathy, as she had been\nexperiencing chronic diarrhea for the past three years. On admission,\nthe patient reported an overall good general and nutritional condition.\nShe described her current subjective well-being as good but mentioned\nhaving chronic diarrhea for the past three years, with up to 7 bowel\nmovements per day. The stools were watery without any signs of blood.\nThere were no indications of infection, such as fever, chills, dysuria,\nhematuria, cough, sputum, or dyspnea. She also experienced intermittent\nleft-sided upper abdominal pain, primarily postprandially. She had a\ngood appetite.\n\nOn the day of admission, an esophagogastroduodenoscopy was performed,\nwhich revealed erythematous antral gastritis. Additionally, there was an\napproximately 1 cm irregular mucosal area at the corpus-antrum junction\non the greater curvature side. A magnetic resonance imaging scan showed\nno evidence of inflamed bowel loops, ruling out chronic inflammatory\nbowel disease or celiac disease. To further investigate, a capsule\nendoscopy was performed, with results pending at the time of discharge.\nHypovitaminosis B12 and folate deficiency were ruled out. However,\niron-deficiency anemia was confirmed, and the patient had already\nscheduled an outpatient appointment for iron substitution. Serum levels\nof vitamin B6 and zinc were pending at discharge.\n\nDue to a moderate increase in transaminases and evidence of\nhepatosplenomegaly, we decided, after detailed explanation and with the\npatient\\'s consent, to perform a sonographically guided liver biopsy in\naddition to the planned endoscopy. The differential diagnosis included\nCVID-associated hepatopathy. The biopsy was successfully conducted ,\nwithout any post-interventional bleeding. Histology revealed mild acute\nhepatitis and nodular regenerative hyperplasia.This finding could be\nconsistent with changes in CVID-associated hepatopathy. Granulomas were\nnot observed. With only slightly elevated liver values, a trial therapy\nwith budesonide was initiated, and clinical (diarrhea?) and laboratory\n(transaminases?) follow-up will be performed in the outpatient setting.\n\nWe discharged Mrs. Sanders in a cardiopulmonarily stable condition.\n\n[Current Recommendations:]{.underline}\n\n- Follow-up in the gastroenterological outpatient clinic\n\n**Esophagogastroduodenoscopy (EGD) on 04/01/2023:** Introduction of the\ngastroscope in a left lateral position. Visualized up to the descending\npart of the duodenum. Unremarkable upper esophageal sphincter. Normal\nmotility and mucosa in the upper, middle, and distal esophagus. The\nZ-line is sharply demarcated in the hiatus. The cardia closes\nsufficiently. The stomach expands normally in all parts under air\ninsufflation. Multiple glandular cysts \\< 8 mm in size in the fundus and\ncorpus. Approximately 1 cm irregular mucosal area at the corpus-antrum\njunction on the greater curvature side. Streaky redness of the mucosa in\nthe antrum. Unremarkable mucosa in the bulb. Unremarkable mucosa in the\ndescending part of the duodenum. Step biopsies performed.\n\n[Summary]{.underline}: Erythematous antral gastritis. Approximately 1 cm\nirregular mucosal area at the corpus-antrum junction on the greater\ncurvature side, suggestive of inflammation. Multiple glandular cysts\nobserved in the fundus and corpus.\n\n[Abdominal MRI on 04/02/2023:]{.underline}\n\n[Clinical information, questions, and justification for the\nexam]{.underline}: Chronic diarrhea, suspected CVID-associated\nenteropathy, differential diagnosis of celiac disease, and inflammatory\nbowel disease (IBD). Assessment of malignancy.\n\nTechnique: After oral administration of mannitol solution and injection\nof 40 mg Buscopan, a 3-Tesla abdominal MRI was performed.\n\n[Findings]{.underline}: Multiple nodular consolidations and opacities\ndetected in the lower basal lung segments, measuring 7 x 4 mm, for\nexample, in the right lateral lower lobe (Series 18, Image 3).\nAdditionally, streaky-reticular changes observed. Left diaphragmatic\nelevation. Liver globally enlarged and smooth-bordered with several\nlesions showing mild to moderately hyperintense signals in T2-weighted\nimages and hypointense signals in T1-weighted images. These lesions\ndemonstrated increased enhancement in the early contrast phases,\nespecially those at the periphery, and more diffuse enhancement in the\nlate phases. For example, a lesion measuring 12 x 11 mm in Segment 2, a\nlesion measuring 8 mm in Segment 8 and a lesion measuring 21 x 13 mm in\nSegment 7. The portal vein measures borderline wide, up to 15 mm in\ndiameter. Gallbladder is unremarkable without evidence of stones. Intra-\nand extrahepatic bile ducts are not dilated. Spleen significantly\nenlarged, measuring 14 cm in pole-to-pole distance and 7.2 cm in\ntransverse diameter, homogeneous enhancement in native phases and late\ncontrast phase. Large accessory spleen located hilarly. Bilateral\nadrenal glands appear slender. Pancreas displays typical appearance with\nno ductal dilatation. Both kidneys are in orthotopic position, with\nunremarkable cortical cysts on the right side. No signs of urinary\nobstruction. The urinary bladder is moderately filled. No free fluid.\nAdequate dilation of small bowel loops. No evidence of significant bowel\nobstruction. No thickened bowel walls or increased post-contrast signal\nin the bowel loops. Cystic lesion in the right ovary measuring 17 x 11\nmm consistent with a corpus luteum cyst. Multiple enlarged\nretroperitoneal lymph nodes observed, for example, paracaval node with a\nshort-axis diameter of 14 mm and right iliacoexternal node with a\nshort-axis diameter of 14.5 mm No evidence of enlarged mesenteric or\ninguinal lymph nodes.\n\n\n\n\nHere is the query:\nFrom 10/09/2016 to 03/04/2017, how did Mrs. Sanders' ß-2-Microglobulin levels change?\n\nChoose the correct answer from the following options:\nA. Increased\nB. Decreased\nC. Stayed within the normal range\nD. Became elevated\nE. Stayed the same\n\n\nYour response:\n", "role": "user" }, { "content": "Stayed the same", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are writing to provide an update on the examination results of our\npatient Mrs. Hilary Sanders, born on 08/24/1976, who presented to our\noutpatient clinic on 10/09/2016.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n human immunoglobulin\n\n**Medical History:** Mrs. Sanders presented with suspected previously\nundiagnosed immunodeficiency. There were no reports of frequent\ninfections during childhood and adolescence. No increased herpes\ninfections. No history of pneumonia, meningitis, or other serious\ninfections.\n\n**Current Presentation:** Mrs. Sanders has experienced recurrent\nrespiratory infections (bronchitis, pharyngitis) for about 3 years.\n\n**Physical Examination:** She reported joint pain in the left knee and\nnumbness below the shoulder blade. A tendency to bruise easily. No\nmucosal lesions, recurrent axillary lymph node swelling. No recurrent\nfevers. No B-symptoms. No resting dyspnea, no subjective heart rhythm\ndisturbances, no syncope, no peripheral edema, or other signs of\ncardiopulmonary decompensation.\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all IgG\n subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and NK-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B-cells.\n\n- Monocytic HLA-DR expression (immune competence marker) within the\n normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n- T-cell function after 24h polyvalent ConA stimulation: TNF-alpha,\n IFN-gamma, IL-2, IL-4 unremarkable\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells.\n\nFurther cellular immune status, including the complement system and\nsoluble mediators, showed no significant abnormalities except for an\nelevated soluble IL-2 receptor. Given the unremarkable monocytic\nTNF-alpha secretion after LPS stimulation, a significant Toll-like\nReceptor 4 defect is unlikely. An antibody response to Tetanus Toxoid\nwas demonstrated in a vaccine titer test. Protective\npneumococcal-specific antibodies could not be detected. There were no\nabnormalities in autoimmune diagnostics.\n\nImmunofixation showed no evidence of monoclonal gammopathy.\nHypogammaglobulinemia due to enteral or renal protein loss is unlikely\nin the presence of normal albumin.\n\nOverall, the picture is consistent with Common Variable\nImmunodeficiency. Formally, CVID is defined by a reduction in the major\nimmunoglobulin class IgG, with accompanying reduction in IgA and/or IgM,\nin the absence of normal or impaired vaccine response. Due to very low\nimmunoglobulin levels and planned travel, determination of vaccine\nresponse was currently omitted in the absence of therapeutic\nconsequence. After stable substitution, specific vaccine antibody levels\ncan be determined before or after vaccination, with the assumption that\nstable antibody concentrations exist due to continuous immunoglobulin\nsubstitution.\n\nAccording to B-cell differentiation, it corresponds to Type Ib according\nto the Freiburg Classification and Type B+smB-CD21lo according to the\nEuro Classification. The classification is clinically relevant, as Type\nIa is associated with increased immunocytopenias (especially ITP and\nAIH) and splenomegaly. In CVID with a high proportion (\\>10%) of CD-21\nlow B-cells, increased granulomatous diseases and splenomegaly have also\nbeen observed.\n\nThe indication for immunoglobulin substitution therapy exists because of\nrecurrent infections. The form of substitution therapy (intravenous. vs.\nsubcutaneous) is primarily based on patient preferences, but also on\nmedical conditions (concomitant diseases such as thrombocytopenia,\nconvenience, insurance, etc.).\n\n**Current Recommendations:**\n\nWe propose to initiate immunoglobulin substitution therapy with Hizentra\n20% (subcutaneous) at a dose of 200 ml once a week on Tuesdays. Further\ninformation and training on subcutaneous immunoglobulin substitution\ntherapy will be provided by a home care nursing service.\n\nMrs. Sanders will remain under regular medical supervision with close\nmonitoring of clinical symptoms, laboratory parameters, and the\neffectiveness of immunoglobulin substitution therapy. Any unexpected\nside effects or changes in her condition should be reported immediately.\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n --------------------------------------- --------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Calcium 2.41 mg/dL 2.15-2.50 mg/dL\n Inorganic Phosphate 1.00 mg/dL 0.87-1.45 mg/dL\n Selenium 0.79 µmol/L 0.60-1.50 µmol/L\n Zinc 10.1 µmol/L 9.0-22.0 µmol/L\n Creatinine 0.75 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 mL/min \\>90 mL/min\n Total Bilirubin 0.37 mg/dL \\< 1.20 mg/dL\n Albumin 4.55 g/dL 3.50-5.20 g/dL\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n A2-Globulin in Serum 10.7% 7.1-11.8%\n ß-Globulin in Serum 9.2% 8.4-13.1%\n Gamma-Globulin in Serum 3.2% 11.1-18.8%\n Immunoglobulin G 514 mg/dL 700-1600 mg/dL\n Immunoglobulin A 14 mg/dL 70-400 mg/dL\n Immunoglobulin M 19 mg/dL 40-230 mg/dL\n Immunoglobulin E 90 kU/L 0.0-100.0 kU/L\n IgG 1 299.5 mg/dL 280-800 mg/dL\n IgG 2 162.7 mg/dL 115-570 mg/dL\n IgG 3 49.1 mg/dL 24-125 mg/dL\n IgG 4 4.0 mg/dL 5.2-125 mg/dL\n Serum Immunofixation \n CRP 4.8 mg/L \\< 5.0 mg/L\n C3 Complement 980 mg/L 900-1800 mg/L\n C4 Complement 120 mg/L 100-400 mg/L\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n HBs Antigen Negative \n HBc Antibody Negative \n HBs Antibody Negative \n Ferritin 56 µg/L 13-140 µg/L\n ALT (GPT) 33 U/L \\< 31 U/L\n AST (GOT) 29 U/L \\< 35 U/L\n Alkaline Phosphatase 84 U/L 35-105 U/L\n Creatine Kinase 90 U/L \\< 167 U/L\n CK-MB 8.3 U/L \\< 24.0 U/L\n Gamma-GT 40 U/L 5-36 U/L\n LDH 204 U/L 135-214 U/L\n Lipase 50 U/L 13-60 U/L\n Cortisol 306.6 nmol/L 64.0-327.0 nmol/L\n 25-OH-Vitamin D3 65.3 nmol/L 50.0-150.0 nmol/L\n 1.25-OH-Vitamin D3 134 pmol/L 18.0-155.0 pmol/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Vitamin B12 770 pg/mL 191-663 pg/mL\n Folic Acid 14.6 ng/mL 4.6-18.7 ng/mL\n Hemoglobin 13.9 g/dL 12.0-15.6 g/dL\n Hematocrit 41.0% 35.5-45.5%\n Erythrocytes 5.2 M/uL 3.9-5.2 M/uL\n Leukocytes 4.13 K/uL 3.90-10.50 K/uL\n Platelets 174 K/uL 150-370 K/uL\n MCV 80.0 fL 80.0-99.0 fL\n MCH 26.7 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n RDW-CV 13.7% 11.5-15.0%\n Absolute Neutrophils 2.87 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.010 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.71 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.42 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.03 K/uL 0.00-0.20 K/uL\n HbA1c 4.9% \\< 6.0%\n HbA1c (IFCC) 30.1 mmol/mol \\< 42.0\n HBV Serology Result Negative \n HIV1/2 Antibodies, P24 Antigen Negative \n Hepatitis C Virus Antibodies in Serum Negative \n\n**Dear colleague,**\n\nWe report the examination results of Mrs. Hilary Sanders, born on\n08/24/1976 who presented at our outpatient clinic on 03/04/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all\n IgG-Subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and natural killer-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B cells.\n\n- Monocytic HLA-DR expression within the normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells. The further cellular immune\nstatus, including the complement system and soluble mediators, showed no\nsignificant abnormalities except for an elevated soluble IL-2 receptor.\n\n**Current Presentation:** Mrs. Sanders was again provided with detailed\ninformation about her condition and the planned course of action. We\nscheduled an appointment to initiate regular subcutaneous immunoglobulin\ntherapy.\n\n**Medical History:** Mrs. Sanders received her first dose of Hizentra\n20% subcutaneously as immunoglobulin substitution therapy for CVID. The\nadministration was well-tolerated initially, with no evidence of\nsignificant local or systemic side effects. Mrs. Sanders was once again\ninformed about possible risks (especially hypersensitivity reactions)\nand advised to contact us immediately in case of questions,\nuncertainties, or any abnormalities. The dosing for the first four weeks\nwas 3x20mL Hizentra 20% subcutaneously, and from the fifth week onward,\nit was changed to either 1x40mL or 2x20mL Hizentra 20% subcutaneously\nper week.\n\nIn the past days, Mrs. Sanders has been experiencing a cold: runny nose,\ncough (green-yellow), difficulty clearing mucus, slight fever, sinus\ninflammation, sore throat, difficulty speaking, and swallowing problems.\nThere was no improvement.\n\n**Physical Examination:** Reddened throat, no exudates, non-swollen\ncervical lymph nodes, lung examination showed bronchitis-like breathing\nsounds, no rales.\n\n**Therapy and Progression**: Today\\'s CRP is not elevated. IgGs are\nstill below normal. We recommended increasing immunoglobulin\nsubstitution during the infection. The patient had difficulty finding a\nsuitable injection site on her abdomen. However, she reported that the\nsecretions were gradually becoming lighter, so she decided to wait with\nthe antibiotic and only use it if there was no improvement.\n\nThe patient has been receiving 3x20mL Hizentra 20% per week since her\nlast visit. She complained of developing skin hardening at the injection\nsites, so a slower infusion time was discussed. She has been\nexperiencing a strong cough for several weeks without fever. No rales or\nsigns of pleuritis were detected on auscultation. No abnormalities were\nobserved on the chest X-ray. Laboratory results now show normal IgG\nlevels, so the dose was reduced to 2x20mL per week. A CT scan of the\nthorax and abdominal ultrasound were requested.\n\n**Chest X-ray in two planes from 03/04/2017:**\n\n[Findings/Assessment:]{.underline} No previous images are available for\ncomparison. Upper mediastinum and heart appear normal, with no central\ncongestion. No pneumothorax, effusions, confluent infiltrates, or\nsignificant focal lesions.\n\n**Abdominal ultrasound on 03/04/2017:**\n\nHepatosplenomegaly and retroperitoneal lymphadenopathy up to 26mm.\n\n**CT Chest/Abdomen/ from 03/04/2017:**\n\n[Methodology]{.underline}: Digital overview radiographs. After\nintravenous injection of contrast agent a 16-row CT scan of the thorax\nand entire abdomen was performed in the venous contrast phase, with\nprimary data set reconstruction at a thickness of 1.25 mm. Multiplanar\nreconstructions were created.\n\n[Findings]{.underline}: A conventional radiographic pre-image from\n11/18/2014 is available for comparison.\n\n[Thorax]{.underline}: Normal lung parenchyma with normal vascular\nmarkings. Small, sometimes hazy, sometimes nodular densities measuring\nup to 4mm in both lower lobes and the left upper lobe. Small\npleura-adjacent density in the right lower lobe. No evidence of\nconfluent infiltrates. No pleural effusion or pneumothorax. Normal heart\nsize and configuration. Normal diameter of the thoracic aorta and\npulmonary trunk. Increased number and enlarged retroclavicular lymph\nnodes on the right and left, axillary on both sides measuring up to 30mm\nin diameter. Trachea and esophagus displayed normally. No hiatus hernia.\nThyroid and neck soft tissues were unremarkable, as far as depicted.\nNormal thoracic soft tissue mantle. No soft tissue emphysema.\n\n[Abdomen]{.underline}: Hepatomegaly with morphologically normal liver\nparenchyma. No portal vein thrombosis. Gallbladder is unremarkable with\nno calculi. Intrahepatic and extrahepatic bile ducts are not dilated.\nPancreas is normally lobulated and structured, with no dilation of the\npancreatic duct. Splenomegaly. Accessory spleen measuring approximately\n20 mm in diameter. Splenic parenchyma is homogeneously contrasted in the\nvenous phase. Kidneys are orthotopically positioned, normal size with no\nside differences, and contrasted equally on both sides. Two regularly\nconfigured hypodense lesions in the left kidney, suggestive of\nuncomplicated renal cysts. No dilation of the urinary tract, and no\nevidence of stones. Adrenal glands are not visualized. Increased and\nenlarged mesenteric, pararaortic, parailiacal, and inguinal lymph nodes\nup to 30 mm in size. Gastrointestinal tract is displayed normally, as\nfar as assessable. Normal representation of major abdominal vessels. No\nfree intraperitoneal fluid or air.\n\n[Osseous structures:]{.underline} No evidence of suspicious osseous\ndestruction. Normal soft tissue mantle.\n\n[Assessment:]{.underline} Intrapulmonary multifocal, sometimes hazy,\nsometimes nodular densities, differential diagnosis includes atypical\npneumonia. Thoracoabdominal lymphadenopathy. Hepatosplenomegaly without\nsuspicious lesions.\n\n**Current Recommendations:**\n\n- Outpatient follow-up for discussion of findings\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% 2x20mL/week\n\n- Lung function test\n\n- Gastroscopy\n\n- In case of acute infection: increase immunoglobulin administration\n\n- Abdominal ultrasound: annually\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually Seasonal influenza vaccination: annually\n\n**Lab results upon discharge:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n Gamma-Globulin 3.2% 11.1-18.8%\n Immunoglobulin G 188 mg/dL 700-1600 mg/dL\n Immunoglobulin A 11 mg/dL 70-400 mg/dL\n Immunoglobulin M 12 mg/dL 40-230 mg/dL\n IgG Subclass 1 113 mg/dL 280-800 mg/dL\n IgG Subclass 2 49.1 mg/dL 115-570 mg/dL\n IgG Subclass 4 \\<0.0 mg/dL 5.2-125 mg/dL\n aPCP-IgG 7.32 mg/dL 10.00-191.20 mg/dL\n aPCP-IgG2 2.74 mg/dL 4.70-89.40 mg/dL\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n LDH 224 U/L 135-214 U/L\n Vitamin B12 708 pg/mL 191-663 pg/mL\n Erythrocytes 5.3 M/uL 3.9-5.2 M/uL\n Platelets 129 K/uL 150-370 K/uL\n MCV 78.0 fL 80.0-99.0 fL\n MCH 25.1 pg 27.0-33.5 pg\n Absolute Lymphocytes 0.91 K/uL 1.10-4.50 K/uL\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mrs. Hilary Sanders, born on 08/24/1976, who\npresented to our Immunodeficiency Clinic on 10/06/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Hepatosplenomegaly\n\n- Thoracoabdominal, inguinal, and axillary lymphadenopathy\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** Mrs. Sanders first presented herself to our clinic,\nwith suspected undiagnosed immunodeficiency. Regular subcutaneous\nimmunoglobulin therapy with Hizentra 20% (2x20mL/week) has been\nwell-tolerated. Initially, there were frequent upper respiratory tract\ninfections with sore throat and cough. In the absence of fever, a\none-time course of Cotrim was prescribed for 7 days due to sinusitis. We\ndiscussed Mrs. Sanders' medical history in detail, including the recent\nCT findings. She has been informed about the necessity of vigilance in\ncase of unclear and especially persistent lymph node swellings.\nRegarding the inguinal and axillary lymph nodes measuring up to 30mm in\ndiameter found on CT, we recommend an observational approach with\nregular sonographic monitoring. There have been no significant changes\nin laboratory parameters, with good IgG levels during ongoing\nsubstitution therapy and known moderate leukopenia and lymphopenia.\nDuring the next appointment, an additional lung function test, including\ndiffusion measurement, will be conducted\n\n**Current Recommendations:**\n\n- Outpatient follow-up, including lung function test\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% (2x20mL/week).\n\n- Current gastroscopy.\n\n<!-- -->\n\n- In case of acute infection: increase immunoglobulin administration.\n\n- Administer targeted, sufficiently long, and high-dose antibiotic\n therapy if bacterial infections require treatment.\n\n- Ideally, obtain material for microbiological diagnostics.\n\n- In case of increasing diarrhea, consider outpatient stool\n examinations, including Giardia lamblia and Cryptosporidium.\n\n- Abdominal ultrasound: annually.\n\n- Lung function test, including diffusion measurement: annually.\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually.\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings or H. pylori testing\n\n- Chest X-ray or CT thorax: if clinical symptoms or lung function\n abnormalities are observed.\n\n- Seasonal influenza vaccination: annually.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.1 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffé) 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n Immunoglobulin G 1025 mg/dL 700-1600 mg/dL\n Immunoglobulin A 16 mg/dL 70-400 mg/dL\n Immunoglobulin M 28 mg/dL 40-230 mg/dL\n Free Lambda Light Chains 5.86 5.70-26.30\n Free Kappa Light Chains 6.05 3.30-19.40\n Kappa/Lambda Ratio 1.03 0.26-1.65\n IgG Subclass 1 580.9 mg/dL 280-800 mg/dL\n IgG Subclass 2 340.7 mg/dL 115-570 mg/dL\n IgG Subclass 3 50.9 mg/dL 24-125 mg/dL\n IgG Subclass 4 5.7 mg/dL 5.2-125 mg/dL\n CRP 7.3 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 13.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 5.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n**Abdominal Ultrasound on 10/06/2017:**\n\n[Liver]{.underline}: Measures 19 cm in the MCL, homogeneous parenchyma,\nno focal lesions.\n\n[Gallbladder/Biliary Tract:]{.underline} No evidence of calculi, no\nsigns of inflammation, no congestion.\n\n[Spleen]{.underline}: Measures 14 cm in diameter, homogeneous. Accessory\nspleen measures 16 mm at the hilus.\n\n[Pancreas]{.underline}: Morphologically unremarkable, as far as visible\ndue to intestinal gas overlay, no evidence of space-occupying processes.\n\nRetroperitoneum: No signs of aneurysms. Enlarged retroperitoneal and\niliac lymph nodes, measuring up to approximately 2.5 cm in diameter.\n\n[Kidneys]{.underline}: Both kidneys are of normal size (right 4.3 x 11.8\ncm, left 4.6 cm x 11.9 cm). No congestion, no evidence of calculi\n(stones), no evidence of space-occupying processes.\n\n[Bladder]{.underline}: Smoothly defined and normally configured.\nMinimally filled.\n\n[Uterus]{.underline}: Size within the normal range, homogeneous.\n\nNo ascites.\n\n[Assessment:]{.underline} Evidence of enlarged lymph nodes up to 2.5 cm\nretroperitoneal and iliac. Compared to previous findings, a slight\ndecrease in splenomegaly.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination results of our patient, Mrs. Hilary\nSanders, born on 08/24/1976, who presented herself in our\nImmunodeficiency Clinic on 02/10/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Ongoing diarrhea in the morning, often\nrecurring in the afternoon. No melena, no fresh blood. Resolving\nrespiratory infection, positive influenza.\n\nCurrently, IgG levels remain within the target range. An increased need\nfor immunoglobulins is expected, especially in the third trimester of\npregnancy. Therefore, we recommend close monitoring with us during\npregnancy. Ferritin levels have further declined, indicating the need\nfor iron substitution. Anamnestically, there is an intolerance to oral\niron preparations.\n\n**Recommendations:**\n\n- Outpatient follow-up\n\n- Early follow-up in case of infections or persistent diarrhea\n\n- Continue regular subcutaneous immunoglobulin therapy, currently with\n Hizentra 20% 2x20mL/week\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n04/12/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infection with symptoms for 3-4\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance.\n\nIgG levels remain within the target range; therefore, we recommend\ncontinuing the current treatment unchanged.\n\nSince the last visit, mild upper respiratory tract infections. No fever\n(except for one episode of sinusitis), no antibiotics. SCIG treatment\nunchanged with 3x20mL/week of Hizentra ®.\n\nMrs. Sanders continues to experience watery diarrhea about 5-7 times\ndaily. No blood in stools, no pain, no vomiting, no nausea. There has\nbeen no clear association with specific foods observed. Current weight:\n69kg.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori testing: e.g., breath test or Helicobacter\n pylori antigen in stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and Helicobacter pylori testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n02/18/2019.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infections with symptoms for 7\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance. Continued diarrhea, approximately 6 times a\nday, without weight loss. IgG levels remain within the target range;\ntherefore, we recommend continuing the current treatment unchanged.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue treatment as is\n\n- External upper gastrointestinal endoscopy (and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are writing to provide summary on the clinical course of Mrs. Hilary\nSanders, born on 08/24/1976, who presented at our outpatient\nImmunodeficiency Clinic.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n- Iron-deficiency anemia\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Overall stable condition. No longer\nexperiencing cough. Persistent fatigue. Upcoming appointment with the\nGastroenterology department next week. There is again an indication for\niron substitution.\n\n**Update on 11/15/2019: Laboratory results from 11/15/2019:**\nTransaminase elevation, Protein 18, markedly elevated BNP. However, IgA\nis at 0.5 (otherwise not detectable), IgG subclasses within normal\nrange. Findings do not align. Patient informed by phone, returning for\nfurther evaluation today; also screening for Hepatitis A, B, C, and E,\nEBV, CMV, TSH, coagulation. No shortness of breath, no edema, no\nabdominal enlargement, stable weight at 69 kg. In case of worsening\nsymptoms, shortness of breath, or fever, immediate referral to the\nemergency department recommended.\n\n**02/12/2020:** The patient is doing reasonably well. She has had a mild\ncold for about 2 weeks, no fever, but nasal congestion and\nyellowish-green sputum. No other infections. No antibiotics prescribed.\nShe has adapted to her gastrointestinal issues. An appointment with the\nGastroenterology department. She is currently working from home.\nMedication: no new medications, only Cuvitru 20mL 3x weekly. Weight\nremains stable at 67 kg. The last lung function test was in the summer\nof this year and was within normal limits. Imaging has not been\nperformed recently. Gastroscopy and colonoscopy have not been conducted\nfor some time.\n\n**04/14/2020:** Referral to Gastroenterology at is recommended for\npersistent abdominal symptoms.\n\n**10/24/2020:** The patient has mostly avoided social contacts due to\nthe pandemic. She continues to experience digestive problems (food\nintolerances, diarrhea, flatulence). She has less stamina. Few\ninfections in the past year, at most a minor cold. No significant\ninfections. Hizentra injections remain unchanged at 20 mL 3 times a\nweek.\n\n**03/22/2021:** Constant colds since December 2020. One-time antibiotic\ntreatment in October 2019. Subcutaneous Immunoglobulin therapy remains\nunchanged at 20 mL 3 times weekly.\n\n**09/19/2021:** She feels disoriented and very tired, more so than\nusual. Difficulty maintaining a steady gaze. No steroid therapy was\nadministered. CT showed enlarged lymph nodes. Diarrhea, especially in\nthe morning, 3-4 times a day, additional bowel movements with meals,\nsometimes watery. No fever, no infections. Hizentra injections continued\nunchanged.\n\n**Summary**: IgG levels are currently within the target range, so we\nrecommend continuing immunoglobulin substitution therapy without\nchanges. The antibody response (SARS-CoV-2 (S-Ag) IgG ELISA) to the\nCovid-19 vaccination is, as expected, negative. However, there is a\npositive detection of SARS-CoV-2 (N-Ag) IgG ELISA, as expected in the\ncase of viral contact (not vaccination). We consider this to be an\nunspecific reaction and recommend further monitoring at the next\nfollow-up appointment. With a platelet count currently at 55 K/uL, we\nrecommend a short-term blood count check with us or your primary care\nphysician.\n\nDue to the immunodeficiency, a lack of antibody response to vaccination\nwas expected. In the medium term, passive protection through\nimmunoglobulin substitution therapy will play a role. This is contingent\non a significant portion of plasma donors having antibodies against\nSARS-CoV2. There is a multi-month delay from the time of donation to the\nrelease of the preparations, so we anticipate that meaningful protection\nthrough immunoglobulin products will not be expected. An exact prognosis\nin this regard is not possible.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Consultation with Gastroenterology\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update regarding our patient Mrs. Hilary\nSanders, born on 08/24/1976. She was under our inpatient care from\n03/29/2023 to 04/05/2023.\n\n**Diagnoses:**\n\n- Suspected CVID-Associated enteropathy\n\n- Known hepatosplenomegaly with a borderline enlarged portal vein, no\n significant portocaval shunts. Multiple liver lesions, possibly\n hemangiomas further evaluation if not already done.\n\n- Known retroperitoneal and iliac lymphadenopathy, likely related to\n the underlying condition.\n\n- Known changes in the lower lung bases, likely associated with the\n underlying condition, e.g., ILD. Refer to previous examinations.\n\n- Capsule endoscopy: Incomplete capsule enteroscopy with no evidence\n of inflammatory changes. Some hyperemia and blurry vascular pattern\n observed in the visible colon.\n\n- CVID-Associated Hepatopathy in the Form of Nodular Regenerative\n Hyperplasia\n\n**Other Diagnoses:** Common Variable Immunodeficiency Syndrome (CVID)\nwith:\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n Hizentra 20%\n\n- Infectious manifestations: Frequent respiratory tract infections\n\n- Non-Infectious manifestations:\n\n - ITP (Immune Thrombocytopenia)\n\n - Hepatosplenomegaly\n\n - Lymphadenopathy in supraclavicular, infraclavicular,\n thoracoabdominal, inguinal, and axillary regions\n\n - Suspected Granulomatous-Lymphocytic Interstitial Lung Disease in\n CVID\n\n<!-- -->\n\n- Iron-deficiency anemia\n\n**Pysical Examination:** Patient in normal general condition and\nnutritional status (175 cm, 65.8 kg. No resting dyspnea.\n\n[Neuro (grossly orienting):]{.underline} awake, oriented to\ntime/place/person/situation, No evidence of focal neurological deficit.\nNo meningism.\n\n[Head/neck]{.underline}: pharynx non-irritable. Moist, rosy mucous\nmembranes. Tongue occupied.\n\n[Skin]{.underline}: intact, turgor normal, no icterus, no cyanosis.\n\n[Thorax]{.underline}: normal configuration, no spinal palpitation, renal\nbed clear.\n\n[Lung]{.underline}: vesicular breath sound bds, no accessory sounds,\nsonorous tapping sound bds.\n\n[Cor]{.underline}: Cardiac action pure, rhythmic, no vitia typical\nmurmurs.\n\n[Abdomen]{.underline}: regular bowel sounds, soft abdominal wall, no\ntenderness, no resistances, no hepatosplenomegaly.\n\n[Extremities]{.underline}: no edema. Feet warm. Dorsalis pedis +/+ and\nposterior tibial artery +/+.\n\n**Current Presentation:** The patient was admitted for further\nevaluation of suspected CVID-associated enteropathy, as she had been\nexperiencing chronic diarrhea for the past three years. On admission,\nthe patient reported an overall good general and nutritional condition.\nShe described her current subjective well-being as good but mentioned\nhaving chronic diarrhea for the past three years, with up to 7 bowel\nmovements per day. The stools were watery without any signs of blood.\nThere were no indications of infection, such as fever, chills, dysuria,\nhematuria, cough, sputum, or dyspnea. She also experienced intermittent\nleft-sided upper abdominal pain, primarily postprandially. She had a\ngood appetite.\n\nOn the day of admission, an esophagogastroduodenoscopy was performed,\nwhich revealed erythematous antral gastritis. Additionally, there was an\napproximately 1 cm irregular mucosal area at the corpus-antrum junction\non the greater curvature side. A magnetic resonance imaging scan showed\nno evidence of inflamed bowel loops, ruling out chronic inflammatory\nbowel disease or celiac disease. To further investigate, a capsule\nendoscopy was performed, with results pending at the time of discharge.\nHypovitaminosis B12 and folate deficiency were ruled out. However,\niron-deficiency anemia was confirmed, and the patient had already\nscheduled an outpatient appointment for iron substitution. Serum levels\nof vitamin B6 and zinc were pending at discharge.\n\nDue to a moderate increase in transaminases and evidence of\nhepatosplenomegaly, we decided, after detailed explanation and with the\npatient\\'s consent, to perform a sonographically guided liver biopsy in\naddition to the planned endoscopy. The differential diagnosis included\nCVID-associated hepatopathy. The biopsy was successfully conducted ,\nwithout any post-interventional bleeding. Histology revealed mild acute\nhepatitis and nodular regenerative hyperplasia.This finding could be\nconsistent with changes in CVID-associated hepatopathy. Granulomas were\nnot observed. With only slightly elevated liver values, a trial therapy\nwith budesonide was initiated, and clinical (diarrhea?) and laboratory\n(transaminases?) follow-up will be performed in the outpatient setting.\n\nWe discharged Mrs. Sanders in a cardiopulmonarily stable condition.\n\n[Current Recommendations:]{.underline}\n\n- Follow-up in the gastroenterological outpatient clinic\n\n**Esophagogastroduodenoscopy (EGD) on 04/01/2023:** Introduction of the\ngastroscope in a left lateral position. Visualized up to the descending\npart of the duodenum. Unremarkable upper esophageal sphincter. Normal\nmotility and mucosa in the upper, middle, and distal esophagus. The\nZ-line is sharply demarcated in the hiatus. The cardia closes\nsufficiently. The stomach expands normally in all parts under air\ninsufflation. Multiple glandular cysts \\< 8 mm in size in the fundus and\ncorpus. Approximately 1 cm irregular mucosal area at the corpus-antrum\njunction on the greater curvature side. Streaky redness of the mucosa in\nthe antrum. Unremarkable mucosa in the bulb. Unremarkable mucosa in the\ndescending part of the duodenum. Step biopsies performed.\n\n[Summary]{.underline}: Erythematous antral gastritis. Approximately 1 cm\nirregular mucosal area at the corpus-antrum junction on the greater\ncurvature side, suggestive of inflammation. Multiple glandular cysts\nobserved in the fundus and corpus.\n\n[Abdominal MRI on 04/02/2023:]{.underline}\n\n[Clinical information, questions, and justification for the\nexam]{.underline}: Chronic diarrhea, suspected CVID-associated\nenteropathy, differential diagnosis of celiac disease, and inflammatory\nbowel disease (IBD). Assessment of malignancy.\n\nTechnique: After oral administration of mannitol solution and injection\nof 40 mg Buscopan, a 3-Tesla abdominal MRI was performed.\n\n[Findings]{.underline}: Multiple nodular consolidations and opacities\ndetected in the lower basal lung segments, measuring 7 x 4 mm, for\nexample, in the right lateral lower lobe (Series 18, Image 3).\nAdditionally, streaky-reticular changes observed. Left diaphragmatic\nelevation. Liver globally enlarged and smooth-bordered with several\nlesions showing mild to moderately hyperintense signals in T2-weighted\nimages and hypointense signals in T1-weighted images. These lesions\ndemonstrated increased enhancement in the early contrast phases,\nespecially those at the periphery, and more diffuse enhancement in the\nlate phases. For example, a lesion measuring 12 x 11 mm in Segment 2, a\nlesion measuring 8 mm in Segment 8 and a lesion measuring 21 x 13 mm in\nSegment 7. The portal vein measures borderline wide, up to 15 mm in\ndiameter. Gallbladder is unremarkable without evidence of stones. Intra-\nand extrahepatic bile ducts are not dilated. Spleen significantly\nenlarged, measuring 14 cm in pole-to-pole distance and 7.2 cm in\ntransverse diameter, homogeneous enhancement in native phases and late\ncontrast phase. Large accessory spleen located hilarly. Bilateral\nadrenal glands appear slender. Pancreas displays typical appearance with\nno ductal dilatation. Both kidneys are in orthotopic position, with\nunremarkable cortical cysts on the right side. No signs of urinary\nobstruction. The urinary bladder is moderately filled. No free fluid.\nAdequate dilation of small bowel loops. No evidence of significant bowel\nobstruction. No thickened bowel walls or increased post-contrast signal\nin the bowel loops. Cystic lesion in the right ovary measuring 17 x 11\nmm consistent with a corpus luteum cyst. Multiple enlarged\nretroperitoneal lymph nodes observed, for example, paracaval node with a\nshort-axis diameter of 14 mm and right iliacoexternal node with a\nshort-axis diameter of 14.5 mm No evidence of enlarged mesenteric or\ninguinal lymph nodes.\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Anna Sample, born on\n01.01.1970. She was admitted to our clinic from 01/01/2017 to\n01/02/2017.\n\n**Diagnosis:** Diffuse large B-cell lymphoma of germinal center type; ID\n01/2017\n\n- Ann-Arbor: Stage IV\n\n- R-IPI: 2 (LDH, stage)\n\n- CNS-IPI: 2\n\n- Histology: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\n translocation. Ki-67 at 40%. Positive reaction to MUM1, numerous\n CD68-positive macrophages. Negative reaction to ALK1 and TdT.\n\n- cMRI: Chronic inflammatory lesions suggestive of Multiple Sclerosis (MS)\n\n- CSF: no evidence of malignancy\n\n- Bone marrow aspiration: no infiltration from the pre-existing\n lymphoma.\n\n**Current treatment: **\n\nInitiated R-Pola-CHP regimen q21\n\n- Polatuzumab vedotin: 1.8mg/kg on Day 1.\n\n- Rituximab: 375mg/m² on Day 0.\n\n- Cyclophosphamide: 750mg/m² on Day 1.\n\n- Doxorubicin: 50mg/m on Day 1.\n\n- Prednisone: 100mg orally from Day 1-5.\n\n**Previous therapy and course**\n\nFrom 12/01/2016: Discomfort in the dorsal calf and thoracic spine,\nweakness in the arms with limited ability to lift and grasp, occasional\ndizziness.\n\n12/19/2016 cMRI: chronic inflammatory marks indicative of MS. \n\n12/20/2016 MRI: thoracic/lumbar spinal cord: Indication of a\nmetastatic mass starting from the left pedicle T1 with a significant\nextraosseous tumor element and full spinal narrowing at the level of\nT10-L1 with pressure on the myelon and growth into the neuroforamen\nT11/T12 on the right and T12/L1 left. More lesions suggestive for\nmetastasis are L2, L3, and L4, once more with extraosseous tumor element\nand invasion of the left pedicle.\n\n12/21/2016 Fixed dorsal support T8-9 to L3-4. Decompression via\nlaminectomy T10 and partial laminectomy lumbar vertebra 3.\n\n12/24/2016 CT chest/abdomen/pelvis: Magnified left axillary lymph node.\nIn the ventral left upper lobe, indication of a round, loose, cloudy\ndeposit, i.e., of inflammatory origin, follow-up in 5-7 weeks.\nNodule-like deposit in the upper inner quadrant of the right breast,\nsenological examination suggested.\n\n**Pathology**: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\ntranslocation. Ki-67 staining was at 40%. Positive reaction to MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\n**Other diagnoses**\n\n- Primary progressive type of multiple sclerosis (ID 03/02) \n\n- Mood disorder.\n\n- 2-vessel CHD\n\n**Medical History**\n\nMrs. Sample was transferred inpatient from DC for the initiation of\nchemotherapy (R-Pola-CHP) for her DLBCL. In the context of her\npre-existing ALS, she presented on 12/19/2016 with acute pains and\nrestricted mobility in her upper limbs. After her admission to HK\nFlowermoon, an MRI was performed which revealed a thoracic neoplastic\ngrowth especially at the level of T10-L1, but also affecting lumbar\nvertebra 3, L4 and L6. Surgical intervention on 12/21/2016 at DC\nresulted in symptom relief. Presently, her complaints are restricted to\npost-operative spine discomfort, shoulder hypoesthesia, and intermittent\nhand numbness. She reported a weight loss of 5 kg during her\nhospitalization. She denied having respiratory symptoms, infections,\nsystemic symptoms, or gastrointestinal complaints. Mrs. Sample currently\nhas a urinary catheter in place.\n\n**Physical examination on admission**\n\nGeneral: The patient has a satisfactory nutritional status, normal\nweight, and is dependent on a walker. Her functional status is evaluated\nas ECOG 2. Cardiovascular: Regular heart rhythm at a normal rate. Heart\nsounds are clear with no detected murmurs. Respiratory: Normal alveolar\nbreath sounds. No wheezing, stridor, or other abnormal sounds.\nAbdominal: The abdomen is soft, non-tender, and non-distended with\nnormal bowel sounds in all quadrants. There is no palpable enlargement\nof the liver or spleen, and the kidneys are not palpable.\nMusculoskeletal: Tenderness noted in the cervical and thoracic spine\narea, but no other remarkable findings. This is consistent with her\npost-operative status. Lymphatic: No enlargement detected in the\ntemporal, occipital, cubital, or popliteal lymph nodes. Oral: The oral\nmucosa is moist and well-perfused. The oropharynx is unremarkable, and\nthe tongue appears normal. Peripheral Vascular: Pulses in the hands are\nstrong and regular. No edema observed. Neurological: Cranial nerves are\nintact. There is numbness in both hands and mild hypoesthesia in the\nshoulders. Motor strength is 3/5 in the right arm, attributed to her\nknown ALS diagnosis. No other motor or sensory deficits noted.\nOccasional bladder incontinence and intermittent gastrointestinal\ndisturbances are reported.\n\n**Medications on admission**\n\nAcetylsalicylic acid (Aspirin®) 100 mg: Take 1 tablet in the morning.\nAtorvastatin (Lipitor®) 40 mg: Take 1 tablet in the evening. Fingolimod\n(Gilenya®) 0.5 mg: Take 1 capsule in the evening. Sertraline (Zoloft®)\n50 mg: Take 2 tablets in the morning. Hydromorphone (Dilaudid® or\nExalgo® for extended-release) 2 mg: Take 1 capsule in the morning and 1\nin the evening. Lorazepam (Ativan®) 1 mg: 1 tablet as needed.\n\n**Radiology/Nuclear Medicine**\n\n**MR Head 3D unenhanced + contrast from 12/19/2016 10:30 AM**\n\n**Technique:** Sequences obtained include 3D FLAIR, 3D DIR, 3D T2, SWI,\nDTI/DWI, plain MPRAGE, and post-contrast MPRAGE. All images are of good\nquality. Imaging area: Brain.\n\nThere are 20 FLAIR hyperintense lesions in the brain parenchyma,\nspecifically located periventricularly and in the cortical/juxtacortical\nregions (right and left frontal, left temporal, and right and left\ninsular). No contrast-enhancing lesions are identified. There are also\nsubcortical/nonspecific lesions present, with some lesions appearing\nconfluent. The spinal cord is visualized up to the C4 level. No spinal\nlesions are noted.\n\n[Incidental findings:]{.underline}\n\n- Brain volume assessment: no indication of reduced brain volume.\n\n- CSF space: age-appropriate usual wide, moderate, and symmetric CSF\n spacing with no signs of CSF flow abnormalities.\n\n- Cortical-Subcortical Differentiation: Clear cortical-subcortical\n distinction.\n\n- RML-characteristic alterations: none detected.\n\n- Eye socket: appears normal.\n\n- Nasal cavities: Symmetric mucosal thickening with a focus on the\n right ethmoidal sinus.\n\n- Pituitary and peri-auricular region: no abnormalities.\n\n- Subcutaneous lesion measuring 14.4 x 21.3 mm, right parietal likely\n representing an inflamed cyst or abscess, differential includes soft\n tissue growth.\n\n[Evaluation]{.underline}\n\nDissemination: MRI standards for spatial distribution are satisfied. MRI\ncriteria for temporal distribution are unfulfilled. Comprehensive\nneurological review: The findings are consistent with a chronic\ninflammatory CNS disease in the sense of Multiple Sclerosis.\n\n**MR Spine plain + post-contrast from 12/20/2016 10:00 AM**\n\n**Technique:** GE 3T MRI Scanner\n\nMRI was conducted under anesthesia due to claustrophobia.\n\n**Sequences**: Holospinal T2 Dixon sagittal, T1 pre-contrast, T1 fs\npost-contrast. The spine is visualized from the craniocervical junction\nto S2.\n\n**Thoracic spine: **\n\nOn T2-STIR and T2, there is a hyperintense signal of vertebral bodies T5\nand T6 with inconsistent delineation of the vertebral endplates,\nindicative of age-related changes. There is a reduction in the height of\nthe disc spaces T4/5 and T5/6 with subligamentous disc protrusion\nleading to a spongy appearance of the spinal cord at this location.\nMyelon atrophy is noted at T5/6, along with a T2 bright lesion\nsuggestive of MS at the level of T3 and also T4/5. Spine: A large\nintraspinal mass extends from T10-L1, causing an anterior spongy\nappearance of the spinal cord and resulting in complete spinal canal\nstenosis at this level. On fat-only imaging, there is almost total\nreplacement of the marrow space of vertebral body T11 with external\ntumor extension and infiltration into the lateral structures (more on\nthe left than the right) and neural foramen T11 on both sides. There is\nmild disc herniation at T8/9 with slight sponginess of the spinal cord.\nMS-characteristic spinal cord lesions are noted at segments T5 and T8/9.\n\n**Lumbar spine: **\n\nT2-DIXON shows bright signal intensity of the anterior part of lumbar\nvertebra 1, a patchy appearance of lumbar vertebra 2, and lumbar\nvertebra 4. Almost the entire marrow space is replaced in the fat-only\nimaging. There is an external tumor mass posterior to lumbar vertebra 4\nwithout significant spinal canal stenosis, which involves the left\nlateral structure and a pronounced appearance of the cauda equina at\nlumbar vertebra 1. A call to communicate the results was made at 11:15\na.m. to the on-duty orthopedic surgeon and to colleagues in neurology.\nEvaluation Evidence of a metastatic lesion originating from the left\npedicle of T10 with a significant extramedullary tumor mass and full\nspinal canal narrowing at the level of T10 with compression of the\nspinal cord and extension into the neural foramen T11-T12 on the right,\nand T12-L1 on the left. Additional sites suggestive of metastasis\ninclude L2, L3, and L4, again with extramedullary tumor components and\ninvasion of the left lateral structure. Contrast enhancement of the\ndistal cord is noted. There are MS-characteristic spinal cord lesions at\nthe levels of T3, T4-5, T5, and T8-9. The conus medullaris is not\nvisualized due to spinal cord displacement.\n\n\n**CT Thoracic Spine from 01/03/2017**\n\n[Clinical Findings]{.underline}\n\nLateral and medial alignment is stable. No sign of vertebral column\ndamage. Multiple segment degenerative alterations in the spine. No\nindications of mineralization in the recognized space at the level of\nT10/L2. Invasion of T10 and L4 with composite osteolytic-osteoblastic\ndefects starting from the left pedicle into the vertebral column. More\ncortical inconsistency with enhanced sclerosis at the endplate of L2.\nReview with prior MRI indicative of a different composite defect. Defect\npit at the endplate of lumbar vertebra 2.\n\nMinor pericardial effusion with nearby superior ventilation. Intubation\ntube placed. Mild cardiomediastinum. Splenomegaly. Standard display of\nthe tissue organs of the mid-abdomen, as naturally observed. Normal\nspleen. Thin adrenals. Tightly raised kidney bowls and leading ureter\nfrom both aspects, e.g., upon entry during the exhalation period after\ngadolinium inclusion in the earlier MRI. No bowel obstruction.\nIntestinal stasis. No sign of abnormally magnified lymphatic vessels.\nRemaining pin holes in the femoral head on both sides.\n\n[Evaluation]{.underline}\n\nComposite osteolytic-osteoblastic defects starting from the left pedicle\nin T10 and lumbar vertebra 4, and at the endplate of lumbar vertebra 2.\n\n**CT Thoracic Spine from 01/04/2017 **\n\nIntraoperative CT imaging for enhanced guidance.\n\nTwo intraoperative CT scans were undertaken in total.\n\nOn the concluding CT scan, recently implanted non-radiopaque pedicle\nscrews T8-9 to L2-L3 at tumor band T10. Regular screw placement. No\nevident sign of material breakage.\n\nApart from this, no notable alteration in findings from CT of\n01/03/2017.\n\nEvaluation Intraoperative CT imaging for better guidance. Recently\ninserted pedicle screws T8/T9 and L2/L3 in tumor indication T10,\nultimate standard screw positioning done transpedicular.\n\n**CT Chest/Abdomen/Pelvis + Contrast from 01/09/2017**\n\nResults: After uneventful intravenous administration of Omnipaque 320, a\nmulti-slice helical CT of the chest, abdomen, and pelvis was performed\nduring the venous phase of contrast enhancement. Additional oral\ncontrast was given using Gastrografin (diluted 1:35). Thin slice\nreconstructions were obtained, along with secondary coronal and sagittal\nreconstructions.\n\n[Thorax]{.underline}:\n\nUniform presentation of the apical thoracic sections when included. No \nevidence of subclavian lymphadenopathy. Uniform visualization of the pectoral \ntissues. No evidence of mediastinal lymphadenopathy. The anterior segment \nof the left upper lobe (series 205, image 88 of 389) shows a subpleural \nground-glass opaque solid consolidation. There is an enlarged lymph node \nin the left hilar region measuring approximately 1.2 cm laterally. Otherwise, \nthere are no signs of suspicious intrapulmonary markings, no new inflammatory \ninfiltrates, no pneumothorax, no pericardial effusion. In the upper inner \nquadrant of the right breast there is an oval mass, DD cystadenoma, \nDD glandular cluster (measuring 1.2 cm).\n\n[Abdomen/pelvis: ]{.underline}\n\nDominant display of the gastrocolic junction; absence of oral contrast\nin this zone prevents more detailed analysis. Uniformly displayed\nhepatic tissue with no signs of focal, density-varied lesions. Portal\nand liver veins are well filled. Liver with minor auxiliary liver.\nAdrenal nodes thin on both sides. Natural kidneys on both sides. Urinary\nsac with placed transurethral tube and intravesical gas pockets.\nGallbladder typical. Paravertebral and within vertebral and in the\ndomain of the superior hepatic artery multiple pronounced lymph nodes,\nthese up to a maximum of 8 mm. Typical representation of the organs in\nthe pelvic region.\n\n[Skeleton: ]{.underline}\n\nCondition post dorsal reinforcement (T8-T9-L2-L3). After surgery,\nepidermal air pockets and bloated tissue inflammation in the access path\nzone. Signs of a resin in a pre-spinal vessel anterior to T8 and T9.\nKnown mixed osteoblastic/osteolytic bony metastasis of lumbar vertebra 4\nand the cap plate of lumbar vertebra 2. State post-cutting of the\npedicle of T10. L5 also with slightly multiple solidified core\nosteolytic defects.\n\n[Evaluation:]{.underline}\n\n- No sign of primary malignancy in the previously mentioned mixed\n osteoblastic/osteolytic lesions in the vertebra (to be deemed\n suspicious in coordination with the MR review of 12/20/2016).\n\n- A magnified lymph node exists in the left hilar territory. In the\n anterior left upper lobe, evidence of a solid cloudy consolidation,\n i.e., of inflammatory origin, revisitation in 5-7 weeks recommended.\n\n- Rounded consolidation in the upper inner quadrant of the right\n breast, further breast examination advised.\n\n**Functional Diagnostics**\n\nExtended Respiratory Function (Diffusion) from 01/15/2017\n\n[Evaluation]{.underline}\n\nPatient cooperation: satisfactory. No detectable obstructive ventilation\nissue. No pulmonary over-expansion after RV/TLC. No identified\nrestrictive ventilation impairment. Standard O2 diffusion ability. No\nevidence of low oxygen levels, no blockage.\n\n[Consultations / Therapy Reports]{.underline}\n\nPsychological Support Consultation from 01/22/2017\n\n[Current Situation/History:]{.underline}\n\nThe patient initially discussed \\\"night episodes\\\" in the calves, which\nover time manifested during the day and were coupled with discomfort in\nthe cervical region. Prior, she had visited the Riverside Medical Center\nmultiple times before an MRI was executed. A \\\"mass in the neck\\\" was\nidentified. Since she suffers from fear of heights and fear of crowds,\nthe MRI could only be done under mild sedation. The phobias emerged\nabruptly in 2011 with no apparent cause, leading to multiple hospital\nvisits. She is now in outpatient care. Additionally, she battles with\nMS, with the most recent flare-up in 2012. She declined a procedure,\nwhich was set for the MRI is day, because \\\"two sedatives in one day\nfelt excessive.\\\" She anticipates avoiding a repeated procedure.\nCurrently, however, she still experiences spasms in her right hand and a\nnumbing sensation in her fingers. She still encounters discomfort (NRS\n5/10). She was previously informed that relief might be gradual, but she\nis \\\"historically been restless\\\". Therefore, \\\"resting and inactivity\\\"\nnegatively impact her spirits and rest.\n\n[Medical background:]{.underline}\n\nSeveral in-patient and day clinic admissions since 2011.\n\nNow, from 2015, continuous outpatient psychological counseling (CBT),\nsomatic therapy, particular sessions for driving anxieties. Also\nundergoing outpatient psychiatric care (fluoxetine 90mg).\n\n[Psychopathological Observations:]{.underline}\n\nPatient appears well-groomed, responsive and clear-minded, talkative and\nforthright. Aware of location, date, and identity. Adequate focus,\nrecall, and concentration. Mental organization is orderly. No evidence\nof delusional beliefs or identity disturbances. No compulsions, mentions\nfear of expansive spaces and fear of water. Emotional responsiveness\nintact, heightened psychomotor activity. Mood swings between despondent\nand irritable, lowered motivation. Diminished appetite, issues with\nsleep initiation and maintenance. Firm and believable denial of\nimmediate suicidal thoughts, patient appears cooperative. No current\nsigns of self-harm or threat to others.\n\n[Handling the Condition, Strengths:]{.underline}\n\nCurrently, her coping strategy seems to be proactive with some restless\nelements. Ms. S. says she remains \\\"optimistic\\\" and is well-backed by\nher communal links. Notably, she shares a close bond with her\n80-year-old aunt. Her other social bonds primarily arise from her\nassociation with a hockey enthusiasts club. Hockey has been a crucial\nsupport for her from a young age.\n\n[Evaluation Diagnoses:]{.underline}\n\nAdjustment disorder: anxiety and depressive reaction mixed\n\nAgoraphobia\n\nAcrophobia\n\n[Interventions, approaches:]{.underline}\n\nAn evaluative and assistive discussion was conducted. The patient has a\ndependable therapeutic community for post-hospitalization. Additionally,\nshe was provided the contact of the psychological support outpatient\ncenter. She mentioned finding the therapeutic conversation comforting,\nprompting an arranged check-in the subsequent week. We also suggest\nguidance in self-initiated physical activities to aid her recovery and\ntemper restlessness.\n\n**NC: Consultation of 01/15/2017**\n\n[Examination findings:]{.underline}\n\nPatient alert, fully oriented. Articulate and spontaneous speech.\nCranial nerve evaluation normal. No evident sensorimotor abnormalities.\nBDK with voiding challenges. Sphincter response diminished, but fecal\ncontrol maintained. KPPS at 85%. Wound site clean and non-irritated,\nexcept for the lower central portion.\n\n[Procedure:]{.underline}\n\nNeurosurgical intervention not required; no reassessment of the lower\nwound needed. Advise return if neurological symptoms intensify.\n\nThe patient, diagnosed with relapsing-remitting multiple sclerosis that\ninitially manifested aggressively, has been relapse-free on fingolimod\nsince 2009 and was generally well, barring a slight imbalance when\nwalking due to minor weakness in her left leg. She later experienced\nnumbness and weakness in her legs, reaching up to the hip, persisting\nfor several days and then faced challenges with urination and bowel\nmovements approximately 7 weeks prior. During a home examination, a\nlesion was identified in the T10 which was surgically addressed by our\nin-house neurosurgery team. Histology identified it as a DLBCL, leading\nto a chemotherapy plan inclusive of Rituximab. Post-surgery, her\nsymptoms have subsided somewhat, but the patient still has BDK and\nrelies on a wheelchair.\n\nOn clinical neurological assessment, a mild paraparesis was noted in her\nleft leg, accompanied by heightened reflex response and sporadic left\nfoot spasms, which were intense but temporary.\n\nTo conclude, the new neurological manifestations are not a recurrence of\nthe formerly stable multiple sclerosis. As Rituximab is also an\neffective third-phase drug for MS treatment and is essential,\ndiscontinuing fingolimod (second phase) was discussed with the patient.\nAfter a span of approximately 4-5 months following the last Rituximab\ntreatment, a radiological (cMRI) and clinical review is suggested. Based\non results, either resuming fingolimod or, if no adverse effects\npresent, potentially continuing Rituximab treatment is recommended (for\nthis, reach our neuroimmunology outpatient department). The primary\nneurologist was unavailable for comments.\n\n**Boards**\n\nOncology tumor board as of 01/22/2017\n\n6 cycles of R-Pola-CHP\n\n[Pathology]{.underline}\n\nPathology. Findings from 01/05/2017\n\n[Clinical information/question:]{.underline}\n\nTumor cuff T10. dignity? Entity? Macroscopy:\n\n1st lamina T10: fixed. some assembled 0.7 x 0.5 x 0.2 cm calcareous\ntissue fragments. Complete embedding. Decalcify in EDTA. 2nd ligament:\nFix. some assembled 0.9 x 0.7 x 0.2 cm, coarse, partly also calcareous\ntissue fragments. Complete embedding. Decalcify overnight in EDTA.\n\n3\\. epidural tumor: Numerous beige-colored tissue fragments, 3.8 x 2.8 x\n0.6 cm. Embedding of exemplary sections after lamellation.\n\n[Processing]{.underline}: 1 block, HE. Microscopy:\n\n1\\. and 2. (lamina T10 and ligament) are still being decalcified.\n\n3rd epidural tumor: Paravertebral soft tissue with infiltrates of a\npartly lymphoid, partly blastic neoplasia. The tumor cells are diffuse,\nsometimes nodular in the tissue and have hyperchromatic nuclei with\ncoarse-grained chromatin and a narrow cytoplasmic border. There are also\nblastic cells with enlarged nuclei, vesicular chromatin, and sometimes\nprominent nucleoli. The stroma is loose and vacuolated. Clearly\npronounced crush artifacts.\n\nPreliminary report of critical findings:\n\n3\\. epidural tumor: paravertebral soft tissue with infiltrates of\nlymphoid and blastic cells compatible with hematologic neoplasia.\n\nAdditional immunohistochemical staining is being performed to further\ncharacterize the tumor. In addition, material 1 (lamina T10) and\nmaterial 2 (ligament) are still undergoing decalcification. A follow-up\nreport will be provided.\n\nProcessing: 2 blocks, decalcification, HE, Giemsa, IHC: CD20, PAX5,\nBcl2, Bcl6, CD5, CD3, CD23, CD21, Kappa, Lambda, CD10, c-Myc, CyclinD1,\nCD30, MIB1, EBV/EBER.\n\nMolecular pathology: testing for B-cell clonal expansion and IgH/Bcl2\ntranslocation.\n\n[Microscopy]{.underline}:\n\n1\\. Ligament: Scarred connective tissue and fragmented bone tissue\nwithout evidence of the tumor described in the preliminary findings\nunder 3.\n\n2\\. Lamina T10: Bone tissue without evidence of the tumor described in\nthe preliminary findings under 3.\n\n3\\. Epidural tumor: Immunohistochemically, blastic tumor cells show a\npositive reaction after incubation with antibodies against CD20, PAX5\nand BCL2. Partially positive reaction against Bcl-6 (\\<20%). Some\nisolated blastic cells staining positive for CD30. Lymphoid cells\npositive for CD3 and CD5. Some residual germinal centers with positive\nreaction to CD23 and CD21. Predominantly weak positive reaction of\nblasts and lymphoid cells to CD10. Some solitary cells with positive\nreaction to kappa, rather unspecific, flat reaction to lambda. No\noverexpression of c-Myc or cyclinD1. No\n\nNo reaction to EBV/EBER. The Ki-67 proliferation index is 40%, related\nto blastic tumor cells \\> 90%.\n\nSignificantly limited evaluability of immunohistochemical staining due\nto severe squeezing artifacts of the material.\n\n[Molecular pathology report:]{.underline}\n\nExamination for clonal B-cell expansion and t(14;18) translocation\nMethodology:\n\nDNA was isolated from the sent tissues and used in duplicate in specific\nPCRs (B-cell clonality analysis with Biomed-2 primer sets: IGHG1 gene:\nscaffold 2 and 3). The size distribution of the PCR products was further\nanalyzed by fragment analysis.\n\nTo detect a BCL2/IgH fusion corresponding to a t(14;18) translocation,\nDNA was inserted into a specific PCR (according to Stetler-Stevenson et\nal. Blood. 1998;72:1822-25).\n\nResults:\n\nAmplification of isolated DNA: good. B cell clonality analyses\n\nIGHG1 fragment 2: polyclonal signal pattern.\n\nIGHG1 frame 3: reproducible clonal signal at approximately 115/116 bp.\nt(14;18) translocation: negative.\n\n[Molecular pathology report:]{.underline}\n\nMolecular pathologic evidence of clonal B-cell expansion. No evidence of\nt(14;18) translocation in test material with normal control reactions.\n\nPreliminary critical findings report:\n\n1\\. Lamina TH 10: tumor-free bone tissue.\n\n2\\. Ligament: Tumor-free, scarred connective tissue and fragmented bone\ntissue.\n\n3\\. Epidural tumor: aggressive B non-Hodgkin\\'s lymphoma.\n\nFindings (continued)\n\nAdditional findings from 01/06/2017\n\nImmunohistochemical processing: MUM1, ALK1, CD68, TdT. Microscopy:\n\n3\\. Immunohistochemically, blastic tumor cells are positive for MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\nCritical findings report:\n\n1\\. Lamina T10: Tumor-free bone tissue. 2: Tumor free, scarred connective\ntissue and fragmented bone tissue.\n\n3\\. epidural tumor: aggressive B-non-Hodgkin lymphoma, morphologically\nand immunohistochemically most compatible with diffuse large B-cell\nlymphoma (DLBCL, NOS) of germinal center type according to Hans\nclassifier (GCB).\n\n**Path. Findings from 01/05/2017**\n\nClinical Findings\n\nClinical data:\n\nInitial diagnosis of DLBCL with spinal involvement.\n\nPuncture Site(s): 1\n\nCollection date: 01/04/2017\n\nArrival at cytology lab: 01/04/2017, 8 PM. Material:\n\n1 Liquid Material: 2 mL colorless, clear Processing:\n\nMGG staining Microscopic:\n\nZTA:\n\nLiquid precipitate Erythrocytes\n\n(+) Lymphocytes (+) Granulocytes\n\nEosinophils Histiocytes Siderophages\n\n\\+ Monocytes\n\nOthers: Isolated evidence of fewer monocytes. No evidence of atypical\ncells. Critical report of findings:\n\nCSF sediment without evidence of inflammation or malignancy. Diagnostic\nGrading:\n\nNegative\n\nTherapy and course\n\nMrs. S was admitted from the neurosurgical department for chemotherapy\n(R-POLA-CHP) of suspected DLBCL with spinal/vertebral manifestations.\n\nAfter exclusion of clinical and laboratory contraindications,\nantineoplastic therapy was started on 01/08/2017. This was well\ntolerated under the usual supportive measures. There were no acute\ncomplications.\n\nDuring her hospitalization, Ms. S reported numbness in both vascular\nhemispheres. A neurosurgical and neurological presentation was made\nwithout acute need for action. In consultation with the neurology\ndepartment, the existing therapy with fingolimod should be discontinued\ndue to the concomitant use of rituximab and the associated risk of PML.\nIf necessary, re-exposure to fingolimod may be considered after\ncompletion of oncologic therapy.\n\nOn 01/07/2017, a port placement was performed by our vascular surgery\ndepartment without complications.\n\nOn 01/19/2017, a single administration of Pegfilgrastim 6 mg s.c. was\nperformed. With a latency of 10 days, G-CSF should not be repeated in\nthe meantime.\n\nWe are able to transfer Mrs. S to the Mountain Hospital Center\n(Neurological Initial Therapy & Recovery) on 02/01/2017. We thank you\nfor accommodating the patient and are available for any additional\ninquiries.\n\n**Medications at Discharge**\n\n**Aspirin (Aspirin®)** - 100mg, 1 tablet in the morning\n\n**Atorvastatin - 40mg -** 1 tablet at bedtime\n\n**Sertraline - 50mg** - 2 tablets in the morning\n\n**Lorazepam (Tavor®)** - 1mg, as needed\n\n**Fingolimod** - 0.5mg, 1 capsule at bedtime, Note: Take a break as\ndirected\n\n**Hydromorphone hydrochloride** - 2mg (extended-release), 2 capsules in\nthe morning and 2 capsules at bedtime\n\n**Melatonin -** 2mg (sustained-release), 1 tablet at bedtime\n\n**Baclofen (Lioresal®) -** 10mg, 1 tablet three times a day\n\n**Pregabalin -** 75mg, 1 capsule in the morning and 1 capsule at bedtime\n\n**MoviCOL® (Macrogol, Sodium chloride, Potassium chloride) -** 1 packet\nthree times a day, mixed with water for oral intake\n\n**Pantoprazole -** 40mg, 1 tablet in the morning\n\n**Colecalciferol (Vitamin D3) -** 20000 I.U., 1 capsule on Monday and\nThursday\n\n**Co-trimoxazole -** 960mg, 1 tablet on Monday, Wednesday, and Friday\n\n**Valaciclovir -** 500mg, 1 tablet in the morning and 1 tablet at\nbedtime\n\n**Prednisolone -** 50mg, 2 tablets in the morning, Continue through\n02/19/2017\n\n**Enoxaparin sodium (Clexane®) -** 40mg (4000 I.U.), 1 injection at\nbedtime, Note: Continue in case of immobility\n\n**Dimenhydrinate (Vomex A®)** - 150mg (sustained-release), as needed for\nnausea, up to 2 capsules daily.\n\n**Procedure**\n\n**Oncology board decision: 6 cycles of R-Pola-CHP.**\n\n- Fingolimod pause, re-evaluation in 4-5 months.\n\n- Continuation of therapy near residence in the clinic as of\n 02/28/2017\n\n- Bi-Weekly laboratory tests (electrolytes, blood count, kidney and\n liver function tests)\n\n- In case of fever \\>38.3 °C please report immediately to our\n emergency room\n\n- Immediate gynecological examination for nodular mass in the left\n breast\n\nDates:\n\n- From 03/01/2017 third cycle of R-Pola-CHP in the clinic. The patient\n will be informed of the date by telephone.\n\nIf symptoms persist or exacerbate, we advocate for an urgent revisit.\nOutside standard working hours, emergencies can also be addressed at the\nemergency hub.\n\nDuring discharge management, the patient was extensively educated and\nassisted, and equipped with required appliances, medication scripts, and\nabsence from work notices.\n\nAll observations were thoroughly deliberated upon. Multiple alternate\ntherapy notions were considered before making a treatment proposition.\nThe opportunity for a second viewpoint and recommendation to our\nfacility was also emphasized.\n\n**Lab values at discharge: **\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 136 mEq/L 135 - 145 mEq/L\n Potassium 3.9 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.2 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 19 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 138 U/L 40 - 129 U/L\n Total Bilirubin 0.3 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 82 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 42 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 34 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 366 U/L \\< 244 U/L\n Uric Acid 4.1 mg/dL 3 - 7 mg/dL\n Calcium 9.0 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>60 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 64 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 2.5 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 103% 70 - 120%\n INR 1.0 N/A\n aPTT 25 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- ---------------- ---------------------\n WBC 12.71 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 2.9 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.1 g/dL 14 - 18 g/dL\n Hematocrit 24.7% 40 - 48%\n MCH 28 pg 27 - 32 pg\n MCV 86 fL 82 - 92 fL\n MCHC 32.8 g/dL 32 - 36 g/dL\n Platelets 257 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 77% 40 - 70%\n Lymphocytes 4% 25 - 40%\n Monocytes 18% 4 - 10%\n Eosinophils 0% 2 - 4%\n Basophils 0% 0 - 1%\n\n\n\n### text_1\n**Dear colleague, **\n\nI am writing to provide a follow-up report on our mutual patient, Mrs.\nAnna Sample, born on January 1st, 1970, post her recent visit to our\nclinic on October 9th, 2017.\n\nUpon assessment, Mrs. Sample reported experiencing a moderate\nimprovement in symptoms since the initiation of the R-Pola-CHP regimen.\nThe discomfort in her dorsal calf and thoracic spine has notably\nreduced, and her arm strength has seen gradual improvement, though she\noccasionally still encounters difficulty in grasping objects.\n\nShe has been undergoing physiotherapy to aid in the recovery of her arm\nstrength.\n\n**Physical Examination:** No palpable lymphadenopathy. Her neurological\nexamination was stable with no new deficits.\n\n**Laboratory Findings:** Most recent blood counts and biochemistry\npanels showed a trend towards normalization, with liver enzymes within\nthe reference range.\n\n**Imaging:**\n\n-Ultrasound of the abdomen was conducted.\n\n-A follow-up MRI conducted showed a reduction in the size of the\npreviously noted metastatic masses. There\\'s a decreased impingement on\nthe myelon at the levels of T10-L1. The lesions in L2, L3, and L4 also\nshowed signs of regression.\n\n-PET scan was performed: Favourable response. Increased FDG avidity in\nthe liver: Liver MRI recommended.\n\n-Liver MRI: No pathology of the liver.\n\n**Senological Examination:** The nodule-like deposit in the right breast\nwas found to be benign.\n\n**Medication on admission:** Aspirin (Aspirin®) - 100mg, 1 tablet in the\nmorning Atorvastatin - 40mg - 1 tablet at bedtime Sertraline - 50mg - 2\ntablets in the morning Lorazepam (Tavor®) - 1mg, as needed Fingolimod -\n0.5mg, 1 capsule at bedtime, Note: Take a break as directed\nHydromorphone hydrochloride - 2mg (extended-release), 2 capsules in the\nmorning and 2 capsules at bedtime Melatonin - 2mg (sustained-release), 1\ntablet at bedtime Baclofen (Lioresal®) - 10mg, 1 tablet three times a\nday Pregabalin - 75mg, 1 capsule in the morning and 1 capsule at bedtime\nMoviCOL® (Macrogol, Sodium chloride, Potassium chloride) - 1 packet\nthree times a day, mixed with water for oral intake Pantoprazole - 40mg,\n1 tablet in the morning Colecalciferol (Vitamin D3) - 20000 I.U., 1\ncapsule on Monday and Thursday Co-trimoxazole - 960mg, 1 tablet on\nMonday, Wednesday, and Friday Valaciclovir - 500mg, 1 tablet in the\nmorning and 1 tablet at bedtime Prednisolone - 50mg, 2 tablets in the\nmorning, Continue through 02/19/2017 Enoxaparin sodium (Clexane®) - 40mg\n(4000 I.U.), 1 injection at bedtime, Note: Continue in case of\nimmobility Dimenhydrinate (Vomex A®) - 150mg (sustained-release), as\nneeded for nausea, up to 2 capsules daily.\n\n**Physician\\'s report for ultrasound on 10/05/2017:**\n\nLiver: The liver is large with 18.1 cm in the MCL, 18.5 cm in the CCD\nand 20.2 cm in the AL. The internal structure is not compacted. Focal\nchanges are not seen. Orthograde flow in the portal vein (vmax 16 cm/s).\nGallbladder: the gallbladder is 9.0 x 2.9 cm, the lumen is free of\nstones.\n\nBiliary tract: The intra- and extrahepatic bile ducts are not\nobstructed, DHC 5 mm, DC 3 mm.\n\nPancreas: The pancreas is approximately 3.2/1.5/3.0 cm in size, the\ninternal structure is moderately echo-rich.\n\nSpleen: The spleen is 28.0 x 9.6 cm, the parenchyma is homogeneous.\n\nKidneys: The right kidney is 9.8/2.0 cm, the pelvis is not congested.\nThe left kidney is 12.4/1.2 cm, the pelvis is not congested. Vessels\nretroperitoneal: the aorta is normal in width in the partially visible\narea.\n\nStomach/intestine: The gastric corpus wall is up to 14 mm thick. No\nevidence of free fluid in the abdominal cavity.\n\nBladder/genitals: The prostate is orientationally about 3.8 x 4.8 x 3.1\ncm, the urinary bladder is moderately full.\n\n**MR Spine plain + post-contrast from 10/06/2017**\n\n**Study:** Magnetic Resonance Imaging (MRI) of the thoracolumbar spine\n\n**Clinical Information:** Follow-up MRI post treatment for previously\nnoted metastatic masses.\n\n**Technique:** Standard T1-weighted, T2-weighted, and post-contrast\nenhanced sequences of the thoracolumbar spine were obtained in sagittal\nand axial planes.\n\n**Findings:** There is a reduction in the size of the previously noted\nmetastatic masses when compared to prior MRI studies. A reduced mass\neffect is observed at the levels of T10-L1. Notably, there is decreased\nimpingement on the myelon at these levels. This indicates a significant\nimprovement, suggesting a positive response to the recent therapy. The\nlesion noted in the previous study at the level of L2 has shown signs of\nregression in both size and intensity. Similar regression is noted for\nthe lesion at the L3 level. The lesion at the L4 level has also\ndecreased in size as compared to previous imaging. The intervertebral\ndiscs show preserved hydration. No significant disc protrusions or\nherniations are observed. The vertebral bodies do not show any\nsignificant collapse or deformity. Bone marrow signal is otherwise\nnormal, apart from the aforementioned lesions. The spinal canal\nmaintains a normal caliber throughout, and there is no significant canal\nstenosis. The conus medullaris and cauda equina nerve roots appear\nunremarkable without evidence of displacement or compression.\n\n**Impression:** Reduction in the size of previously noted metastatic\nmasses, indicating a positive therapeutic response. Decreased\nimpingement on the myelon at the levels of T10-L1, suggesting\nsignificant regression of the previously observed mass effect.\nRegression of lesions at L2, L3, and L4 levels, further indicating the\npositive response to treatment.\n\n**Positron Emission Tomography (PET)/CT from 10/09/2017:**\n\n**Indication:** Follow-up evaluation of Diffuse large B-cell lymphoma of\ngerminal center type diagnosed in 01/2017.\n\n**Technique:** Whole-body FDG-PET/CT was performed from the base of the\nskull to the mid-thighs.\n\n**Findings:** Liver: There is increased FDG uptake in the liver,\npredominantly in the anterolateral segment. The size of the liver is\nconsistent with the previous ultrasound report, measuring 18.1 cm in the\nMCL, 18.5 cm in the CCD, and 20.2 cm in the AL. The SUV max is 5.5.\nLymph Nodes: There is no pathological FDG uptake in the previously noted\nleft axillary lymph node, suggesting a therapeutic response. Lungs:\nPreviously noted deposit in the ventral left upper lobe now demonstrates\nreduced FDG avidity. No other FDG-avid nodules or masses. Bone: There\\'s\nno FDG uptake in the spine, including the previously described\nmetastatic lesion, indicating a positive response to treatment.\n\n**Impression:** Overall, the findings demonstrate a marked metabolic\nimprovement in the sites of lymphoma previously noted, particularly in\nthe left axillary lymph node and the vertebral bone lesions. The liver,\nhowever, presents with increased FDG avidity, especially in the\nanterolateral segment. This uptake might represent active lymphomatous\ninvolvement or could be due to an inflammatory process. Given the\ndifferential, and to ascertain the etiology, further diagnostic\nevaluation, such as a liver MRI or biopsy, is recommended.\n\n**Liver MRI from 10/11/2017:**\n\n**Clinical Indication:** Evaluation of increased FDG uptake in the liver\nas noted on the recent PET scan. Concern for active lymphomatous\ninvolvement or an inflammatory process.\n\n**Technique:** MRI of the liver was performed using a 3T scanner.\nSequences included T1-weighted (in-phase and out-of-phase), T2-weighted,\ndiffusion-weighted imaging (DWI), and post-contrast dynamic imaging\nafter the administration of gadolinium-based contrast agent.\n\n**Detailed Findings:** The liver demonstrates enlargement with\nmeasurements consistent with the recent ultrasound: 18.1 cm in the\nmid-clavicular line (MCL), 18.5 cm in the maximum cranial-caudal\ndiameter (CCD), and 20.2 cm along the anterior line (AL).\n\nThe liver parenchyma is mostly homogenous. However, there is a region in\nthe anterolateral segment demonstrating T2 hyperintensity and\nhypointensity on T1-weighted images. The aforementioned region in the\nanterolateral segment demonstrates restricted diffusion, suggestive of\nincreased cellular density. After gadolinium administration, there is\nperipheral enhancement of the lesion in the arterial phase, followed by\nprogressive central filling in portal venous and delayed phases. This\npattern is suggestive of a focal nodular hyperplasia (FNH) or atypical\nhemangioma. The intrahepatic and extrahepatic bile ducts are not\ndilated. No evidence of any obstructing lesion. The hepatic arteries,\nportal vein, and hepatic veins appear patent with no evidence of\nthrombosis or stenosis. The gallbladder, pancreas, spleen, and adjacent\nsegments of the bowel appear normal. No lymphadenopathy is noted in the\nporta hepatis or celiac axis.\n\n**Impression:** Enlarged liver with a suspicious lesion in the\nanterolateral segment demonstrating characteristics that might be\nconsistent with focal nodular hyperplasia or atypical hemangioma. No\nindication of lymphomatous involvement of the liver.\n\n**Discussion: **\n\nGiven her positive response to the treatment so far, we intend to\ncontinue with the current regimen, with careful monitoring of her side\neffects and symptomatology.\n\nWe deeply appreciate your continued involvement in Mrs. Sample\\'s\nhealthcare journey. Collaborative care is paramount, especially in cases\nas complex as hers. Should you have any recommendations, insights, or if\nyou require additional information, please do not hesitate to reach out.\n\n**Medication at discharge: **\n\nAspirin 100mg: Take 1 tablet in the morning; Atorvastatin 40mg: Take 1\ntablet at bedtime; Sertraline 50mg: Take 2 tablets in the morning;\nLorazepam 1mg: Take as needed; Melatonin (sustained-release) 2mg: Take 1\ntablet at bedtime; Fingolimod 0.5mg: Take 1 capsule at bedtime/take a\nbreak as directed; Hydromorphone hydrochloride (extended-release) 2mg:\nTake 2 capsules in the morning and 2 capsules at bedtime; Pregabalin\n75mg: Take 1 capsule in the morning and 1 capsule at bedtime; Baclofen\n10mg: Take 1 tablet three times a day; MoviCOL®: Mix 1 packet with water\nand take orally three times a day; Pantoprazole 40mg: Take 1 tablet in\nthe morning; Colecalciferol (Vitamin D3) 20000 I.U.: Take 1 capsule on\nMonday and Thursday; Dimenhydrinate (sustained-release) 150mg: Take as\nneeded for nausea, up to 2 capsules daily.\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 135 - 145 mEq/L\n Potassium 4.1 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 17 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 124 U/L 40 - 129 U/L\n Total Bilirubin 0.4 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 75 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 39 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 36 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 342 U/L \\< 244 U/L\n Uric Acid 3.8 mg/dL 3 - 7 mg/dL\n Calcium 9.12 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>62 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 67 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 1.8 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 105% 70 - 120%\n INR 0.98 N/A\n aPTT 28 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- --------------- ---------------------\n WBC 11.9 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 3.1 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.4 g/dL 14 - 18 g/dL\n Hematocrit 26% 40 - 48%\n MCH 27.8 pg 27 - 32 pg\n MCV 84 fL 82 - 92 fL\n MCHC 33 g/dL 32 - 36 g/dL\n Platelets 263 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 73% 40 - 70%\n Lymphocytes 7% 25 - 40%\n Monocytes 16% 4 - 10%\n Eosinophils 1% 2 - 4%\n Basophils 0.5% 0 - 1%\n\n\n\n\nHere is the query:\nWhich therapy regime does the oncology board recommend for Mrs. Sample?\n\nChoose the correct answer from the following options:\nA. 5 cycles of T-Pola-RHP\nB. 7 cycles of R-Luna-CHT\nC. 6 cycles of L-Pola-CRP\nD. 6 cycles of R-Pola-CHP\nE. 8 cycles of M-Pola-CHZ\n\n\nYour response:\n", "role": "user" }, { "content": "6 cycles of R-Pola-CHP", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Anna Sample, born on\n01.01.1970. She was admitted to our clinic from 01/01/2017 to\n01/02/2017.\n\n**Diagnosis:** Diffuse large B-cell lymphoma of germinal center type; ID\n01/2017\n\n- Ann-Arbor: Stage IV\n\n- R-IPI: 2 (LDH, stage)\n\n- CNS-IPI: 2\n\n- Histology: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\n translocation. Ki-67 at 40%. Positive reaction to MUM1, numerous\n CD68-positive macrophages. Negative reaction to ALK1 and TdT.\n\n- cMRI: Chronic inflammatory lesions suggestive of Multiple Sclerosis (MS)\n\n- CSF: no evidence of malignancy\n\n- Bone marrow aspiration: no infiltration from the pre-existing\n lymphoma.\n\n**Current treatment: **\n\nInitiated R-Pola-CHP regimen q21\n\n- Polatuzumab vedotin: 1.8mg/kg on Day 1.\n\n- Rituximab: 375mg/m² on Day 0.\n\n- Cyclophosphamide: 750mg/m² on Day 1.\n\n- Doxorubicin: 50mg/m on Day 1.\n\n- Prednisone: 100mg orally from Day 1-5.\n\n**Previous therapy and course**\n\nFrom 12/01/2016: Discomfort in the dorsal calf and thoracic spine,\nweakness in the arms with limited ability to lift and grasp, occasional\ndizziness.\n\n12/19/2016 cMRI: chronic inflammatory marks indicative of MS. \n\n12/20/2016 MRI: thoracic/lumbar spinal cord: Indication of a\nmetastatic mass starting from the left pedicle T1 with a significant\nextraosseous tumor element and full spinal narrowing at the level of\nT10-L1 with pressure on the myelon and growth into the neuroforamen\nT11/T12 on the right and T12/L1 left. More lesions suggestive for\nmetastasis are L2, L3, and L4, once more with extraosseous tumor element\nand invasion of the left pedicle.\n\n12/21/2016 Fixed dorsal support T8-9 to L3-4. Decompression via\nlaminectomy T10 and partial laminectomy lumbar vertebra 3.\n\n12/24/2016 CT chest/abdomen/pelvis: Magnified left axillary lymph node.\nIn the ventral left upper lobe, indication of a round, loose, cloudy\ndeposit, i.e., of inflammatory origin, follow-up in 5-7 weeks.\nNodule-like deposit in the upper inner quadrant of the right breast,\nsenological examination suggested.\n\n**Pathology**: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\ntranslocation. Ki-67 staining was at 40%. Positive reaction to MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\n**Other diagnoses**\n\n- Primary progressive type of multiple sclerosis (ID 03/02) \n\n- Mood disorder.\n\n- 2-vessel CHD\n\n**Medical History**\n\nMrs. Sample was transferred inpatient from DC for the initiation of\nchemotherapy (R-Pola-CHP) for her DLBCL. In the context of her\npre-existing ALS, she presented on 12/19/2016 with acute pains and\nrestricted mobility in her upper limbs. After her admission to HK\nFlowermoon, an MRI was performed which revealed a thoracic neoplastic\ngrowth especially at the level of T10-L1, but also affecting lumbar\nvertebra 3, L4 and L6. Surgical intervention on 12/21/2016 at DC\nresulted in symptom relief. Presently, her complaints are restricted to\npost-operative spine discomfort, shoulder hypoesthesia, and intermittent\nhand numbness. She reported a weight loss of 5 kg during her\nhospitalization. She denied having respiratory symptoms, infections,\nsystemic symptoms, or gastrointestinal complaints. Mrs. Sample currently\nhas a urinary catheter in place.\n\n**Physical examination on admission**\n\nGeneral: The patient has a satisfactory nutritional status, normal\nweight, and is dependent on a walker. Her functional status is evaluated\nas ECOG 2. Cardiovascular: Regular heart rhythm at a normal rate. Heart\nsounds are clear with no detected murmurs. Respiratory: Normal alveolar\nbreath sounds. No wheezing, stridor, or other abnormal sounds.\nAbdominal: The abdomen is soft, non-tender, and non-distended with\nnormal bowel sounds in all quadrants. There is no palpable enlargement\nof the liver or spleen, and the kidneys are not palpable.\nMusculoskeletal: Tenderness noted in the cervical and thoracic spine\narea, but no other remarkable findings. This is consistent with her\npost-operative status. Lymphatic: No enlargement detected in the\ntemporal, occipital, cubital, or popliteal lymph nodes. Oral: The oral\nmucosa is moist and well-perfused. The oropharynx is unremarkable, and\nthe tongue appears normal. Peripheral Vascular: Pulses in the hands are\nstrong and regular. No edema observed. Neurological: Cranial nerves are\nintact. There is numbness in both hands and mild hypoesthesia in the\nshoulders. Motor strength is 3/5 in the right arm, attributed to her\nknown ALS diagnosis. No other motor or sensory deficits noted.\nOccasional bladder incontinence and intermittent gastrointestinal\ndisturbances are reported.\n\n**Medications on admission**\n\nAcetylsalicylic acid (Aspirin®) 100 mg: Take 1 tablet in the morning.\nAtorvastatin (Lipitor®) 40 mg: Take 1 tablet in the evening. Fingolimod\n(Gilenya®) 0.5 mg: Take 1 capsule in the evening. Sertraline (Zoloft®)\n50 mg: Take 2 tablets in the morning. Hydromorphone (Dilaudid® or\nExalgo® for extended-release) 2 mg: Take 1 capsule in the morning and 1\nin the evening. Lorazepam (Ativan®) 1 mg: 1 tablet as needed.\n\n**Radiology/Nuclear Medicine**\n\n**MR Head 3D unenhanced + contrast from 12/19/2016 10:30 AM**\n\n**Technique:** Sequences obtained include 3D FLAIR, 3D DIR, 3D T2, SWI,\nDTI/DWI, plain MPRAGE, and post-contrast MPRAGE. All images are of good\nquality. Imaging area: Brain.\n\nThere are 20 FLAIR hyperintense lesions in the brain parenchyma,\nspecifically located periventricularly and in the cortical/juxtacortical\nregions (right and left frontal, left temporal, and right and left\ninsular). No contrast-enhancing lesions are identified. There are also\nsubcortical/nonspecific lesions present, with some lesions appearing\nconfluent. The spinal cord is visualized up to the C4 level. No spinal\nlesions are noted.\n\n[Incidental findings:]{.underline}\n\n- Brain volume assessment: no indication of reduced brain volume.\n\n- CSF space: age-appropriate usual wide, moderate, and symmetric CSF\n spacing with no signs of CSF flow abnormalities.\n\n- Cortical-Subcortical Differentiation: Clear cortical-subcortical\n distinction.\n\n- RML-characteristic alterations: none detected.\n\n- Eye socket: appears normal.\n\n- Nasal cavities: Symmetric mucosal thickening with a focus on the\n right ethmoidal sinus.\n\n- Pituitary and peri-auricular region: no abnormalities.\n\n- Subcutaneous lesion measuring 14.4 x 21.3 mm, right parietal likely\n representing an inflamed cyst or abscess, differential includes soft\n tissue growth.\n\n[Evaluation]{.underline}\n\nDissemination: MRI standards for spatial distribution are satisfied. MRI\ncriteria for temporal distribution are unfulfilled. Comprehensive\nneurological review: The findings are consistent with a chronic\ninflammatory CNS disease in the sense of Multiple Sclerosis.\n\n**MR Spine plain + post-contrast from 12/20/2016 10:00 AM**\n\n**Technique:** GE 3T MRI Scanner\n\nMRI was conducted under anesthesia due to claustrophobia.\n\n**Sequences**: Holospinal T2 Dixon sagittal, T1 pre-contrast, T1 fs\npost-contrast. The spine is visualized from the craniocervical junction\nto S2.\n\n**Thoracic spine: **\n\nOn T2-STIR and T2, there is a hyperintense signal of vertebral bodies T5\nand T6 with inconsistent delineation of the vertebral endplates,\nindicative of age-related changes. There is a reduction in the height of\nthe disc spaces T4/5 and T5/6 with subligamentous disc protrusion\nleading to a spongy appearance of the spinal cord at this location.\nMyelon atrophy is noted at T5/6, along with a T2 bright lesion\nsuggestive of MS at the level of T3 and also T4/5. Spine: A large\nintraspinal mass extends from T10-L1, causing an anterior spongy\nappearance of the spinal cord and resulting in complete spinal canal\nstenosis at this level. On fat-only imaging, there is almost total\nreplacement of the marrow space of vertebral body T11 with external\ntumor extension and infiltration into the lateral structures (more on\nthe left than the right) and neural foramen T11 on both sides. There is\nmild disc herniation at T8/9 with slight sponginess of the spinal cord.\nMS-characteristic spinal cord lesions are noted at segments T5 and T8/9.\n\n**Lumbar spine: **\n\nT2-DIXON shows bright signal intensity of the anterior part of lumbar\nvertebra 1, a patchy appearance of lumbar vertebra 2, and lumbar\nvertebra 4. Almost the entire marrow space is replaced in the fat-only\nimaging. There is an external tumor mass posterior to lumbar vertebra 4\nwithout significant spinal canal stenosis, which involves the left\nlateral structure and a pronounced appearance of the cauda equina at\nlumbar vertebra 1. A call to communicate the results was made at 11:15\na.m. to the on-duty orthopedic surgeon and to colleagues in neurology.\nEvaluation Evidence of a metastatic lesion originating from the left\npedicle of T10 with a significant extramedullary tumor mass and full\nspinal canal narrowing at the level of T10 with compression of the\nspinal cord and extension into the neural foramen T11-T12 on the right,\nand T12-L1 on the left. Additional sites suggestive of metastasis\ninclude L2, L3, and L4, again with extramedullary tumor components and\ninvasion of the left lateral structure. Contrast enhancement of the\ndistal cord is noted. There are MS-characteristic spinal cord lesions at\nthe levels of T3, T4-5, T5, and T8-9. The conus medullaris is not\nvisualized due to spinal cord displacement.\n\n\n**CT Thoracic Spine from 01/03/2017**\n\n[Clinical Findings]{.underline}\n\nLateral and medial alignment is stable. No sign of vertebral column\ndamage. Multiple segment degenerative alterations in the spine. No\nindications of mineralization in the recognized space at the level of\nT10/L2. Invasion of T10 and L4 with composite osteolytic-osteoblastic\ndefects starting from the left pedicle into the vertebral column. More\ncortical inconsistency with enhanced sclerosis at the endplate of L2.\nReview with prior MRI indicative of a different composite defect. Defect\npit at the endplate of lumbar vertebra 2.\n\nMinor pericardial effusion with nearby superior ventilation. Intubation\ntube placed. Mild cardiomediastinum. Splenomegaly. Standard display of\nthe tissue organs of the mid-abdomen, as naturally observed. Normal\nspleen. Thin adrenals. Tightly raised kidney bowls and leading ureter\nfrom both aspects, e.g., upon entry during the exhalation period after\ngadolinium inclusion in the earlier MRI. No bowel obstruction.\nIntestinal stasis. No sign of abnormally magnified lymphatic vessels.\nRemaining pin holes in the femoral head on both sides.\n\n[Evaluation]{.underline}\n\nComposite osteolytic-osteoblastic defects starting from the left pedicle\nin T10 and lumbar vertebra 4, and at the endplate of lumbar vertebra 2.\n\n**CT Thoracic Spine from 01/04/2017 **\n\nIntraoperative CT imaging for enhanced guidance.\n\nTwo intraoperative CT scans were undertaken in total.\n\nOn the concluding CT scan, recently implanted non-radiopaque pedicle\nscrews T8-9 to L2-L3 at tumor band T10. Regular screw placement. No\nevident sign of material breakage.\n\nApart from this, no notable alteration in findings from CT of\n01/03/2017.\n\nEvaluation Intraoperative CT imaging for better guidance. Recently\ninserted pedicle screws T8/T9 and L2/L3 in tumor indication T10,\nultimate standard screw positioning done transpedicular.\n\n**CT Chest/Abdomen/Pelvis + Contrast from 01/09/2017**\n\nResults: After uneventful intravenous administration of Omnipaque 320, a\nmulti-slice helical CT of the chest, abdomen, and pelvis was performed\nduring the venous phase of contrast enhancement. Additional oral\ncontrast was given using Gastrografin (diluted 1:35). Thin slice\nreconstructions were obtained, along with secondary coronal and sagittal\nreconstructions.\n\n[Thorax]{.underline}:\n\nUniform presentation of the apical thoracic sections when included. No \nevidence of subclavian lymphadenopathy. Uniform visualization of the pectoral \ntissues. No evidence of mediastinal lymphadenopathy. The anterior segment \nof the left upper lobe (series 205, image 88 of 389) shows a subpleural \nground-glass opaque solid consolidation. There is an enlarged lymph node \nin the left hilar region measuring approximately 1.2 cm laterally. Otherwise, \nthere are no signs of suspicious intrapulmonary markings, no new inflammatory \ninfiltrates, no pneumothorax, no pericardial effusion. In the upper inner \nquadrant of the right breast there is an oval mass, DD cystadenoma, \nDD glandular cluster (measuring 1.2 cm).\n\n[Abdomen/pelvis: ]{.underline}\n\nDominant display of the gastrocolic junction; absence of oral contrast\nin this zone prevents more detailed analysis. Uniformly displayed\nhepatic tissue with no signs of focal, density-varied lesions. Portal\nand liver veins are well filled. Liver with minor auxiliary liver.\nAdrenal nodes thin on both sides. Natural kidneys on both sides. Urinary\nsac with placed transurethral tube and intravesical gas pockets.\nGallbladder typical. Paravertebral and within vertebral and in the\ndomain of the superior hepatic artery multiple pronounced lymph nodes,\nthese up to a maximum of 8 mm. Typical representation of the organs in\nthe pelvic region.\n\n[Skeleton: ]{.underline}\n\nCondition post dorsal reinforcement (T8-T9-L2-L3). After surgery,\nepidermal air pockets and bloated tissue inflammation in the access path\nzone. Signs of a resin in a pre-spinal vessel anterior to T8 and T9.\nKnown mixed osteoblastic/osteolytic bony metastasis of lumbar vertebra 4\nand the cap plate of lumbar vertebra 2. State post-cutting of the\npedicle of T10. L5 also with slightly multiple solidified core\nosteolytic defects.\n\n[Evaluation:]{.underline}\n\n- No sign of primary malignancy in the previously mentioned mixed\n osteoblastic/osteolytic lesions in the vertebra (to be deemed\n suspicious in coordination with the MR review of 12/20/2016).\n\n- A magnified lymph node exists in the left hilar territory. In the\n anterior left upper lobe, evidence of a solid cloudy consolidation,\n i.e., of inflammatory origin, revisitation in 5-7 weeks recommended.\n\n- Rounded consolidation in the upper inner quadrant of the right\n breast, further breast examination advised.\n\n**Functional Diagnostics**\n\nExtended Respiratory Function (Diffusion) from 01/15/2017\n\n[Evaluation]{.underline}\n\nPatient cooperation: satisfactory. No detectable obstructive ventilation\nissue. No pulmonary over-expansion after RV/TLC. No identified\nrestrictive ventilation impairment. Standard O2 diffusion ability. No\nevidence of low oxygen levels, no blockage.\n\n[Consultations / Therapy Reports]{.underline}\n\nPsychological Support Consultation from 01/22/2017\n\n[Current Situation/History:]{.underline}\n\nThe patient initially discussed \\\"night episodes\\\" in the calves, which\nover time manifested during the day and were coupled with discomfort in\nthe cervical region. Prior, she had visited the Riverside Medical Center\nmultiple times before an MRI was executed. A \\\"mass in the neck\\\" was\nidentified. Since she suffers from fear of heights and fear of crowds,\nthe MRI could only be done under mild sedation. The phobias emerged\nabruptly in 2011 with no apparent cause, leading to multiple hospital\nvisits. She is now in outpatient care. Additionally, she battles with\nMS, with the most recent flare-up in 2012. She declined a procedure,\nwhich was set for the MRI is day, because \\\"two sedatives in one day\nfelt excessive.\\\" She anticipates avoiding a repeated procedure.\nCurrently, however, she still experiences spasms in her right hand and a\nnumbing sensation in her fingers. She still encounters discomfort (NRS\n5/10). She was previously informed that relief might be gradual, but she\nis \\\"historically been restless\\\". Therefore, \\\"resting and inactivity\\\"\nnegatively impact her spirits and rest.\n\n[Medical background:]{.underline}\n\nSeveral in-patient and day clinic admissions since 2011.\n\nNow, from 2015, continuous outpatient psychological counseling (CBT),\nsomatic therapy, particular sessions for driving anxieties. Also\nundergoing outpatient psychiatric care (fluoxetine 90mg).\n\n[Psychopathological Observations:]{.underline}\n\nPatient appears well-groomed, responsive and clear-minded, talkative and\nforthright. Aware of location, date, and identity. Adequate focus,\nrecall, and concentration. Mental organization is orderly. No evidence\nof delusional beliefs or identity disturbances. No compulsions, mentions\nfear of expansive spaces and fear of water. Emotional responsiveness\nintact, heightened psychomotor activity. Mood swings between despondent\nand irritable, lowered motivation. Diminished appetite, issues with\nsleep initiation and maintenance. Firm and believable denial of\nimmediate suicidal thoughts, patient appears cooperative. No current\nsigns of self-harm or threat to others.\n\n[Handling the Condition, Strengths:]{.underline}\n\nCurrently, her coping strategy seems to be proactive with some restless\nelements. Ms. S. says she remains \\\"optimistic\\\" and is well-backed by\nher communal links. Notably, she shares a close bond with her\n80-year-old aunt. Her other social bonds primarily arise from her\nassociation with a hockey enthusiasts club. Hockey has been a crucial\nsupport for her from a young age.\n\n[Evaluation Diagnoses:]{.underline}\n\nAdjustment disorder: anxiety and depressive reaction mixed\n\nAgoraphobia\n\nAcrophobia\n\n[Interventions, approaches:]{.underline}\n\nAn evaluative and assistive discussion was conducted. The patient has a\ndependable therapeutic community for post-hospitalization. Additionally,\nshe was provided the contact of the psychological support outpatient\ncenter. She mentioned finding the therapeutic conversation comforting,\nprompting an arranged check-in the subsequent week. We also suggest\nguidance in self-initiated physical activities to aid her recovery and\ntemper restlessness.\n\n**NC: Consultation of 01/15/2017**\n\n[Examination findings:]{.underline}\n\nPatient alert, fully oriented. Articulate and spontaneous speech.\nCranial nerve evaluation normal. No evident sensorimotor abnormalities.\nBDK with voiding challenges. Sphincter response diminished, but fecal\ncontrol maintained. KPPS at 85%. Wound site clean and non-irritated,\nexcept for the lower central portion.\n\n[Procedure:]{.underline}\n\nNeurosurgical intervention not required; no reassessment of the lower\nwound needed. Advise return if neurological symptoms intensify.\n\nThe patient, diagnosed with relapsing-remitting multiple sclerosis that\ninitially manifested aggressively, has been relapse-free on fingolimod\nsince 2009 and was generally well, barring a slight imbalance when\nwalking due to minor weakness in her left leg. She later experienced\nnumbness and weakness in her legs, reaching up to the hip, persisting\nfor several days and then faced challenges with urination and bowel\nmovements approximately 7 weeks prior. During a home examination, a\nlesion was identified in the T10 which was surgically addressed by our\nin-house neurosurgery team. Histology identified it as a DLBCL, leading\nto a chemotherapy plan inclusive of Rituximab. Post-surgery, her\nsymptoms have subsided somewhat, but the patient still has BDK and\nrelies on a wheelchair.\n\nOn clinical neurological assessment, a mild paraparesis was noted in her\nleft leg, accompanied by heightened reflex response and sporadic left\nfoot spasms, which were intense but temporary.\n\nTo conclude, the new neurological manifestations are not a recurrence of\nthe formerly stable multiple sclerosis. As Rituximab is also an\neffective third-phase drug for MS treatment and is essential,\ndiscontinuing fingolimod (second phase) was discussed with the patient.\nAfter a span of approximately 4-5 months following the last Rituximab\ntreatment, a radiological (cMRI) and clinical review is suggested. Based\non results, either resuming fingolimod or, if no adverse effects\npresent, potentially continuing Rituximab treatment is recommended (for\nthis, reach our neuroimmunology outpatient department). The primary\nneurologist was unavailable for comments.\n\n**Boards**\n\nOncology tumor board as of 01/22/2017\n\n6 cycles of R-Pola-CHP\n\n[Pathology]{.underline}\n\nPathology. Findings from 01/05/2017\n\n[Clinical information/question:]{.underline}\n\nTumor cuff T10. dignity? Entity? Macroscopy:\n\n1st lamina T10: fixed. some assembled 0.7 x 0.5 x 0.2 cm calcareous\ntissue fragments. Complete embedding. Decalcify in EDTA. 2nd ligament:\nFix. some assembled 0.9 x 0.7 x 0.2 cm, coarse, partly also calcareous\ntissue fragments. Complete embedding. Decalcify overnight in EDTA.\n\n3\\. epidural tumor: Numerous beige-colored tissue fragments, 3.8 x 2.8 x\n0.6 cm. Embedding of exemplary sections after lamellation.\n\n[Processing]{.underline}: 1 block, HE. Microscopy:\n\n1\\. and 2. (lamina T10 and ligament) are still being decalcified.\n\n3rd epidural tumor: Paravertebral soft tissue with infiltrates of a\npartly lymphoid, partly blastic neoplasia. The tumor cells are diffuse,\nsometimes nodular in the tissue and have hyperchromatic nuclei with\ncoarse-grained chromatin and a narrow cytoplasmic border. There are also\nblastic cells with enlarged nuclei, vesicular chromatin, and sometimes\nprominent nucleoli. The stroma is loose and vacuolated. Clearly\npronounced crush artifacts.\n\nPreliminary report of critical findings:\n\n3\\. epidural tumor: paravertebral soft tissue with infiltrates of\nlymphoid and blastic cells compatible with hematologic neoplasia.\n\nAdditional immunohistochemical staining is being performed to further\ncharacterize the tumor. In addition, material 1 (lamina T10) and\nmaterial 2 (ligament) are still undergoing decalcification. A follow-up\nreport will be provided.\n\nProcessing: 2 blocks, decalcification, HE, Giemsa, IHC: CD20, PAX5,\nBcl2, Bcl6, CD5, CD3, CD23, CD21, Kappa, Lambda, CD10, c-Myc, CyclinD1,\nCD30, MIB1, EBV/EBER.\n\nMolecular pathology: testing for B-cell clonal expansion and IgH/Bcl2\ntranslocation.\n\n[Microscopy]{.underline}:\n\n1\\. Ligament: Scarred connective tissue and fragmented bone tissue\nwithout evidence of the tumor described in the preliminary findings\nunder 3.\n\n2\\. Lamina T10: Bone tissue without evidence of the tumor described in\nthe preliminary findings under 3.\n\n3\\. Epidural tumor: Immunohistochemically, blastic tumor cells show a\npositive reaction after incubation with antibodies against CD20, PAX5\nand BCL2. Partially positive reaction against Bcl-6 (\\<20%). Some\nisolated blastic cells staining positive for CD30. Lymphoid cells\npositive for CD3 and CD5. Some residual germinal centers with positive\nreaction to CD23 and CD21. Predominantly weak positive reaction of\nblasts and lymphoid cells to CD10. Some solitary cells with positive\nreaction to kappa, rather unspecific, flat reaction to lambda. No\noverexpression of c-Myc or cyclinD1. No\n\nNo reaction to EBV/EBER. The Ki-67 proliferation index is 40%, related\nto blastic tumor cells \\> 90%.\n\nSignificantly limited evaluability of immunohistochemical staining due\nto severe squeezing artifacts of the material.\n\n[Molecular pathology report:]{.underline}\n\nExamination for clonal B-cell expansion and t(14;18) translocation\nMethodology:\n\nDNA was isolated from the sent tissues and used in duplicate in specific\nPCRs (B-cell clonality analysis with Biomed-2 primer sets: IGHG1 gene:\nscaffold 2 and 3). The size distribution of the PCR products was further\nanalyzed by fragment analysis.\n\nTo detect a BCL2/IgH fusion corresponding to a t(14;18) translocation,\nDNA was inserted into a specific PCR (according to Stetler-Stevenson et\nal. Blood. 1998;72:1822-25).\n\nResults:\n\nAmplification of isolated DNA: good. B cell clonality analyses\n\nIGHG1 fragment 2: polyclonal signal pattern.\n\nIGHG1 frame 3: reproducible clonal signal at approximately 115/116 bp.\nt(14;18) translocation: negative.\n\n[Molecular pathology report:]{.underline}\n\nMolecular pathologic evidence of clonal B-cell expansion. No evidence of\nt(14;18) translocation in test material with normal control reactions.\n\nPreliminary critical findings report:\n\n1\\. Lamina TH 10: tumor-free bone tissue.\n\n2\\. Ligament: Tumor-free, scarred connective tissue and fragmented bone\ntissue.\n\n3\\. Epidural tumor: aggressive B non-Hodgkin\\'s lymphoma.\n\nFindings (continued)\n\nAdditional findings from 01/06/2017\n\nImmunohistochemical processing: MUM1, ALK1, CD68, TdT. Microscopy:\n\n3\\. Immunohistochemically, blastic tumor cells are positive for MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\nCritical findings report:\n\n1\\. Lamina T10: Tumor-free bone tissue. 2: Tumor free, scarred connective\ntissue and fragmented bone tissue.\n\n3\\. epidural tumor: aggressive B-non-Hodgkin lymphoma, morphologically\nand immunohistochemically most compatible with diffuse large B-cell\nlymphoma (DLBCL, NOS) of germinal center type according to Hans\nclassifier (GCB).\n\n**Path. Findings from 01/05/2017**\n\nClinical Findings\n\nClinical data:\n\nInitial diagnosis of DLBCL with spinal involvement.\n\nPuncture Site(s): 1\n\nCollection date: 01/04/2017\n\nArrival at cytology lab: 01/04/2017, 8 PM. Material:\n\n1 Liquid Material: 2 mL colorless, clear Processing:\n\nMGG staining Microscopic:\n\nZTA:\n\nLiquid precipitate Erythrocytes\n\n(+) Lymphocytes (+) Granulocytes\n\nEosinophils Histiocytes Siderophages\n\n\\+ Monocytes\n\nOthers: Isolated evidence of fewer monocytes. No evidence of atypical\ncells. Critical report of findings:\n\nCSF sediment without evidence of inflammation or malignancy. Diagnostic\nGrading:\n\nNegative\n\nTherapy and course\n\nMrs. S was admitted from the neurosurgical department for chemotherapy\n(R-POLA-CHP) of suspected DLBCL with spinal/vertebral manifestations.\n\nAfter exclusion of clinical and laboratory contraindications,\nantineoplastic therapy was started on 01/08/2017. This was well\ntolerated under the usual supportive measures. There were no acute\ncomplications.\n\nDuring her hospitalization, Ms. S reported numbness in both vascular\nhemispheres. A neurosurgical and neurological presentation was made\nwithout acute need for action. In consultation with the neurology\ndepartment, the existing therapy with fingolimod should be discontinued\ndue to the concomitant use of rituximab and the associated risk of PML.\nIf necessary, re-exposure to fingolimod may be considered after\ncompletion of oncologic therapy.\n\nOn 01/07/2017, a port placement was performed by our vascular surgery\ndepartment without complications.\n\nOn 01/19/2017, a single administration of Pegfilgrastim 6 mg s.c. was\nperformed. With a latency of 10 days, G-CSF should not be repeated in\nthe meantime.\n\nWe are able to transfer Mrs. S to the Mountain Hospital Center\n(Neurological Initial Therapy & Recovery) on 02/01/2017. We thank you\nfor accommodating the patient and are available for any additional\ninquiries.\n\n**Medications at Discharge**\n\n**Aspirin (Aspirin®)** - 100mg, 1 tablet in the morning\n\n**Atorvastatin - 40mg -** 1 tablet at bedtime\n\n**Sertraline - 50mg** - 2 tablets in the morning\n\n**Lorazepam (Tavor®)** - 1mg, as needed\n\n**Fingolimod** - 0.5mg, 1 capsule at bedtime, Note: Take a break as\ndirected\n\n**Hydromorphone hydrochloride** - 2mg (extended-release), 2 capsules in\nthe morning and 2 capsules at bedtime\n\n**Melatonin -** 2mg (sustained-release), 1 tablet at bedtime\n\n**Baclofen (Lioresal®) -** 10mg, 1 tablet three times a day\n\n**Pregabalin -** 75mg, 1 capsule in the morning and 1 capsule at bedtime\n\n**MoviCOL® (Macrogol, Sodium chloride, Potassium chloride) -** 1 packet\nthree times a day, mixed with water for oral intake\n\n**Pantoprazole -** 40mg, 1 tablet in the morning\n\n**Colecalciferol (Vitamin D3) -** 20000 I.U., 1 capsule on Monday and\nThursday\n\n**Co-trimoxazole -** 960mg, 1 tablet on Monday, Wednesday, and Friday\n\n**Valaciclovir -** 500mg, 1 tablet in the morning and 1 tablet at\nbedtime\n\n**Prednisolone -** 50mg, 2 tablets in the morning, Continue through\n02/19/2017\n\n**Enoxaparin sodium (Clexane®) -** 40mg (4000 I.U.), 1 injection at\nbedtime, Note: Continue in case of immobility\n\n**Dimenhydrinate (Vomex A®)** - 150mg (sustained-release), as needed for\nnausea, up to 2 capsules daily.\n\n**Procedure**\n\n**Oncology board decision: 6 cycles of R-Pola-CHP.**\n\n- Fingolimod pause, re-evaluation in 4-5 months.\n\n- Continuation of therapy near residence in the clinic as of\n 02/28/2017\n\n- Bi-Weekly laboratory tests (electrolytes, blood count, kidney and\n liver function tests)\n\n- In case of fever \\>38.3 °C please report immediately to our\n emergency room\n\n- Immediate gynecological examination for nodular mass in the left\n breast\n\nDates:\n\n- From 03/01/2017 third cycle of R-Pola-CHP in the clinic. The patient\n will be informed of the date by telephone.\n\nIf symptoms persist or exacerbate, we advocate for an urgent revisit.\nOutside standard working hours, emergencies can also be addressed at the\nemergency hub.\n\nDuring discharge management, the patient was extensively educated and\nassisted, and equipped with required appliances, medication scripts, and\nabsence from work notices.\n\nAll observations were thoroughly deliberated upon. Multiple alternate\ntherapy notions were considered before making a treatment proposition.\nThe opportunity for a second viewpoint and recommendation to our\nfacility was also emphasized.\n\n**Lab values at discharge: **\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 136 mEq/L 135 - 145 mEq/L\n Potassium 3.9 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.2 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 19 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 138 U/L 40 - 129 U/L\n Total Bilirubin 0.3 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 82 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 42 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 34 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 366 U/L \\< 244 U/L\n Uric Acid 4.1 mg/dL 3 - 7 mg/dL\n Calcium 9.0 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>60 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 64 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 2.5 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 103% 70 - 120%\n INR 1.0 N/A\n aPTT 25 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- ---------------- ---------------------\n WBC 12.71 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 2.9 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.1 g/dL 14 - 18 g/dL\n Hematocrit 24.7% 40 - 48%\n MCH 28 pg 27 - 32 pg\n MCV 86 fL 82 - 92 fL\n MCHC 32.8 g/dL 32 - 36 g/dL\n Platelets 257 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 77% 40 - 70%\n Lymphocytes 4% 25 - 40%\n Monocytes 18% 4 - 10%\n Eosinophils 0% 2 - 4%\n Basophils 0% 0 - 1%\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nI am writing to provide a follow-up report on our mutual patient, Mrs.\nAnna Sample, born on January 1st, 1970, post her recent visit to our\nclinic on October 9th, 2017.\n\nUpon assessment, Mrs. Sample reported experiencing a moderate\nimprovement in symptoms since the initiation of the R-Pola-CHP regimen.\nThe discomfort in her dorsal calf and thoracic spine has notably\nreduced, and her arm strength has seen gradual improvement, though she\noccasionally still encounters difficulty in grasping objects.\n\nShe has been undergoing physiotherapy to aid in the recovery of her arm\nstrength.\n\n**Physical Examination:** No palpable lymphadenopathy. Her neurological\nexamination was stable with no new deficits.\n\n**Laboratory Findings:** Most recent blood counts and biochemistry\npanels showed a trend towards normalization, with liver enzymes within\nthe reference range.\n\n**Imaging:**\n\n-Ultrasound of the abdomen was conducted.\n\n-A follow-up MRI conducted showed a reduction in the size of the\npreviously noted metastatic masses. There\\'s a decreased impingement on\nthe myelon at the levels of T10-L1. The lesions in L2, L3, and L4 also\nshowed signs of regression.\n\n-PET scan was performed: Favourable response. Increased FDG avidity in\nthe liver: Liver MRI recommended.\n\n-Liver MRI: No pathology of the liver.\n\n**Senological Examination:** The nodule-like deposit in the right breast\nwas found to be benign.\n\n**Medication on admission:** Aspirin (Aspirin®) - 100mg, 1 tablet in the\nmorning Atorvastatin - 40mg - 1 tablet at bedtime Sertraline - 50mg - 2\ntablets in the morning Lorazepam (Tavor®) - 1mg, as needed Fingolimod -\n0.5mg, 1 capsule at bedtime, Note: Take a break as directed\nHydromorphone hydrochloride - 2mg (extended-release), 2 capsules in the\nmorning and 2 capsules at bedtime Melatonin - 2mg (sustained-release), 1\ntablet at bedtime Baclofen (Lioresal®) - 10mg, 1 tablet three times a\nday Pregabalin - 75mg, 1 capsule in the morning and 1 capsule at bedtime\nMoviCOL® (Macrogol, Sodium chloride, Potassium chloride) - 1 packet\nthree times a day, mixed with water for oral intake Pantoprazole - 40mg,\n1 tablet in the morning Colecalciferol (Vitamin D3) - 20000 I.U., 1\ncapsule on Monday and Thursday Co-trimoxazole - 960mg, 1 tablet on\nMonday, Wednesday, and Friday Valaciclovir - 500mg, 1 tablet in the\nmorning and 1 tablet at bedtime Prednisolone - 50mg, 2 tablets in the\nmorning, Continue through 02/19/2017 Enoxaparin sodium (Clexane®) - 40mg\n(4000 I.U.), 1 injection at bedtime, Note: Continue in case of\nimmobility Dimenhydrinate (Vomex A®) - 150mg (sustained-release), as\nneeded for nausea, up to 2 capsules daily.\n\n**Physician\\'s report for ultrasound on 10/05/2017:**\n\nLiver: The liver is large with 18.1 cm in the MCL, 18.5 cm in the CCD\nand 20.2 cm in the AL. The internal structure is not compacted. Focal\nchanges are not seen. Orthograde flow in the portal vein (vmax 16 cm/s).\nGallbladder: the gallbladder is 9.0 x 2.9 cm, the lumen is free of\nstones.\n\nBiliary tract: The intra- and extrahepatic bile ducts are not\nobstructed, DHC 5 mm, DC 3 mm.\n\nPancreas: The pancreas is approximately 3.2/1.5/3.0 cm in size, the\ninternal structure is moderately echo-rich.\n\nSpleen: The spleen is 28.0 x 9.6 cm, the parenchyma is homogeneous.\n\nKidneys: The right kidney is 9.8/2.0 cm, the pelvis is not congested.\nThe left kidney is 12.4/1.2 cm, the pelvis is not congested. Vessels\nretroperitoneal: the aorta is normal in width in the partially visible\narea.\n\nStomach/intestine: The gastric corpus wall is up to 14 mm thick. No\nevidence of free fluid in the abdominal cavity.\n\nBladder/genitals: The prostate is orientationally about 3.8 x 4.8 x 3.1\ncm, the urinary bladder is moderately full.\n\n**MR Spine plain + post-contrast from 10/06/2017**\n\n**Study:** Magnetic Resonance Imaging (MRI) of the thoracolumbar spine\n\n**Clinical Information:** Follow-up MRI post treatment for previously\nnoted metastatic masses.\n\n**Technique:** Standard T1-weighted, T2-weighted, and post-contrast\nenhanced sequences of the thoracolumbar spine were obtained in sagittal\nand axial planes.\n\n**Findings:** There is a reduction in the size of the previously noted\nmetastatic masses when compared to prior MRI studies. A reduced mass\neffect is observed at the levels of T10-L1. Notably, there is decreased\nimpingement on the myelon at these levels. This indicates a significant\nimprovement, suggesting a positive response to the recent therapy. The\nlesion noted in the previous study at the level of L2 has shown signs of\nregression in both size and intensity. Similar regression is noted for\nthe lesion at the L3 level. The lesion at the L4 level has also\ndecreased in size as compared to previous imaging. The intervertebral\ndiscs show preserved hydration. No significant disc protrusions or\nherniations are observed. The vertebral bodies do not show any\nsignificant collapse or deformity. Bone marrow signal is otherwise\nnormal, apart from the aforementioned lesions. The spinal canal\nmaintains a normal caliber throughout, and there is no significant canal\nstenosis. The conus medullaris and cauda equina nerve roots appear\nunremarkable without evidence of displacement or compression.\n\n**Impression:** Reduction in the size of previously noted metastatic\nmasses, indicating a positive therapeutic response. Decreased\nimpingement on the myelon at the levels of T10-L1, suggesting\nsignificant regression of the previously observed mass effect.\nRegression of lesions at L2, L3, and L4 levels, further indicating the\npositive response to treatment.\n\n**Positron Emission Tomography (PET)/CT from 10/09/2017:**\n\n**Indication:** Follow-up evaluation of Diffuse large B-cell lymphoma of\ngerminal center type diagnosed in 01/2017.\n\n**Technique:** Whole-body FDG-PET/CT was performed from the base of the\nskull to the mid-thighs.\n\n**Findings:** Liver: There is increased FDG uptake in the liver,\npredominantly in the anterolateral segment. The size of the liver is\nconsistent with the previous ultrasound report, measuring 18.1 cm in the\nMCL, 18.5 cm in the CCD, and 20.2 cm in the AL. The SUV max is 5.5.\nLymph Nodes: There is no pathological FDG uptake in the previously noted\nleft axillary lymph node, suggesting a therapeutic response. Lungs:\nPreviously noted deposit in the ventral left upper lobe now demonstrates\nreduced FDG avidity. No other FDG-avid nodules or masses. Bone: There\\'s\nno FDG uptake in the spine, including the previously described\nmetastatic lesion, indicating a positive response to treatment.\n\n**Impression:** Overall, the findings demonstrate a marked metabolic\nimprovement in the sites of lymphoma previously noted, particularly in\nthe left axillary lymph node and the vertebral bone lesions. The liver,\nhowever, presents with increased FDG avidity, especially in the\nanterolateral segment. This uptake might represent active lymphomatous\ninvolvement or could be due to an inflammatory process. Given the\ndifferential, and to ascertain the etiology, further diagnostic\nevaluation, such as a liver MRI or biopsy, is recommended.\n\n**Liver MRI from 10/11/2017:**\n\n**Clinical Indication:** Evaluation of increased FDG uptake in the liver\nas noted on the recent PET scan. Concern for active lymphomatous\ninvolvement or an inflammatory process.\n\n**Technique:** MRI of the liver was performed using a 3T scanner.\nSequences included T1-weighted (in-phase and out-of-phase), T2-weighted,\ndiffusion-weighted imaging (DWI), and post-contrast dynamic imaging\nafter the administration of gadolinium-based contrast agent.\n\n**Detailed Findings:** The liver demonstrates enlargement with\nmeasurements consistent with the recent ultrasound: 18.1 cm in the\nmid-clavicular line (MCL), 18.5 cm in the maximum cranial-caudal\ndiameter (CCD), and 20.2 cm along the anterior line (AL).\n\nThe liver parenchyma is mostly homogenous. However, there is a region in\nthe anterolateral segment demonstrating T2 hyperintensity and\nhypointensity on T1-weighted images. The aforementioned region in the\nanterolateral segment demonstrates restricted diffusion, suggestive of\nincreased cellular density. After gadolinium administration, there is\nperipheral enhancement of the lesion in the arterial phase, followed by\nprogressive central filling in portal venous and delayed phases. This\npattern is suggestive of a focal nodular hyperplasia (FNH) or atypical\nhemangioma. The intrahepatic and extrahepatic bile ducts are not\ndilated. No evidence of any obstructing lesion. The hepatic arteries,\nportal vein, and hepatic veins appear patent with no evidence of\nthrombosis or stenosis. The gallbladder, pancreas, spleen, and adjacent\nsegments of the bowel appear normal. No lymphadenopathy is noted in the\nporta hepatis or celiac axis.\n\n**Impression:** Enlarged liver with a suspicious lesion in the\nanterolateral segment demonstrating characteristics that might be\nconsistent with focal nodular hyperplasia or atypical hemangioma. No\nindication of lymphomatous involvement of the liver.\n\n**Discussion: **\n\nGiven her positive response to the treatment so far, we intend to\ncontinue with the current regimen, with careful monitoring of her side\neffects and symptomatology.\n\nWe deeply appreciate your continued involvement in Mrs. Sample\\'s\nhealthcare journey. Collaborative care is paramount, especially in cases\nas complex as hers. Should you have any recommendations, insights, or if\nyou require additional information, please do not hesitate to reach out.\n\n**Medication at discharge: **\n\nAspirin 100mg: Take 1 tablet in the morning; Atorvastatin 40mg: Take 1\ntablet at bedtime; Sertraline 50mg: Take 2 tablets in the morning;\nLorazepam 1mg: Take as needed; Melatonin (sustained-release) 2mg: Take 1\ntablet at bedtime; Fingolimod 0.5mg: Take 1 capsule at bedtime/take a\nbreak as directed; Hydromorphone hydrochloride (extended-release) 2mg:\nTake 2 capsules in the morning and 2 capsules at bedtime; Pregabalin\n75mg: Take 1 capsule in the morning and 1 capsule at bedtime; Baclofen\n10mg: Take 1 tablet three times a day; MoviCOL®: Mix 1 packet with water\nand take orally three times a day; Pantoprazole 40mg: Take 1 tablet in\nthe morning; Colecalciferol (Vitamin D3) 20000 I.U.: Take 1 capsule on\nMonday and Thursday; Dimenhydrinate (sustained-release) 150mg: Take as\nneeded for nausea, up to 2 capsules daily.\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 135 - 145 mEq/L\n Potassium 4.1 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 17 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 124 U/L 40 - 129 U/L\n Total Bilirubin 0.4 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 75 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 39 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 36 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 342 U/L \\< 244 U/L\n Uric Acid 3.8 mg/dL 3 - 7 mg/dL\n Calcium 9.12 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>62 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 67 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 1.8 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 105% 70 - 120%\n INR 0.98 N/A\n aPTT 28 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- --------------- ---------------------\n WBC 11.9 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 3.1 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.4 g/dL 14 - 18 g/dL\n Hematocrit 26% 40 - 48%\n MCH 27.8 pg 27 - 32 pg\n MCV 84 fL 82 - 92 fL\n MCHC 33 g/dL 32 - 36 g/dL\n Platelets 263 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 73% 40 - 70%\n Lymphocytes 7% 25 - 40%\n Monocytes 16% 4 - 10%\n Eosinophils 1% 2 - 4%\n Basophils 0.5% 0 - 1%\n", "title": "text_1" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Anna Sample, born on\n01.01.1970. She was admitted to our clinic from 01/01/2017 to\n01/02/2017.\n\n**Diagnosis:** Diffuse large B-cell lymphoma of germinal center type; ID\n01/2017\n\n- Ann-Arbor: Stage IV\n\n- R-IPI: 2 (LDH, stage)\n\n- CNS-IPI: 2\n\n- Histology: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\n translocation. Ki-67 at 40%. Positive reaction to MUM1, numerous\n CD68-positive macrophages. Negative reaction to ALK1 and TdT.\n\n- cMRI: Chronic inflammatory lesions suggestive of Multiple Sclerosis (MS)\n\n- CSF: no evidence of malignancy\n\n- Bone marrow aspiration: no infiltration from the pre-existing\n lymphoma.\n\n**Current treatment: **\n\nInitiated R-Pola-CHP regimen q21\n\n- Polatuzumab vedotin: 1.8mg/kg on Day 1.\n\n- Rituximab: 375mg/m² on Day 0.\n\n- Cyclophosphamide: 750mg/m² on Day 1.\n\n- Doxorubicin: 50mg/m on Day 1.\n\n- Prednisone: 100mg orally from Day 1-5.\n\n**Previous therapy and course**\n\nFrom 12/01/2016: Discomfort in the dorsal calf and thoracic spine,\nweakness in the arms with limited ability to lift and grasp, occasional\ndizziness.\n\n12/19/2016 cMRI: chronic inflammatory marks indicative of MS. \n\n12/20/2016 MRI: thoracic/lumbar spinal cord: Indication of a\nmetastatic mass starting from the left pedicle T1 with a significant\nextraosseous tumor element and full spinal narrowing at the level of\nT10-L1 with pressure on the myelon and growth into the neuroforamen\nT11/T12 on the right and T12/L1 left. More lesions suggestive for\nmetastasis are L2, L3, and L4, once more with extraosseous tumor element\nand invasion of the left pedicle.\n\n12/21/2016 Fixed dorsal support T8-9 to L3-4. Decompression via\nlaminectomy T10 and partial laminectomy lumbar vertebra 3.\n\n12/24/2016 CT chest/abdomen/pelvis: Magnified left axillary lymph node.\nIn the ventral left upper lobe, indication of a round, loose, cloudy\ndeposit, i.e., of inflammatory origin, follow-up in 5-7 weeks.\nNodule-like deposit in the upper inner quadrant of the right breast,\nsenological examination suggested.\n\n**Pathology**: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\ntranslocation. Ki-67 staining was at 40%. Positive reaction to MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\n**Other diagnoses**\n\n- Primary progressive type of multiple sclerosis (ID 03/02) \n\n- Mood disorder.\n\n- 2-vessel CHD\n\n**Medical History**\n\nMrs. Sample was transferred inpatient from DC for the initiation of\nchemotherapy (R-Pola-CHP) for her DLBCL. In the context of her\npre-existing ALS, she presented on 12/19/2016 with acute pains and\nrestricted mobility in her upper limbs. After her admission to HK\nFlowermoon, an MRI was performed which revealed a thoracic neoplastic\ngrowth especially at the level of T10-L1, but also affecting lumbar\nvertebra 3, L4 and L6. Surgical intervention on 12/21/2016 at DC\nresulted in symptom relief. Presently, her complaints are restricted to\npost-operative spine discomfort, shoulder hypoesthesia, and intermittent\nhand numbness. She reported a weight loss of 5 kg during her\nhospitalization. She denied having respiratory symptoms, infections,\nsystemic symptoms, or gastrointestinal complaints. Mrs. Sample currently\nhas a urinary catheter in place.\n\n**Physical examination on admission**\n\nGeneral: The patient has a satisfactory nutritional status, normal\nweight, and is dependent on a walker. Her functional status is evaluated\nas ECOG 2. Cardiovascular: Regular heart rhythm at a normal rate. Heart\nsounds are clear with no detected murmurs. Respiratory: Normal alveolar\nbreath sounds. No wheezing, stridor, or other abnormal sounds.\nAbdominal: The abdomen is soft, non-tender, and non-distended with\nnormal bowel sounds in all quadrants. There is no palpable enlargement\nof the liver or spleen, and the kidneys are not palpable.\nMusculoskeletal: Tenderness noted in the cervical and thoracic spine\narea, but no other remarkable findings. This is consistent with her\npost-operative status. Lymphatic: No enlargement detected in the\ntemporal, occipital, cubital, or popliteal lymph nodes. Oral: The oral\nmucosa is moist and well-perfused. The oropharynx is unremarkable, and\nthe tongue appears normal. Peripheral Vascular: Pulses in the hands are\nstrong and regular. No edema observed. Neurological: Cranial nerves are\nintact. There is numbness in both hands and mild hypoesthesia in the\nshoulders. Motor strength is 3/5 in the right arm, attributed to her\nknown ALS diagnosis. No other motor or sensory deficits noted.\nOccasional bladder incontinence and intermittent gastrointestinal\ndisturbances are reported.\n\n**Medications on admission**\n\nAcetylsalicylic acid (Aspirin®) 100 mg: Take 1 tablet in the morning.\nAtorvastatin (Lipitor®) 40 mg: Take 1 tablet in the evening. Fingolimod\n(Gilenya®) 0.5 mg: Take 1 capsule in the evening. Sertraline (Zoloft®)\n50 mg: Take 2 tablets in the morning. Hydromorphone (Dilaudid® or\nExalgo® for extended-release) 2 mg: Take 1 capsule in the morning and 1\nin the evening. Lorazepam (Ativan®) 1 mg: 1 tablet as needed.\n\n**Radiology/Nuclear Medicine**\n\n**MR Head 3D unenhanced + contrast from 12/19/2016 10:30 AM**\n\n**Technique:** Sequences obtained include 3D FLAIR, 3D DIR, 3D T2, SWI,\nDTI/DWI, plain MPRAGE, and post-contrast MPRAGE. All images are of good\nquality. Imaging area: Brain.\n\nThere are 20 FLAIR hyperintense lesions in the brain parenchyma,\nspecifically located periventricularly and in the cortical/juxtacortical\nregions (right and left frontal, left temporal, and right and left\ninsular). No contrast-enhancing lesions are identified. There are also\nsubcortical/nonspecific lesions present, with some lesions appearing\nconfluent. The spinal cord is visualized up to the C4 level. No spinal\nlesions are noted.\n\n[Incidental findings:]{.underline}\n\n- Brain volume assessment: no indication of reduced brain volume.\n\n- CSF space: age-appropriate usual wide, moderate, and symmetric CSF\n spacing with no signs of CSF flow abnormalities.\n\n- Cortical-Subcortical Differentiation: Clear cortical-subcortical\n distinction.\n\n- RML-characteristic alterations: none detected.\n\n- Eye socket: appears normal.\n\n- Nasal cavities: Symmetric mucosal thickening with a focus on the\n right ethmoidal sinus.\n\n- Pituitary and peri-auricular region: no abnormalities.\n\n- Subcutaneous lesion measuring 14.4 x 21.3 mm, right parietal likely\n representing an inflamed cyst or abscess, differential includes soft\n tissue growth.\n\n[Evaluation]{.underline}\n\nDissemination: MRI standards for spatial distribution are satisfied. MRI\ncriteria for temporal distribution are unfulfilled. Comprehensive\nneurological review: The findings are consistent with a chronic\ninflammatory CNS disease in the sense of Multiple Sclerosis.\n\n**MR Spine plain + post-contrast from 12/20/2016 10:00 AM**\n\n**Technique:** GE 3T MRI Scanner\n\nMRI was conducted under anesthesia due to claustrophobia.\n\n**Sequences**: Holospinal T2 Dixon sagittal, T1 pre-contrast, T1 fs\npost-contrast. The spine is visualized from the craniocervical junction\nto S2.\n\n**Thoracic spine: **\n\nOn T2-STIR and T2, there is a hyperintense signal of vertebral bodies T5\nand T6 with inconsistent delineation of the vertebral endplates,\nindicative of age-related changes. There is a reduction in the height of\nthe disc spaces T4/5 and T5/6 with subligamentous disc protrusion\nleading to a spongy appearance of the spinal cord at this location.\nMyelon atrophy is noted at T5/6, along with a T2 bright lesion\nsuggestive of MS at the level of T3 and also T4/5. Spine: A large\nintraspinal mass extends from T10-L1, causing an anterior spongy\nappearance of the spinal cord and resulting in complete spinal canal\nstenosis at this level. On fat-only imaging, there is almost total\nreplacement of the marrow space of vertebral body T11 with external\ntumor extension and infiltration into the lateral structures (more on\nthe left than the right) and neural foramen T11 on both sides. There is\nmild disc herniation at T8/9 with slight sponginess of the spinal cord.\nMS-characteristic spinal cord lesions are noted at segments T5 and T8/9.\n\n**Lumbar spine: **\n\nT2-DIXON shows bright signal intensity of the anterior part of lumbar\nvertebra 1, a patchy appearance of lumbar vertebra 2, and lumbar\nvertebra 4. Almost the entire marrow space is replaced in the fat-only\nimaging. There is an external tumor mass posterior to lumbar vertebra 4\nwithout significant spinal canal stenosis, which involves the left\nlateral structure and a pronounced appearance of the cauda equina at\nlumbar vertebra 1. A call to communicate the results was made at 11:15\na.m. to the on-duty orthopedic surgeon and to colleagues in neurology.\nEvaluation Evidence of a metastatic lesion originating from the left\npedicle of T10 with a significant extramedullary tumor mass and full\nspinal canal narrowing at the level of T10 with compression of the\nspinal cord and extension into the neural foramen T11-T12 on the right,\nand T12-L1 on the left. Additional sites suggestive of metastasis\ninclude L2, L3, and L4, again with extramedullary tumor components and\ninvasion of the left lateral structure. Contrast enhancement of the\ndistal cord is noted. There are MS-characteristic spinal cord lesions at\nthe levels of T3, T4-5, T5, and T8-9. The conus medullaris is not\nvisualized due to spinal cord displacement.\n\n\n**CT Thoracic Spine from 01/03/2017**\n\n[Clinical Findings]{.underline}\n\nLateral and medial alignment is stable. No sign of vertebral column\ndamage. Multiple segment degenerative alterations in the spine. No\nindications of mineralization in the recognized space at the level of\nT10/L2. Invasion of T10 and L4 with composite osteolytic-osteoblastic\ndefects starting from the left pedicle into the vertebral column. More\ncortical inconsistency with enhanced sclerosis at the endplate of L2.\nReview with prior MRI indicative of a different composite defect. Defect\npit at the endplate of lumbar vertebra 2.\n\nMinor pericardial effusion with nearby superior ventilation. Intubation\ntube placed. Mild cardiomediastinum. Splenomegaly. Standard display of\nthe tissue organs of the mid-abdomen, as naturally observed. Normal\nspleen. Thin adrenals. Tightly raised kidney bowls and leading ureter\nfrom both aspects, e.g., upon entry during the exhalation period after\ngadolinium inclusion in the earlier MRI. No bowel obstruction.\nIntestinal stasis. No sign of abnormally magnified lymphatic vessels.\nRemaining pin holes in the femoral head on both sides.\n\n[Evaluation]{.underline}\n\nComposite osteolytic-osteoblastic defects starting from the left pedicle\nin T10 and lumbar vertebra 4, and at the endplate of lumbar vertebra 2.\n\n**CT Thoracic Spine from 01/04/2017 **\n\nIntraoperative CT imaging for enhanced guidance.\n\nTwo intraoperative CT scans were undertaken in total.\n\nOn the concluding CT scan, recently implanted non-radiopaque pedicle\nscrews T8-9 to L2-L3 at tumor band T10. Regular screw placement. No\nevident sign of material breakage.\n\nApart from this, no notable alteration in findings from CT of\n01/03/2017.\n\nEvaluation Intraoperative CT imaging for better guidance. Recently\ninserted pedicle screws T8/T9 and L2/L3 in tumor indication T10,\nultimate standard screw positioning done transpedicular.\n\n**CT Chest/Abdomen/Pelvis + Contrast from 01/09/2017**\n\nResults: After uneventful intravenous administration of Omnipaque 320, a\nmulti-slice helical CT of the chest, abdomen, and pelvis was performed\nduring the venous phase of contrast enhancement. Additional oral\ncontrast was given using Gastrografin (diluted 1:35). Thin slice\nreconstructions were obtained, along with secondary coronal and sagittal\nreconstructions.\n\n[Thorax]{.underline}:\n\nUniform presentation of the apical thoracic sections when included. No \nevidence of subclavian lymphadenopathy. Uniform visualization of the pectoral \ntissues. No evidence of mediastinal lymphadenopathy. The anterior segment \nof the left upper lobe (series 205, image 88 of 389) shows a subpleural \nground-glass opaque solid consolidation. There is an enlarged lymph node \nin the left hilar region measuring approximately 1.2 cm laterally. Otherwise, \nthere are no signs of suspicious intrapulmonary markings, no new inflammatory \ninfiltrates, no pneumothorax, no pericardial effusion. In the upper inner \nquadrant of the right breast there is an oval mass, DD cystadenoma, \nDD glandular cluster (measuring 1.2 cm).\n\n[Abdomen/pelvis: ]{.underline}\n\nDominant display of the gastrocolic junction; absence of oral contrast\nin this zone prevents more detailed analysis. Uniformly displayed\nhepatic tissue with no signs of focal, density-varied lesions. Portal\nand liver veins are well filled. Liver with minor auxiliary liver.\nAdrenal nodes thin on both sides. Natural kidneys on both sides. Urinary\nsac with placed transurethral tube and intravesical gas pockets.\nGallbladder typical. Paravertebral and within vertebral and in the\ndomain of the superior hepatic artery multiple pronounced lymph nodes,\nthese up to a maximum of 8 mm. Typical representation of the organs in\nthe pelvic region.\n\n[Skeleton: ]{.underline}\n\nCondition post dorsal reinforcement (T8-T9-L2-L3). After surgery,\nepidermal air pockets and bloated tissue inflammation in the access path\nzone. Signs of a resin in a pre-spinal vessel anterior to T8 and T9.\nKnown mixed osteoblastic/osteolytic bony metastasis of lumbar vertebra 4\nand the cap plate of lumbar vertebra 2. State post-cutting of the\npedicle of T10. L5 also with slightly multiple solidified core\nosteolytic defects.\n\n[Evaluation:]{.underline}\n\n- No sign of primary malignancy in the previously mentioned mixed\n osteoblastic/osteolytic lesions in the vertebra (to be deemed\n suspicious in coordination with the MR review of 12/20/2016).\n\n- A magnified lymph node exists in the left hilar territory. In the\n anterior left upper lobe, evidence of a solid cloudy consolidation,\n i.e., of inflammatory origin, revisitation in 5-7 weeks recommended.\n\n- Rounded consolidation in the upper inner quadrant of the right\n breast, further breast examination advised.\n\n**Functional Diagnostics**\n\nExtended Respiratory Function (Diffusion) from 01/15/2017\n\n[Evaluation]{.underline}\n\nPatient cooperation: satisfactory. No detectable obstructive ventilation\nissue. No pulmonary over-expansion after RV/TLC. No identified\nrestrictive ventilation impairment. Standard O2 diffusion ability. No\nevidence of low oxygen levels, no blockage.\n\n[Consultations / Therapy Reports]{.underline}\n\nPsychological Support Consultation from 01/22/2017\n\n[Current Situation/History:]{.underline}\n\nThe patient initially discussed \\\"night episodes\\\" in the calves, which\nover time manifested during the day and were coupled with discomfort in\nthe cervical region. Prior, she had visited the Riverside Medical Center\nmultiple times before an MRI was executed. A \\\"mass in the neck\\\" was\nidentified. Since she suffers from fear of heights and fear of crowds,\nthe MRI could only be done under mild sedation. The phobias emerged\nabruptly in 2011 with no apparent cause, leading to multiple hospital\nvisits. She is now in outpatient care. Additionally, she battles with\nMS, with the most recent flare-up in 2012. She declined a procedure,\nwhich was set for the MRI is day, because \\\"two sedatives in one day\nfelt excessive.\\\" She anticipates avoiding a repeated procedure.\nCurrently, however, she still experiences spasms in her right hand and a\nnumbing sensation in her fingers. She still encounters discomfort (NRS\n5/10). She was previously informed that relief might be gradual, but she\nis \\\"historically been restless\\\". Therefore, \\\"resting and inactivity\\\"\nnegatively impact her spirits and rest.\n\n[Medical background:]{.underline}\n\nSeveral in-patient and day clinic admissions since 2011.\n\nNow, from 2015, continuous outpatient psychological counseling (CBT),\nsomatic therapy, particular sessions for driving anxieties. Also\nundergoing outpatient psychiatric care (fluoxetine 90mg).\n\n[Psychopathological Observations:]{.underline}\n\nPatient appears well-groomed, responsive and clear-minded, talkative and\nforthright. Aware of location, date, and identity. Adequate focus,\nrecall, and concentration. Mental organization is orderly. No evidence\nof delusional beliefs or identity disturbances. No compulsions, mentions\nfear of expansive spaces and fear of water. Emotional responsiveness\nintact, heightened psychomotor activity. Mood swings between despondent\nand irritable, lowered motivation. Diminished appetite, issues with\nsleep initiation and maintenance. Firm and believable denial of\nimmediate suicidal thoughts, patient appears cooperative. No current\nsigns of self-harm or threat to others.\n\n[Handling the Condition, Strengths:]{.underline}\n\nCurrently, her coping strategy seems to be proactive with some restless\nelements. Ms. S. says she remains \\\"optimistic\\\" and is well-backed by\nher communal links. Notably, she shares a close bond with her\n80-year-old aunt. Her other social bonds primarily arise from her\nassociation with a hockey enthusiasts club. Hockey has been a crucial\nsupport for her from a young age.\n\n[Evaluation Diagnoses:]{.underline}\n\nAdjustment disorder: anxiety and depressive reaction mixed\n\nAgoraphobia\n\nAcrophobia\n\n[Interventions, approaches:]{.underline}\n\nAn evaluative and assistive discussion was conducted. The patient has a\ndependable therapeutic community for post-hospitalization. Additionally,\nshe was provided the contact of the psychological support outpatient\ncenter. She mentioned finding the therapeutic conversation comforting,\nprompting an arranged check-in the subsequent week. We also suggest\nguidance in self-initiated physical activities to aid her recovery and\ntemper restlessness.\n\n**NC: Consultation of 01/15/2017**\n\n[Examination findings:]{.underline}\n\nPatient alert, fully oriented. Articulate and spontaneous speech.\nCranial nerve evaluation normal. No evident sensorimotor abnormalities.\nBDK with voiding challenges. Sphincter response diminished, but fecal\ncontrol maintained. KPPS at 85%. Wound site clean and non-irritated,\nexcept for the lower central portion.\n\n[Procedure:]{.underline}\n\nNeurosurgical intervention not required; no reassessment of the lower\nwound needed. Advise return if neurological symptoms intensify.\n\nThe patient, diagnosed with relapsing-remitting multiple sclerosis that\ninitially manifested aggressively, has been relapse-free on fingolimod\nsince 2009 and was generally well, barring a slight imbalance when\nwalking due to minor weakness in her left leg. She later experienced\nnumbness and weakness in her legs, reaching up to the hip, persisting\nfor several days and then faced challenges with urination and bowel\nmovements approximately 7 weeks prior. During a home examination, a\nlesion was identified in the T10 which was surgically addressed by our\nin-house neurosurgery team. Histology identified it as a DLBCL, leading\nto a chemotherapy plan inclusive of Rituximab. Post-surgery, her\nsymptoms have subsided somewhat, but the patient still has BDK and\nrelies on a wheelchair.\n\nOn clinical neurological assessment, a mild paraparesis was noted in her\nleft leg, accompanied by heightened reflex response and sporadic left\nfoot spasms, which were intense but temporary.\n\nTo conclude, the new neurological manifestations are not a recurrence of\nthe formerly stable multiple sclerosis. As Rituximab is also an\neffective third-phase drug for MS treatment and is essential,\ndiscontinuing fingolimod (second phase) was discussed with the patient.\nAfter a span of approximately 4-5 months following the last Rituximab\ntreatment, a radiological (cMRI) and clinical review is suggested. Based\non results, either resuming fingolimod or, if no adverse effects\npresent, potentially continuing Rituximab treatment is recommended (for\nthis, reach our neuroimmunology outpatient department). The primary\nneurologist was unavailable for comments.\n\n**Boards**\n\nOncology tumor board as of 01/22/2017\n\n6 cycles of R-Pola-CHP\n\n[Pathology]{.underline}\n\nPathology. Findings from 01/05/2017\n\n[Clinical information/question:]{.underline}\n\nTumor cuff T10. dignity? Entity? Macroscopy:\n\n1st lamina T10: fixed. some assembled 0.7 x 0.5 x 0.2 cm calcareous\ntissue fragments. Complete embedding. Decalcify in EDTA. 2nd ligament:\nFix. some assembled 0.9 x 0.7 x 0.2 cm, coarse, partly also calcareous\ntissue fragments. Complete embedding. Decalcify overnight in EDTA.\n\n3\\. epidural tumor: Numerous beige-colored tissue fragments, 3.8 x 2.8 x\n0.6 cm. Embedding of exemplary sections after lamellation.\n\n[Processing]{.underline}: 1 block, HE. Microscopy:\n\n1\\. and 2. (lamina T10 and ligament) are still being decalcified.\n\n3rd epidural tumor: Paravertebral soft tissue with infiltrates of a\npartly lymphoid, partly blastic neoplasia. The tumor cells are diffuse,\nsometimes nodular in the tissue and have hyperchromatic nuclei with\ncoarse-grained chromatin and a narrow cytoplasmic border. There are also\nblastic cells with enlarged nuclei, vesicular chromatin, and sometimes\nprominent nucleoli. The stroma is loose and vacuolated. Clearly\npronounced crush artifacts.\n\nPreliminary report of critical findings:\n\n3\\. epidural tumor: paravertebral soft tissue with infiltrates of\nlymphoid and blastic cells compatible with hematologic neoplasia.\n\nAdditional immunohistochemical staining is being performed to further\ncharacterize the tumor. In addition, material 1 (lamina T10) and\nmaterial 2 (ligament) are still undergoing decalcification. A follow-up\nreport will be provided.\n\nProcessing: 2 blocks, decalcification, HE, Giemsa, IHC: CD20, PAX5,\nBcl2, Bcl6, CD5, CD3, CD23, CD21, Kappa, Lambda, CD10, c-Myc, CyclinD1,\nCD30, MIB1, EBV/EBER.\n\nMolecular pathology: testing for B-cell clonal expansion and IgH/Bcl2\ntranslocation.\n\n[Microscopy]{.underline}:\n\n1\\. Ligament: Scarred connective tissue and fragmented bone tissue\nwithout evidence of the tumor described in the preliminary findings\nunder 3.\n\n2\\. Lamina T10: Bone tissue without evidence of the tumor described in\nthe preliminary findings under 3.\n\n3\\. Epidural tumor: Immunohistochemically, blastic tumor cells show a\npositive reaction after incubation with antibodies against CD20, PAX5\nand BCL2. Partially positive reaction against Bcl-6 (\\<20%). Some\nisolated blastic cells staining positive for CD30. Lymphoid cells\npositive for CD3 and CD5. Some residual germinal centers with positive\nreaction to CD23 and CD21. Predominantly weak positive reaction of\nblasts and lymphoid cells to CD10. Some solitary cells with positive\nreaction to kappa, rather unspecific, flat reaction to lambda. No\noverexpression of c-Myc or cyclinD1. No\n\nNo reaction to EBV/EBER. The Ki-67 proliferation index is 40%, related\nto blastic tumor cells \\> 90%.\n\nSignificantly limited evaluability of immunohistochemical staining due\nto severe squeezing artifacts of the material.\n\n[Molecular pathology report:]{.underline}\n\nExamination for clonal B-cell expansion and t(14;18) translocation\nMethodology:\n\nDNA was isolated from the sent tissues and used in duplicate in specific\nPCRs (B-cell clonality analysis with Biomed-2 primer sets: IGHG1 gene:\nscaffold 2 and 3). The size distribution of the PCR products was further\nanalyzed by fragment analysis.\n\nTo detect a BCL2/IgH fusion corresponding to a t(14;18) translocation,\nDNA was inserted into a specific PCR (according to Stetler-Stevenson et\nal. Blood. 1998;72:1822-25).\n\nResults:\n\nAmplification of isolated DNA: good. B cell clonality analyses\n\nIGHG1 fragment 2: polyclonal signal pattern.\n\nIGHG1 frame 3: reproducible clonal signal at approximately 115/116 bp.\nt(14;18) translocation: negative.\n\n[Molecular pathology report:]{.underline}\n\nMolecular pathologic evidence of clonal B-cell expansion. No evidence of\nt(14;18) translocation in test material with normal control reactions.\n\nPreliminary critical findings report:\n\n1\\. Lamina TH 10: tumor-free bone tissue.\n\n2\\. Ligament: Tumor-free, scarred connective tissue and fragmented bone\ntissue.\n\n3\\. Epidural tumor: aggressive B non-Hodgkin\\'s lymphoma.\n\nFindings (continued)\n\nAdditional findings from 01/06/2017\n\nImmunohistochemical processing: MUM1, ALK1, CD68, TdT. Microscopy:\n\n3\\. Immunohistochemically, blastic tumor cells are positive for MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\nCritical findings report:\n\n1\\. Lamina T10: Tumor-free bone tissue. 2: Tumor free, scarred connective\ntissue and fragmented bone tissue.\n\n3\\. epidural tumor: aggressive B-non-Hodgkin lymphoma, morphologically\nand immunohistochemically most compatible with diffuse large B-cell\nlymphoma (DLBCL, NOS) of germinal center type according to Hans\nclassifier (GCB).\n\n**Path. Findings from 01/05/2017**\n\nClinical Findings\n\nClinical data:\n\nInitial diagnosis of DLBCL with spinal involvement.\n\nPuncture Site(s): 1\n\nCollection date: 01/04/2017\n\nArrival at cytology lab: 01/04/2017, 8 PM. Material:\n\n1 Liquid Material: 2 mL colorless, clear Processing:\n\nMGG staining Microscopic:\n\nZTA:\n\nLiquid precipitate Erythrocytes\n\n(+) Lymphocytes (+) Granulocytes\n\nEosinophils Histiocytes Siderophages\n\n\\+ Monocytes\n\nOthers: Isolated evidence of fewer monocytes. No evidence of atypical\ncells. Critical report of findings:\n\nCSF sediment without evidence of inflammation or malignancy. Diagnostic\nGrading:\n\nNegative\n\nTherapy and course\n\nMrs. S was admitted from the neurosurgical department for chemotherapy\n(R-POLA-CHP) of suspected DLBCL with spinal/vertebral manifestations.\n\nAfter exclusion of clinical and laboratory contraindications,\nantineoplastic therapy was started on 01/08/2017. This was well\ntolerated under the usual supportive measures. There were no acute\ncomplications.\n\nDuring her hospitalization, Ms. S reported numbness in both vascular\nhemispheres. A neurosurgical and neurological presentation was made\nwithout acute need for action. In consultation with the neurology\ndepartment, the existing therapy with fingolimod should be discontinued\ndue to the concomitant use of rituximab and the associated risk of PML.\nIf necessary, re-exposure to fingolimod may be considered after\ncompletion of oncologic therapy.\n\nOn 01/07/2017, a port placement was performed by our vascular surgery\ndepartment without complications.\n\nOn 01/19/2017, a single administration of Pegfilgrastim 6 mg s.c. was\nperformed. With a latency of 10 days, G-CSF should not be repeated in\nthe meantime.\n\nWe are able to transfer Mrs. S to the Mountain Hospital Center\n(Neurological Initial Therapy & Recovery) on 02/01/2017. We thank you\nfor accommodating the patient and are available for any additional\ninquiries.\n\n**Medications at Discharge**\n\n**Aspirin (Aspirin®)** - 100mg, 1 tablet in the morning\n\n**Atorvastatin - 40mg -** 1 tablet at bedtime\n\n**Sertraline - 50mg** - 2 tablets in the morning\n\n**Lorazepam (Tavor®)** - 1mg, as needed\n\n**Fingolimod** - 0.5mg, 1 capsule at bedtime, Note: Take a break as\ndirected\n\n**Hydromorphone hydrochloride** - 2mg (extended-release), 2 capsules in\nthe morning and 2 capsules at bedtime\n\n**Melatonin -** 2mg (sustained-release), 1 tablet at bedtime\n\n**Baclofen (Lioresal®) -** 10mg, 1 tablet three times a day\n\n**Pregabalin -** 75mg, 1 capsule in the morning and 1 capsule at bedtime\n\n**MoviCOL® (Macrogol, Sodium chloride, Potassium chloride) -** 1 packet\nthree times a day, mixed with water for oral intake\n\n**Pantoprazole -** 40mg, 1 tablet in the morning\n\n**Colecalciferol (Vitamin D3) -** 20000 I.U., 1 capsule on Monday and\nThursday\n\n**Co-trimoxazole -** 960mg, 1 tablet on Monday, Wednesday, and Friday\n\n**Valaciclovir -** 500mg, 1 tablet in the morning and 1 tablet at\nbedtime\n\n**Prednisolone -** 50mg, 2 tablets in the morning, Continue through\n02/19/2017\n\n**Enoxaparin sodium (Clexane®) -** 40mg (4000 I.U.), 1 injection at\nbedtime, Note: Continue in case of immobility\n\n**Dimenhydrinate (Vomex A®)** - 150mg (sustained-release), as needed for\nnausea, up to 2 capsules daily.\n\n**Procedure**\n\n**Oncology board decision: 6 cycles of R-Pola-CHP.**\n\n- Fingolimod pause, re-evaluation in 4-5 months.\n\n- Continuation of therapy near residence in the clinic as of\n 02/28/2017\n\n- Bi-Weekly laboratory tests (electrolytes, blood count, kidney and\n liver function tests)\n\n- In case of fever \\>38.3 °C please report immediately to our\n emergency room\n\n- Immediate gynecological examination for nodular mass in the left\n breast\n\nDates:\n\n- From 03/01/2017 third cycle of R-Pola-CHP in the clinic. The patient\n will be informed of the date by telephone.\n\nIf symptoms persist or exacerbate, we advocate for an urgent revisit.\nOutside standard working hours, emergencies can also be addressed at the\nemergency hub.\n\nDuring discharge management, the patient was extensively educated and\nassisted, and equipped with required appliances, medication scripts, and\nabsence from work notices.\n\nAll observations were thoroughly deliberated upon. Multiple alternate\ntherapy notions were considered before making a treatment proposition.\nThe opportunity for a second viewpoint and recommendation to our\nfacility was also emphasized.\n\n**Lab values at discharge: **\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 136 mEq/L 135 - 145 mEq/L\n Potassium 3.9 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.2 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 19 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 138 U/L 40 - 129 U/L\n Total Bilirubin 0.3 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 82 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 42 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 34 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 366 U/L \\< 244 U/L\n Uric Acid 4.1 mg/dL 3 - 7 mg/dL\n Calcium 9.0 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>60 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 64 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 2.5 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 103% 70 - 120%\n INR 1.0 N/A\n aPTT 25 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- ---------------- ---------------------\n WBC 12.71 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 2.9 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.1 g/dL 14 - 18 g/dL\n Hematocrit 24.7% 40 - 48%\n MCH 28 pg 27 - 32 pg\n MCV 86 fL 82 - 92 fL\n MCHC 32.8 g/dL 32 - 36 g/dL\n Platelets 257 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 77% 40 - 70%\n Lymphocytes 4% 25 - 40%\n Monocytes 18% 4 - 10%\n Eosinophils 0% 2 - 4%\n Basophils 0% 0 - 1%\n\n\n\n### text_1\n**Dear colleague, **\n\nI am writing to provide a follow-up report on our mutual patient, Mrs.\nAnna Sample, born on January 1st, 1970, post her recent visit to our\nclinic on October 9th, 2017.\n\nUpon assessment, Mrs. Sample reported experiencing a moderate\nimprovement in symptoms since the initiation of the R-Pola-CHP regimen.\nThe discomfort in her dorsal calf and thoracic spine has notably\nreduced, and her arm strength has seen gradual improvement, though she\noccasionally still encounters difficulty in grasping objects.\n\nShe has been undergoing physiotherapy to aid in the recovery of her arm\nstrength.\n\n**Physical Examination:** No palpable lymphadenopathy. Her neurological\nexamination was stable with no new deficits.\n\n**Laboratory Findings:** Most recent blood counts and biochemistry\npanels showed a trend towards normalization, with liver enzymes within\nthe reference range.\n\n**Imaging:**\n\n-Ultrasound of the abdomen was conducted.\n\n-A follow-up MRI conducted showed a reduction in the size of the\npreviously noted metastatic masses. There\\'s a decreased impingement on\nthe myelon at the levels of T10-L1. The lesions in L2, L3, and L4 also\nshowed signs of regression.\n\n-PET scan was performed: Favourable response. Increased FDG avidity in\nthe liver: Liver MRI recommended.\n\n-Liver MRI: No pathology of the liver.\n\n**Senological Examination:** The nodule-like deposit in the right breast\nwas found to be benign.\n\n**Medication on admission:** Aspirin (Aspirin®) - 100mg, 1 tablet in the\nmorning Atorvastatin - 40mg - 1 tablet at bedtime Sertraline - 50mg - 2\ntablets in the morning Lorazepam (Tavor®) - 1mg, as needed Fingolimod -\n0.5mg, 1 capsule at bedtime, Note: Take a break as directed\nHydromorphone hydrochloride - 2mg (extended-release), 2 capsules in the\nmorning and 2 capsules at bedtime Melatonin - 2mg (sustained-release), 1\ntablet at bedtime Baclofen (Lioresal®) - 10mg, 1 tablet three times a\nday Pregabalin - 75mg, 1 capsule in the morning and 1 capsule at bedtime\nMoviCOL® (Macrogol, Sodium chloride, Potassium chloride) - 1 packet\nthree times a day, mixed with water for oral intake Pantoprazole - 40mg,\n1 tablet in the morning Colecalciferol (Vitamin D3) - 20000 I.U., 1\ncapsule on Monday and Thursday Co-trimoxazole - 960mg, 1 tablet on\nMonday, Wednesday, and Friday Valaciclovir - 500mg, 1 tablet in the\nmorning and 1 tablet at bedtime Prednisolone - 50mg, 2 tablets in the\nmorning, Continue through 02/19/2017 Enoxaparin sodium (Clexane®) - 40mg\n(4000 I.U.), 1 injection at bedtime, Note: Continue in case of\nimmobility Dimenhydrinate (Vomex A®) - 150mg (sustained-release), as\nneeded for nausea, up to 2 capsules daily.\n\n**Physician\\'s report for ultrasound on 10/05/2017:**\n\nLiver: The liver is large with 18.1 cm in the MCL, 18.5 cm in the CCD\nand 20.2 cm in the AL. The internal structure is not compacted. Focal\nchanges are not seen. Orthograde flow in the portal vein (vmax 16 cm/s).\nGallbladder: the gallbladder is 9.0 x 2.9 cm, the lumen is free of\nstones.\n\nBiliary tract: The intra- and extrahepatic bile ducts are not\nobstructed, DHC 5 mm, DC 3 mm.\n\nPancreas: The pancreas is approximately 3.2/1.5/3.0 cm in size, the\ninternal structure is moderately echo-rich.\n\nSpleen: The spleen is 28.0 x 9.6 cm, the parenchyma is homogeneous.\n\nKidneys: The right kidney is 9.8/2.0 cm, the pelvis is not congested.\nThe left kidney is 12.4/1.2 cm, the pelvis is not congested. Vessels\nretroperitoneal: the aorta is normal in width in the partially visible\narea.\n\nStomach/intestine: The gastric corpus wall is up to 14 mm thick. No\nevidence of free fluid in the abdominal cavity.\n\nBladder/genitals: The prostate is orientationally about 3.8 x 4.8 x 3.1\ncm, the urinary bladder is moderately full.\n\n**MR Spine plain + post-contrast from 10/06/2017**\n\n**Study:** Magnetic Resonance Imaging (MRI) of the thoracolumbar spine\n\n**Clinical Information:** Follow-up MRI post treatment for previously\nnoted metastatic masses.\n\n**Technique:** Standard T1-weighted, T2-weighted, and post-contrast\nenhanced sequences of the thoracolumbar spine were obtained in sagittal\nand axial planes.\n\n**Findings:** There is a reduction in the size of the previously noted\nmetastatic masses when compared to prior MRI studies. A reduced mass\neffect is observed at the levels of T10-L1. Notably, there is decreased\nimpingement on the myelon at these levels. This indicates a significant\nimprovement, suggesting a positive response to the recent therapy. The\nlesion noted in the previous study at the level of L2 has shown signs of\nregression in both size and intensity. Similar regression is noted for\nthe lesion at the L3 level. The lesion at the L4 level has also\ndecreased in size as compared to previous imaging. The intervertebral\ndiscs show preserved hydration. No significant disc protrusions or\nherniations are observed. The vertebral bodies do not show any\nsignificant collapse or deformity. Bone marrow signal is otherwise\nnormal, apart from the aforementioned lesions. The spinal canal\nmaintains a normal caliber throughout, and there is no significant canal\nstenosis. The conus medullaris and cauda equina nerve roots appear\nunremarkable without evidence of displacement or compression.\n\n**Impression:** Reduction in the size of previously noted metastatic\nmasses, indicating a positive therapeutic response. Decreased\nimpingement on the myelon at the levels of T10-L1, suggesting\nsignificant regression of the previously observed mass effect.\nRegression of lesions at L2, L3, and L4 levels, further indicating the\npositive response to treatment.\n\n**Positron Emission Tomography (PET)/CT from 10/09/2017:**\n\n**Indication:** Follow-up evaluation of Diffuse large B-cell lymphoma of\ngerminal center type diagnosed in 01/2017.\n\n**Technique:** Whole-body FDG-PET/CT was performed from the base of the\nskull to the mid-thighs.\n\n**Findings:** Liver: There is increased FDG uptake in the liver,\npredominantly in the anterolateral segment. The size of the liver is\nconsistent with the previous ultrasound report, measuring 18.1 cm in the\nMCL, 18.5 cm in the CCD, and 20.2 cm in the AL. The SUV max is 5.5.\nLymph Nodes: There is no pathological FDG uptake in the previously noted\nleft axillary lymph node, suggesting a therapeutic response. Lungs:\nPreviously noted deposit in the ventral left upper lobe now demonstrates\nreduced FDG avidity. No other FDG-avid nodules or masses. Bone: There\\'s\nno FDG uptake in the spine, including the previously described\nmetastatic lesion, indicating a positive response to treatment.\n\n**Impression:** Overall, the findings demonstrate a marked metabolic\nimprovement in the sites of lymphoma previously noted, particularly in\nthe left axillary lymph node and the vertebral bone lesions. The liver,\nhowever, presents with increased FDG avidity, especially in the\nanterolateral segment. This uptake might represent active lymphomatous\ninvolvement or could be due to an inflammatory process. Given the\ndifferential, and to ascertain the etiology, further diagnostic\nevaluation, such as a liver MRI or biopsy, is recommended.\n\n**Liver MRI from 10/11/2017:**\n\n**Clinical Indication:** Evaluation of increased FDG uptake in the liver\nas noted on the recent PET scan. Concern for active lymphomatous\ninvolvement or an inflammatory process.\n\n**Technique:** MRI of the liver was performed using a 3T scanner.\nSequences included T1-weighted (in-phase and out-of-phase), T2-weighted,\ndiffusion-weighted imaging (DWI), and post-contrast dynamic imaging\nafter the administration of gadolinium-based contrast agent.\n\n**Detailed Findings:** The liver demonstrates enlargement with\nmeasurements consistent with the recent ultrasound: 18.1 cm in the\nmid-clavicular line (MCL), 18.5 cm in the maximum cranial-caudal\ndiameter (CCD), and 20.2 cm along the anterior line (AL).\n\nThe liver parenchyma is mostly homogenous. However, there is a region in\nthe anterolateral segment demonstrating T2 hyperintensity and\nhypointensity on T1-weighted images. The aforementioned region in the\nanterolateral segment demonstrates restricted diffusion, suggestive of\nincreased cellular density. After gadolinium administration, there is\nperipheral enhancement of the lesion in the arterial phase, followed by\nprogressive central filling in portal venous and delayed phases. This\npattern is suggestive of a focal nodular hyperplasia (FNH) or atypical\nhemangioma. The intrahepatic and extrahepatic bile ducts are not\ndilated. No evidence of any obstructing lesion. The hepatic arteries,\nportal vein, and hepatic veins appear patent with no evidence of\nthrombosis or stenosis. The gallbladder, pancreas, spleen, and adjacent\nsegments of the bowel appear normal. No lymphadenopathy is noted in the\nporta hepatis or celiac axis.\n\n**Impression:** Enlarged liver with a suspicious lesion in the\nanterolateral segment demonstrating characteristics that might be\nconsistent with focal nodular hyperplasia or atypical hemangioma. No\nindication of lymphomatous involvement of the liver.\n\n**Discussion: **\n\nGiven her positive response to the treatment so far, we intend to\ncontinue with the current regimen, with careful monitoring of her side\neffects and symptomatology.\n\nWe deeply appreciate your continued involvement in Mrs. Sample\\'s\nhealthcare journey. Collaborative care is paramount, especially in cases\nas complex as hers. Should you have any recommendations, insights, or if\nyou require additional information, please do not hesitate to reach out.\n\n**Medication at discharge: **\n\nAspirin 100mg: Take 1 tablet in the morning; Atorvastatin 40mg: Take 1\ntablet at bedtime; Sertraline 50mg: Take 2 tablets in the morning;\nLorazepam 1mg: Take as needed; Melatonin (sustained-release) 2mg: Take 1\ntablet at bedtime; Fingolimod 0.5mg: Take 1 capsule at bedtime/take a\nbreak as directed; Hydromorphone hydrochloride (extended-release) 2mg:\nTake 2 capsules in the morning and 2 capsules at bedtime; Pregabalin\n75mg: Take 1 capsule in the morning and 1 capsule at bedtime; Baclofen\n10mg: Take 1 tablet three times a day; MoviCOL®: Mix 1 packet with water\nand take orally three times a day; Pantoprazole 40mg: Take 1 tablet in\nthe morning; Colecalciferol (Vitamin D3) 20000 I.U.: Take 1 capsule on\nMonday and Thursday; Dimenhydrinate (sustained-release) 150mg: Take as\nneeded for nausea, up to 2 capsules daily.\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 135 - 145 mEq/L\n Potassium 4.1 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 17 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 124 U/L 40 - 129 U/L\n Total Bilirubin 0.4 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 75 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 39 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 36 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 342 U/L \\< 244 U/L\n Uric Acid 3.8 mg/dL 3 - 7 mg/dL\n Calcium 9.12 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>62 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 67 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 1.8 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 105% 70 - 120%\n INR 0.98 N/A\n aPTT 28 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- --------------- ---------------------\n WBC 11.9 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 3.1 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.4 g/dL 14 - 18 g/dL\n Hematocrit 26% 40 - 48%\n MCH 27.8 pg 27 - 32 pg\n MCV 84 fL 82 - 92 fL\n MCHC 33 g/dL 32 - 36 g/dL\n Platelets 263 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 73% 40 - 70%\n Lymphocytes 7% 25 - 40%\n Monocytes 16% 4 - 10%\n Eosinophils 1% 2 - 4%\n Basophils 0.5% 0 - 1%\n\n\n\n\nHere is the query:\nWhich chronic, neuroinflammatory disease does Mrs. Sample suffer from? \n\nChoose the correct answer from the following options:\nA. Multiple sclerosis\nB. Dementia\nC. Parkinson\nD. Brain abscess\nE. Autoimmune encephalitis\n\n\nYour response:\n", "role": "user" }, { "content": "Multiple sclerosis", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Anna Sample, born on\n01.01.1970. She was admitted to our clinic from 01/01/2017 to\n01/02/2017.\n\n**Diagnosis:** Diffuse large B-cell lymphoma of germinal center type; ID\n01/2017\n\n- Ann-Arbor: Stage IV\n\n- R-IPI: 2 (LDH, stage)\n\n- CNS-IPI: 2\n\n- Histology: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\n translocation. Ki-67 at 40%. Positive reaction to MUM1, numerous\n CD68-positive macrophages. Negative reaction to ALK1 and TdT.\n\n- cMRI: Chronic inflammatory lesions suggestive of Multiple Sclerosis (MS)\n\n- CSF: no evidence of malignancy\n\n- Bone marrow aspiration: no infiltration from the pre-existing\n lymphoma.\n\n**Current treatment: **\n\nInitiated R-Pola-CHP regimen q21\n\n- Polatuzumab vedotin: 1.8mg/kg on Day 1.\n\n- Rituximab: 375mg/m² on Day 0.\n\n- Cyclophosphamide: 750mg/m² on Day 1.\n\n- Doxorubicin: 50mg/m on Day 1.\n\n- Prednisone: 100mg orally from Day 1-5.\n\n**Previous therapy and course**\n\nFrom 12/01/2016: Discomfort in the dorsal calf and thoracic spine,\nweakness in the arms with limited ability to lift and grasp, occasional\ndizziness.\n\n12/19/2016 cMRI: chronic inflammatory marks indicative of MS. \n\n12/20/2016 MRI: thoracic/lumbar spinal cord: Indication of a\nmetastatic mass starting from the left pedicle T1 with a significant\nextraosseous tumor element and full spinal narrowing at the level of\nT10-L1 with pressure on the myelon and growth into the neuroforamen\nT11/T12 on the right and T12/L1 left. More lesions suggestive for\nmetastasis are L2, L3, and L4, once more with extraosseous tumor element\nand invasion of the left pedicle.\n\n12/21/2016 Fixed dorsal support T8-9 to L3-4. Decompression via\nlaminectomy T10 and partial laminectomy lumbar vertebra 3.\n\n12/24/2016 CT chest/abdomen/pelvis: Magnified left axillary lymph node.\nIn the ventral left upper lobe, indication of a round, loose, cloudy\ndeposit, i.e., of inflammatory origin, follow-up in 5-7 weeks.\nNodule-like deposit in the upper inner quadrant of the right breast,\nsenological examination suggested.\n\n**Pathology**: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\ntranslocation. Ki-67 staining was at 40%. Positive reaction to MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\n**Other diagnoses**\n\n- Primary progressive type of multiple sclerosis (ID 03/02) \n\n- Mood disorder.\n\n- 2-vessel CHD\n\n**Medical History**\n\nMrs. Sample was transferred inpatient from DC for the initiation of\nchemotherapy (R-Pola-CHP) for her DLBCL. In the context of her\npre-existing ALS, she presented on 12/19/2016 with acute pains and\nrestricted mobility in her upper limbs. After her admission to HK\nFlowermoon, an MRI was performed which revealed a thoracic neoplastic\ngrowth especially at the level of T10-L1, but also affecting lumbar\nvertebra 3, L4 and L6. Surgical intervention on 12/21/2016 at DC\nresulted in symptom relief. Presently, her complaints are restricted to\npost-operative spine discomfort, shoulder hypoesthesia, and intermittent\nhand numbness. She reported a weight loss of 5 kg during her\nhospitalization. She denied having respiratory symptoms, infections,\nsystemic symptoms, or gastrointestinal complaints. Mrs. Sample currently\nhas a urinary catheter in place.\n\n**Physical examination on admission**\n\nGeneral: The patient has a satisfactory nutritional status, normal\nweight, and is dependent on a walker. Her functional status is evaluated\nas ECOG 2. Cardiovascular: Regular heart rhythm at a normal rate. Heart\nsounds are clear with no detected murmurs. Respiratory: Normal alveolar\nbreath sounds. No wheezing, stridor, or other abnormal sounds.\nAbdominal: The abdomen is soft, non-tender, and non-distended with\nnormal bowel sounds in all quadrants. There is no palpable enlargement\nof the liver or spleen, and the kidneys are not palpable.\nMusculoskeletal: Tenderness noted in the cervical and thoracic spine\narea, but no other remarkable findings. This is consistent with her\npost-operative status. Lymphatic: No enlargement detected in the\ntemporal, occipital, cubital, or popliteal lymph nodes. Oral: The oral\nmucosa is moist and well-perfused. The oropharynx is unremarkable, and\nthe tongue appears normal. Peripheral Vascular: Pulses in the hands are\nstrong and regular. No edema observed. Neurological: Cranial nerves are\nintact. There is numbness in both hands and mild hypoesthesia in the\nshoulders. Motor strength is 3/5 in the right arm, attributed to her\nknown ALS diagnosis. No other motor or sensory deficits noted.\nOccasional bladder incontinence and intermittent gastrointestinal\ndisturbances are reported.\n\n**Medications on admission**\n\nAcetylsalicylic acid (Aspirin®) 100 mg: Take 1 tablet in the morning.\nAtorvastatin (Lipitor®) 40 mg: Take 1 tablet in the evening. Fingolimod\n(Gilenya®) 0.5 mg: Take 1 capsule in the evening. Sertraline (Zoloft®)\n50 mg: Take 2 tablets in the morning. Hydromorphone (Dilaudid® or\nExalgo® for extended-release) 2 mg: Take 1 capsule in the morning and 1\nin the evening. Lorazepam (Ativan®) 1 mg: 1 tablet as needed.\n\n**Radiology/Nuclear Medicine**\n\n**MR Head 3D unenhanced + contrast from 12/19/2016 10:30 AM**\n\n**Technique:** Sequences obtained include 3D FLAIR, 3D DIR, 3D T2, SWI,\nDTI/DWI, plain MPRAGE, and post-contrast MPRAGE. All images are of good\nquality. Imaging area: Brain.\n\nThere are 20 FLAIR hyperintense lesions in the brain parenchyma,\nspecifically located periventricularly and in the cortical/juxtacortical\nregions (right and left frontal, left temporal, and right and left\ninsular). No contrast-enhancing lesions are identified. There are also\nsubcortical/nonspecific lesions present, with some lesions appearing\nconfluent. The spinal cord is visualized up to the C4 level. No spinal\nlesions are noted.\n\n[Incidental findings:]{.underline}\n\n- Brain volume assessment: no indication of reduced brain volume.\n\n- CSF space: age-appropriate usual wide, moderate, and symmetric CSF\n spacing with no signs of CSF flow abnormalities.\n\n- Cortical-Subcortical Differentiation: Clear cortical-subcortical\n distinction.\n\n- RML-characteristic alterations: none detected.\n\n- Eye socket: appears normal.\n\n- Nasal cavities: Symmetric mucosal thickening with a focus on the\n right ethmoidal sinus.\n\n- Pituitary and peri-auricular region: no abnormalities.\n\n- Subcutaneous lesion measuring 14.4 x 21.3 mm, right parietal likely\n representing an inflamed cyst or abscess, differential includes soft\n tissue growth.\n\n[Evaluation]{.underline}\n\nDissemination: MRI standards for spatial distribution are satisfied. MRI\ncriteria for temporal distribution are unfulfilled. Comprehensive\nneurological review: The findings are consistent with a chronic\ninflammatory CNS disease in the sense of Multiple Sclerosis.\n\n**MR Spine plain + post-contrast from 12/20/2016 10:00 AM**\n\n**Technique:** GE 3T MRI Scanner\n\nMRI was conducted under anesthesia due to claustrophobia.\n\n**Sequences**: Holospinal T2 Dixon sagittal, T1 pre-contrast, T1 fs\npost-contrast. The spine is visualized from the craniocervical junction\nto S2.\n\n**Thoracic spine: **\n\nOn T2-STIR and T2, there is a hyperintense signal of vertebral bodies T5\nand T6 with inconsistent delineation of the vertebral endplates,\nindicative of age-related changes. There is a reduction in the height of\nthe disc spaces T4/5 and T5/6 with subligamentous disc protrusion\nleading to a spongy appearance of the spinal cord at this location.\nMyelon atrophy is noted at T5/6, along with a T2 bright lesion\nsuggestive of MS at the level of T3 and also T4/5. Spine: A large\nintraspinal mass extends from T10-L1, causing an anterior spongy\nappearance of the spinal cord and resulting in complete spinal canal\nstenosis at this level. On fat-only imaging, there is almost total\nreplacement of the marrow space of vertebral body T11 with external\ntumor extension and infiltration into the lateral structures (more on\nthe left than the right) and neural foramen T11 on both sides. There is\nmild disc herniation at T8/9 with slight sponginess of the spinal cord.\nMS-characteristic spinal cord lesions are noted at segments T5 and T8/9.\n\n**Lumbar spine: **\n\nT2-DIXON shows bright signal intensity of the anterior part of lumbar\nvertebra 1, a patchy appearance of lumbar vertebra 2, and lumbar\nvertebra 4. Almost the entire marrow space is replaced in the fat-only\nimaging. There is an external tumor mass posterior to lumbar vertebra 4\nwithout significant spinal canal stenosis, which involves the left\nlateral structure and a pronounced appearance of the cauda equina at\nlumbar vertebra 1. A call to communicate the results was made at 11:15\na.m. to the on-duty orthopedic surgeon and to colleagues in neurology.\nEvaluation Evidence of a metastatic lesion originating from the left\npedicle of T10 with a significant extramedullary tumor mass and full\nspinal canal narrowing at the level of T10 with compression of the\nspinal cord and extension into the neural foramen T11-T12 on the right,\nand T12-L1 on the left. Additional sites suggestive of metastasis\ninclude L2, L3, and L4, again with extramedullary tumor components and\ninvasion of the left lateral structure. Contrast enhancement of the\ndistal cord is noted. There are MS-characteristic spinal cord lesions at\nthe levels of T3, T4-5, T5, and T8-9. The conus medullaris is not\nvisualized due to spinal cord displacement.\n\n\n**CT Thoracic Spine from 01/03/2017**\n\n[Clinical Findings]{.underline}\n\nLateral and medial alignment is stable. No sign of vertebral column\ndamage. Multiple segment degenerative alterations in the spine. No\nindications of mineralization in the recognized space at the level of\nT10/L2. Invasion of T10 and L4 with composite osteolytic-osteoblastic\ndefects starting from the left pedicle into the vertebral column. More\ncortical inconsistency with enhanced sclerosis at the endplate of L2.\nReview with prior MRI indicative of a different composite defect. Defect\npit at the endplate of lumbar vertebra 2.\n\nMinor pericardial effusion with nearby superior ventilation. Intubation\ntube placed. Mild cardiomediastinum. Splenomegaly. Standard display of\nthe tissue organs of the mid-abdomen, as naturally observed. Normal\nspleen. Thin adrenals. Tightly raised kidney bowls and leading ureter\nfrom both aspects, e.g., upon entry during the exhalation period after\ngadolinium inclusion in the earlier MRI. No bowel obstruction.\nIntestinal stasis. No sign of abnormally magnified lymphatic vessels.\nRemaining pin holes in the femoral head on both sides.\n\n[Evaluation]{.underline}\n\nComposite osteolytic-osteoblastic defects starting from the left pedicle\nin T10 and lumbar vertebra 4, and at the endplate of lumbar vertebra 2.\n\n**CT Thoracic Spine from 01/04/2017 **\n\nIntraoperative CT imaging for enhanced guidance.\n\nTwo intraoperative CT scans were undertaken in total.\n\nOn the concluding CT scan, recently implanted non-radiopaque pedicle\nscrews T8-9 to L2-L3 at tumor band T10. Regular screw placement. No\nevident sign of material breakage.\n\nApart from this, no notable alteration in findings from CT of\n01/03/2017.\n\nEvaluation Intraoperative CT imaging for better guidance. Recently\ninserted pedicle screws T8/T9 and L2/L3 in tumor indication T10,\nultimate standard screw positioning done transpedicular.\n\n**CT Chest/Abdomen/Pelvis + Contrast from 01/09/2017**\n\nResults: After uneventful intravenous administration of Omnipaque 320, a\nmulti-slice helical CT of the chest, abdomen, and pelvis was performed\nduring the venous phase of contrast enhancement. Additional oral\ncontrast was given using Gastrografin (diluted 1:35). Thin slice\nreconstructions were obtained, along with secondary coronal and sagittal\nreconstructions.\n\n[Thorax]{.underline}:\n\nUniform presentation of the apical thoracic sections when included. No \nevidence of subclavian lymphadenopathy. Uniform visualization of the pectoral \ntissues. No evidence of mediastinal lymphadenopathy. The anterior segment \nof the left upper lobe (series 205, image 88 of 389) shows a subpleural \nground-glass opaque solid consolidation. There is an enlarged lymph node \nin the left hilar region measuring approximately 1.2 cm laterally. Otherwise, \nthere are no signs of suspicious intrapulmonary markings, no new inflammatory \ninfiltrates, no pneumothorax, no pericardial effusion. In the upper inner \nquadrant of the right breast there is an oval mass, DD cystadenoma, \nDD glandular cluster (measuring 1.2 cm).\n\n[Abdomen/pelvis: ]{.underline}\n\nDominant display of the gastrocolic junction; absence of oral contrast\nin this zone prevents more detailed analysis. Uniformly displayed\nhepatic tissue with no signs of focal, density-varied lesions. Portal\nand liver veins are well filled. Liver with minor auxiliary liver.\nAdrenal nodes thin on both sides. Natural kidneys on both sides. Urinary\nsac with placed transurethral tube and intravesical gas pockets.\nGallbladder typical. Paravertebral and within vertebral and in the\ndomain of the superior hepatic artery multiple pronounced lymph nodes,\nthese up to a maximum of 8 mm. Typical representation of the organs in\nthe pelvic region.\n\n[Skeleton: ]{.underline}\n\nCondition post dorsal reinforcement (T8-T9-L2-L3). After surgery,\nepidermal air pockets and bloated tissue inflammation in the access path\nzone. Signs of a resin in a pre-spinal vessel anterior to T8 and T9.\nKnown mixed osteoblastic/osteolytic bony metastasis of lumbar vertebra 4\nand the cap plate of lumbar vertebra 2. State post-cutting of the\npedicle of T10. L5 also with slightly multiple solidified core\nosteolytic defects.\n\n[Evaluation:]{.underline}\n\n- No sign of primary malignancy in the previously mentioned mixed\n osteoblastic/osteolytic lesions in the vertebra (to be deemed\n suspicious in coordination with the MR review of 12/20/2016).\n\n- A magnified lymph node exists in the left hilar territory. In the\n anterior left upper lobe, evidence of a solid cloudy consolidation,\n i.e., of inflammatory origin, revisitation in 5-7 weeks recommended.\n\n- Rounded consolidation in the upper inner quadrant of the right\n breast, further breast examination advised.\n\n**Functional Diagnostics**\n\nExtended Respiratory Function (Diffusion) from 01/15/2017\n\n[Evaluation]{.underline}\n\nPatient cooperation: satisfactory. No detectable obstructive ventilation\nissue. No pulmonary over-expansion after RV/TLC. No identified\nrestrictive ventilation impairment. Standard O2 diffusion ability. No\nevidence of low oxygen levels, no blockage.\n\n[Consultations / Therapy Reports]{.underline}\n\nPsychological Support Consultation from 01/22/2017\n\n[Current Situation/History:]{.underline}\n\nThe patient initially discussed \\\"night episodes\\\" in the calves, which\nover time manifested during the day and were coupled with discomfort in\nthe cervical region. Prior, she had visited the Riverside Medical Center\nmultiple times before an MRI was executed. A \\\"mass in the neck\\\" was\nidentified. Since she suffers from fear of heights and fear of crowds,\nthe MRI could only be done under mild sedation. The phobias emerged\nabruptly in 2011 with no apparent cause, leading to multiple hospital\nvisits. She is now in outpatient care. Additionally, she battles with\nMS, with the most recent flare-up in 2012. She declined a procedure,\nwhich was set for the MRI is day, because \\\"two sedatives in one day\nfelt excessive.\\\" She anticipates avoiding a repeated procedure.\nCurrently, however, she still experiences spasms in her right hand and a\nnumbing sensation in her fingers. She still encounters discomfort (NRS\n5/10). She was previously informed that relief might be gradual, but she\nis \\\"historically been restless\\\". Therefore, \\\"resting and inactivity\\\"\nnegatively impact her spirits and rest.\n\n[Medical background:]{.underline}\n\nSeveral in-patient and day clinic admissions since 2011.\n\nNow, from 2015, continuous outpatient psychological counseling (CBT),\nsomatic therapy, particular sessions for driving anxieties. Also\nundergoing outpatient psychiatric care (fluoxetine 90mg).\n\n[Psychopathological Observations:]{.underline}\n\nPatient appears well-groomed, responsive and clear-minded, talkative and\nforthright. Aware of location, date, and identity. Adequate focus,\nrecall, and concentration. Mental organization is orderly. No evidence\nof delusional beliefs or identity disturbances. No compulsions, mentions\nfear of expansive spaces and fear of water. Emotional responsiveness\nintact, heightened psychomotor activity. Mood swings between despondent\nand irritable, lowered motivation. Diminished appetite, issues with\nsleep initiation and maintenance. Firm and believable denial of\nimmediate suicidal thoughts, patient appears cooperative. No current\nsigns of self-harm or threat to others.\n\n[Handling the Condition, Strengths:]{.underline}\n\nCurrently, her coping strategy seems to be proactive with some restless\nelements. Ms. S. says she remains \\\"optimistic\\\" and is well-backed by\nher communal links. Notably, she shares a close bond with her\n80-year-old aunt. Her other social bonds primarily arise from her\nassociation with a hockey enthusiasts club. Hockey has been a crucial\nsupport for her from a young age.\n\n[Evaluation Diagnoses:]{.underline}\n\nAdjustment disorder: anxiety and depressive reaction mixed\n\nAgoraphobia\n\nAcrophobia\n\n[Interventions, approaches:]{.underline}\n\nAn evaluative and assistive discussion was conducted. The patient has a\ndependable therapeutic community for post-hospitalization. Additionally,\nshe was provided the contact of the psychological support outpatient\ncenter. She mentioned finding the therapeutic conversation comforting,\nprompting an arranged check-in the subsequent week. We also suggest\nguidance in self-initiated physical activities to aid her recovery and\ntemper restlessness.\n\n**NC: Consultation of 01/15/2017**\n\n[Examination findings:]{.underline}\n\nPatient alert, fully oriented. Articulate and spontaneous speech.\nCranial nerve evaluation normal. No evident sensorimotor abnormalities.\nBDK with voiding challenges. Sphincter response diminished, but fecal\ncontrol maintained. KPPS at 85%. Wound site clean and non-irritated,\nexcept for the lower central portion.\n\n[Procedure:]{.underline}\n\nNeurosurgical intervention not required; no reassessment of the lower\nwound needed. Advise return if neurological symptoms intensify.\n\nThe patient, diagnosed with relapsing-remitting multiple sclerosis that\ninitially manifested aggressively, has been relapse-free on fingolimod\nsince 2009 and was generally well, barring a slight imbalance when\nwalking due to minor weakness in her left leg. She later experienced\nnumbness and weakness in her legs, reaching up to the hip, persisting\nfor several days and then faced challenges with urination and bowel\nmovements approximately 7 weeks prior. During a home examination, a\nlesion was identified in the T10 which was surgically addressed by our\nin-house neurosurgery team. Histology identified it as a DLBCL, leading\nto a chemotherapy plan inclusive of Rituximab. Post-surgery, her\nsymptoms have subsided somewhat, but the patient still has BDK and\nrelies on a wheelchair.\n\nOn clinical neurological assessment, a mild paraparesis was noted in her\nleft leg, accompanied by heightened reflex response and sporadic left\nfoot spasms, which were intense but temporary.\n\nTo conclude, the new neurological manifestations are not a recurrence of\nthe formerly stable multiple sclerosis. As Rituximab is also an\neffective third-phase drug for MS treatment and is essential,\ndiscontinuing fingolimod (second phase) was discussed with the patient.\nAfter a span of approximately 4-5 months following the last Rituximab\ntreatment, a radiological (cMRI) and clinical review is suggested. Based\non results, either resuming fingolimod or, if no adverse effects\npresent, potentially continuing Rituximab treatment is recommended (for\nthis, reach our neuroimmunology outpatient department). The primary\nneurologist was unavailable for comments.\n\n**Boards**\n\nOncology tumor board as of 01/22/2017\n\n6 cycles of R-Pola-CHP\n\n[Pathology]{.underline}\n\nPathology. Findings from 01/05/2017\n\n[Clinical information/question:]{.underline}\n\nTumor cuff T10. dignity? Entity? Macroscopy:\n\n1st lamina T10: fixed. some assembled 0.7 x 0.5 x 0.2 cm calcareous\ntissue fragments. Complete embedding. Decalcify in EDTA. 2nd ligament:\nFix. some assembled 0.9 x 0.7 x 0.2 cm, coarse, partly also calcareous\ntissue fragments. Complete embedding. Decalcify overnight in EDTA.\n\n3\\. epidural tumor: Numerous beige-colored tissue fragments, 3.8 x 2.8 x\n0.6 cm. Embedding of exemplary sections after lamellation.\n\n[Processing]{.underline}: 1 block, HE. Microscopy:\n\n1\\. and 2. (lamina T10 and ligament) are still being decalcified.\n\n3rd epidural tumor: Paravertebral soft tissue with infiltrates of a\npartly lymphoid, partly blastic neoplasia. The tumor cells are diffuse,\nsometimes nodular in the tissue and have hyperchromatic nuclei with\ncoarse-grained chromatin and a narrow cytoplasmic border. There are also\nblastic cells with enlarged nuclei, vesicular chromatin, and sometimes\nprominent nucleoli. The stroma is loose and vacuolated. Clearly\npronounced crush artifacts.\n\nPreliminary report of critical findings:\n\n3\\. epidural tumor: paravertebral soft tissue with infiltrates of\nlymphoid and blastic cells compatible with hematologic neoplasia.\n\nAdditional immunohistochemical staining is being performed to further\ncharacterize the tumor. In addition, material 1 (lamina T10) and\nmaterial 2 (ligament) are still undergoing decalcification. A follow-up\nreport will be provided.\n\nProcessing: 2 blocks, decalcification, HE, Giemsa, IHC: CD20, PAX5,\nBcl2, Bcl6, CD5, CD3, CD23, CD21, Kappa, Lambda, CD10, c-Myc, CyclinD1,\nCD30, MIB1, EBV/EBER.\n\nMolecular pathology: testing for B-cell clonal expansion and IgH/Bcl2\ntranslocation.\n\n[Microscopy]{.underline}:\n\n1\\. Ligament: Scarred connective tissue and fragmented bone tissue\nwithout evidence of the tumor described in the preliminary findings\nunder 3.\n\n2\\. Lamina T10: Bone tissue without evidence of the tumor described in\nthe preliminary findings under 3.\n\n3\\. Epidural tumor: Immunohistochemically, blastic tumor cells show a\npositive reaction after incubation with antibodies against CD20, PAX5\nand BCL2. Partially positive reaction against Bcl-6 (\\<20%). Some\nisolated blastic cells staining positive for CD30. Lymphoid cells\npositive for CD3 and CD5. Some residual germinal centers with positive\nreaction to CD23 and CD21. Predominantly weak positive reaction of\nblasts and lymphoid cells to CD10. Some solitary cells with positive\nreaction to kappa, rather unspecific, flat reaction to lambda. No\noverexpression of c-Myc or cyclinD1. No\n\nNo reaction to EBV/EBER. The Ki-67 proliferation index is 40%, related\nto blastic tumor cells \\> 90%.\n\nSignificantly limited evaluability of immunohistochemical staining due\nto severe squeezing artifacts of the material.\n\n[Molecular pathology report:]{.underline}\n\nExamination for clonal B-cell expansion and t(14;18) translocation\nMethodology:\n\nDNA was isolated from the sent tissues and used in duplicate in specific\nPCRs (B-cell clonality analysis with Biomed-2 primer sets: IGHG1 gene:\nscaffold 2 and 3). The size distribution of the PCR products was further\nanalyzed by fragment analysis.\n\nTo detect a BCL2/IgH fusion corresponding to a t(14;18) translocation,\nDNA was inserted into a specific PCR (according to Stetler-Stevenson et\nal. Blood. 1998;72:1822-25).\n\nResults:\n\nAmplification of isolated DNA: good. B cell clonality analyses\n\nIGHG1 fragment 2: polyclonal signal pattern.\n\nIGHG1 frame 3: reproducible clonal signal at approximately 115/116 bp.\nt(14;18) translocation: negative.\n\n[Molecular pathology report:]{.underline}\n\nMolecular pathologic evidence of clonal B-cell expansion. No evidence of\nt(14;18) translocation in test material with normal control reactions.\n\nPreliminary critical findings report:\n\n1\\. Lamina TH 10: tumor-free bone tissue.\n\n2\\. Ligament: Tumor-free, scarred connective tissue and fragmented bone\ntissue.\n\n3\\. Epidural tumor: aggressive B non-Hodgkin\\'s lymphoma.\n\nFindings (continued)\n\nAdditional findings from 01/06/2017\n\nImmunohistochemical processing: MUM1, ALK1, CD68, TdT. Microscopy:\n\n3\\. Immunohistochemically, blastic tumor cells are positive for MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\nCritical findings report:\n\n1\\. Lamina T10: Tumor-free bone tissue. 2: Tumor free, scarred connective\ntissue and fragmented bone tissue.\n\n3\\. epidural tumor: aggressive B-non-Hodgkin lymphoma, morphologically\nand immunohistochemically most compatible with diffuse large B-cell\nlymphoma (DLBCL, NOS) of germinal center type according to Hans\nclassifier (GCB).\n\n**Path. Findings from 01/05/2017**\n\nClinical Findings\n\nClinical data:\n\nInitial diagnosis of DLBCL with spinal involvement.\n\nPuncture Site(s): 1\n\nCollection date: 01/04/2017\n\nArrival at cytology lab: 01/04/2017, 8 PM. Material:\n\n1 Liquid Material: 2 mL colorless, clear Processing:\n\nMGG staining Microscopic:\n\nZTA:\n\nLiquid precipitate Erythrocytes\n\n(+) Lymphocytes (+) Granulocytes\n\nEosinophils Histiocytes Siderophages\n\n\\+ Monocytes\n\nOthers: Isolated evidence of fewer monocytes. No evidence of atypical\ncells. Critical report of findings:\n\nCSF sediment without evidence of inflammation or malignancy. Diagnostic\nGrading:\n\nNegative\n\nTherapy and course\n\nMrs. S was admitted from the neurosurgical department for chemotherapy\n(R-POLA-CHP) of suspected DLBCL with spinal/vertebral manifestations.\n\nAfter exclusion of clinical and laboratory contraindications,\nantineoplastic therapy was started on 01/08/2017. This was well\ntolerated under the usual supportive measures. There were no acute\ncomplications.\n\nDuring her hospitalization, Ms. S reported numbness in both vascular\nhemispheres. A neurosurgical and neurological presentation was made\nwithout acute need for action. In consultation with the neurology\ndepartment, the existing therapy with fingolimod should be discontinued\ndue to the concomitant use of rituximab and the associated risk of PML.\nIf necessary, re-exposure to fingolimod may be considered after\ncompletion of oncologic therapy.\n\nOn 01/07/2017, a port placement was performed by our vascular surgery\ndepartment without complications.\n\nOn 01/19/2017, a single administration of Pegfilgrastim 6 mg s.c. was\nperformed. With a latency of 10 days, G-CSF should not be repeated in\nthe meantime.\n\nWe are able to transfer Mrs. S to the Mountain Hospital Center\n(Neurological Initial Therapy & Recovery) on 02/01/2017. We thank you\nfor accommodating the patient and are available for any additional\ninquiries.\n\n**Medications at Discharge**\n\n**Aspirin (Aspirin®)** - 100mg, 1 tablet in the morning\n\n**Atorvastatin - 40mg -** 1 tablet at bedtime\n\n**Sertraline - 50mg** - 2 tablets in the morning\n\n**Lorazepam (Tavor®)** - 1mg, as needed\n\n**Fingolimod** - 0.5mg, 1 capsule at bedtime, Note: Take a break as\ndirected\n\n**Hydromorphone hydrochloride** - 2mg (extended-release), 2 capsules in\nthe morning and 2 capsules at bedtime\n\n**Melatonin -** 2mg (sustained-release), 1 tablet at bedtime\n\n**Baclofen (Lioresal®) -** 10mg, 1 tablet three times a day\n\n**Pregabalin -** 75mg, 1 capsule in the morning and 1 capsule at bedtime\n\n**MoviCOL® (Macrogol, Sodium chloride, Potassium chloride) -** 1 packet\nthree times a day, mixed with water for oral intake\n\n**Pantoprazole -** 40mg, 1 tablet in the morning\n\n**Colecalciferol (Vitamin D3) -** 20000 I.U., 1 capsule on Monday and\nThursday\n\n**Co-trimoxazole -** 960mg, 1 tablet on Monday, Wednesday, and Friday\n\n**Valaciclovir -** 500mg, 1 tablet in the morning and 1 tablet at\nbedtime\n\n**Prednisolone -** 50mg, 2 tablets in the morning, Continue through\n02/19/2017\n\n**Enoxaparin sodium (Clexane®) -** 40mg (4000 I.U.), 1 injection at\nbedtime, Note: Continue in case of immobility\n\n**Dimenhydrinate (Vomex A®)** - 150mg (sustained-release), as needed for\nnausea, up to 2 capsules daily.\n\n**Procedure**\n\n**Oncology board decision: 6 cycles of R-Pola-CHP.**\n\n- Fingolimod pause, re-evaluation in 4-5 months.\n\n- Continuation of therapy near residence in the clinic as of\n 02/28/2017\n\n- Bi-Weekly laboratory tests (electrolytes, blood count, kidney and\n liver function tests)\n\n- In case of fever \\>38.3 °C please report immediately to our\n emergency room\n\n- Immediate gynecological examination for nodular mass in the left\n breast\n\nDates:\n\n- From 03/01/2017 third cycle of R-Pola-CHP in the clinic. The patient\n will be informed of the date by telephone.\n\nIf symptoms persist or exacerbate, we advocate for an urgent revisit.\nOutside standard working hours, emergencies can also be addressed at the\nemergency hub.\n\nDuring discharge management, the patient was extensively educated and\nassisted, and equipped with required appliances, medication scripts, and\nabsence from work notices.\n\nAll observations were thoroughly deliberated upon. Multiple alternate\ntherapy notions were considered before making a treatment proposition.\nThe opportunity for a second viewpoint and recommendation to our\nfacility was also emphasized.\n\n**Lab values at discharge: **\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 136 mEq/L 135 - 145 mEq/L\n Potassium 3.9 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.2 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 19 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 138 U/L 40 - 129 U/L\n Total Bilirubin 0.3 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 82 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 42 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 34 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 366 U/L \\< 244 U/L\n Uric Acid 4.1 mg/dL 3 - 7 mg/dL\n Calcium 9.0 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>60 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 64 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 2.5 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 103% 70 - 120%\n INR 1.0 N/A\n aPTT 25 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- ---------------- ---------------------\n WBC 12.71 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 2.9 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.1 g/dL 14 - 18 g/dL\n Hematocrit 24.7% 40 - 48%\n MCH 28 pg 27 - 32 pg\n MCV 86 fL 82 - 92 fL\n MCHC 32.8 g/dL 32 - 36 g/dL\n Platelets 257 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 77% 40 - 70%\n Lymphocytes 4% 25 - 40%\n Monocytes 18% 4 - 10%\n Eosinophils 0% 2 - 4%\n Basophils 0% 0 - 1%\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nI am writing to provide a follow-up report on our mutual patient, Mrs.\nAnna Sample, born on January 1st, 1970, post her recent visit to our\nclinic on October 9th, 2017.\n\nUpon assessment, Mrs. Sample reported experiencing a moderate\nimprovement in symptoms since the initiation of the R-Pola-CHP regimen.\nThe discomfort in her dorsal calf and thoracic spine has notably\nreduced, and her arm strength has seen gradual improvement, though she\noccasionally still encounters difficulty in grasping objects.\n\nShe has been undergoing physiotherapy to aid in the recovery of her arm\nstrength.\n\n**Physical Examination:** No palpable lymphadenopathy. Her neurological\nexamination was stable with no new deficits.\n\n**Laboratory Findings:** Most recent blood counts and biochemistry\npanels showed a trend towards normalization, with liver enzymes within\nthe reference range.\n\n**Imaging:**\n\n-Ultrasound of the abdomen was conducted.\n\n-A follow-up MRI conducted showed a reduction in the size of the\npreviously noted metastatic masses. There\\'s a decreased impingement on\nthe myelon at the levels of T10-L1. The lesions in L2, L3, and L4 also\nshowed signs of regression.\n\n-PET scan was performed: Favourable response. Increased FDG avidity in\nthe liver: Liver MRI recommended.\n\n-Liver MRI: No pathology of the liver.\n\n**Senological Examination:** The nodule-like deposit in the right breast\nwas found to be benign.\n\n**Medication on admission:** Aspirin (Aspirin®) - 100mg, 1 tablet in the\nmorning Atorvastatin - 40mg - 1 tablet at bedtime Sertraline - 50mg - 2\ntablets in the morning Lorazepam (Tavor®) - 1mg, as needed Fingolimod -\n0.5mg, 1 capsule at bedtime, Note: Take a break as directed\nHydromorphone hydrochloride - 2mg (extended-release), 2 capsules in the\nmorning and 2 capsules at bedtime Melatonin - 2mg (sustained-release), 1\ntablet at bedtime Baclofen (Lioresal®) - 10mg, 1 tablet three times a\nday Pregabalin - 75mg, 1 capsule in the morning and 1 capsule at bedtime\nMoviCOL® (Macrogol, Sodium chloride, Potassium chloride) - 1 packet\nthree times a day, mixed with water for oral intake Pantoprazole - 40mg,\n1 tablet in the morning Colecalciferol (Vitamin D3) - 20000 I.U., 1\ncapsule on Monday and Thursday Co-trimoxazole - 960mg, 1 tablet on\nMonday, Wednesday, and Friday Valaciclovir - 500mg, 1 tablet in the\nmorning and 1 tablet at bedtime Prednisolone - 50mg, 2 tablets in the\nmorning, Continue through 02/19/2017 Enoxaparin sodium (Clexane®) - 40mg\n(4000 I.U.), 1 injection at bedtime, Note: Continue in case of\nimmobility Dimenhydrinate (Vomex A®) - 150mg (sustained-release), as\nneeded for nausea, up to 2 capsules daily.\n\n**Physician\\'s report for ultrasound on 10/05/2017:**\n\nLiver: The liver is large with 18.1 cm in the MCL, 18.5 cm in the CCD\nand 20.2 cm in the AL. The internal structure is not compacted. Focal\nchanges are not seen. Orthograde flow in the portal vein (vmax 16 cm/s).\nGallbladder: the gallbladder is 9.0 x 2.9 cm, the lumen is free of\nstones.\n\nBiliary tract: The intra- and extrahepatic bile ducts are not\nobstructed, DHC 5 mm, DC 3 mm.\n\nPancreas: The pancreas is approximately 3.2/1.5/3.0 cm in size, the\ninternal structure is moderately echo-rich.\n\nSpleen: The spleen is 28.0 x 9.6 cm, the parenchyma is homogeneous.\n\nKidneys: The right kidney is 9.8/2.0 cm, the pelvis is not congested.\nThe left kidney is 12.4/1.2 cm, the pelvis is not congested. Vessels\nretroperitoneal: the aorta is normal in width in the partially visible\narea.\n\nStomach/intestine: The gastric corpus wall is up to 14 mm thick. No\nevidence of free fluid in the abdominal cavity.\n\nBladder/genitals: The prostate is orientationally about 3.8 x 4.8 x 3.1\ncm, the urinary bladder is moderately full.\n\n**MR Spine plain + post-contrast from 10/06/2017**\n\n**Study:** Magnetic Resonance Imaging (MRI) of the thoracolumbar spine\n\n**Clinical Information:** Follow-up MRI post treatment for previously\nnoted metastatic masses.\n\n**Technique:** Standard T1-weighted, T2-weighted, and post-contrast\nenhanced sequences of the thoracolumbar spine were obtained in sagittal\nand axial planes.\n\n**Findings:** There is a reduction in the size of the previously noted\nmetastatic masses when compared to prior MRI studies. A reduced mass\neffect is observed at the levels of T10-L1. Notably, there is decreased\nimpingement on the myelon at these levels. This indicates a significant\nimprovement, suggesting a positive response to the recent therapy. The\nlesion noted in the previous study at the level of L2 has shown signs of\nregression in both size and intensity. Similar regression is noted for\nthe lesion at the L3 level. The lesion at the L4 level has also\ndecreased in size as compared to previous imaging. The intervertebral\ndiscs show preserved hydration. No significant disc protrusions or\nherniations are observed. The vertebral bodies do not show any\nsignificant collapse or deformity. Bone marrow signal is otherwise\nnormal, apart from the aforementioned lesions. The spinal canal\nmaintains a normal caliber throughout, and there is no significant canal\nstenosis. The conus medullaris and cauda equina nerve roots appear\nunremarkable without evidence of displacement or compression.\n\n**Impression:** Reduction in the size of previously noted metastatic\nmasses, indicating a positive therapeutic response. Decreased\nimpingement on the myelon at the levels of T10-L1, suggesting\nsignificant regression of the previously observed mass effect.\nRegression of lesions at L2, L3, and L4 levels, further indicating the\npositive response to treatment.\n\n**Positron Emission Tomography (PET)/CT from 10/09/2017:**\n\n**Indication:** Follow-up evaluation of Diffuse large B-cell lymphoma of\ngerminal center type diagnosed in 01/2017.\n\n**Technique:** Whole-body FDG-PET/CT was performed from the base of the\nskull to the mid-thighs.\n\n**Findings:** Liver: There is increased FDG uptake in the liver,\npredominantly in the anterolateral segment. The size of the liver is\nconsistent with the previous ultrasound report, measuring 18.1 cm in the\nMCL, 18.5 cm in the CCD, and 20.2 cm in the AL. The SUV max is 5.5.\nLymph Nodes: There is no pathological FDG uptake in the previously noted\nleft axillary lymph node, suggesting a therapeutic response. Lungs:\nPreviously noted deposit in the ventral left upper lobe now demonstrates\nreduced FDG avidity. No other FDG-avid nodules or masses. Bone: There\\'s\nno FDG uptake in the spine, including the previously described\nmetastatic lesion, indicating a positive response to treatment.\n\n**Impression:** Overall, the findings demonstrate a marked metabolic\nimprovement in the sites of lymphoma previously noted, particularly in\nthe left axillary lymph node and the vertebral bone lesions. The liver,\nhowever, presents with increased FDG avidity, especially in the\nanterolateral segment. This uptake might represent active lymphomatous\ninvolvement or could be due to an inflammatory process. Given the\ndifferential, and to ascertain the etiology, further diagnostic\nevaluation, such as a liver MRI or biopsy, is recommended.\n\n**Liver MRI from 10/11/2017:**\n\n**Clinical Indication:** Evaluation of increased FDG uptake in the liver\nas noted on the recent PET scan. Concern for active lymphomatous\ninvolvement or an inflammatory process.\n\n**Technique:** MRI of the liver was performed using a 3T scanner.\nSequences included T1-weighted (in-phase and out-of-phase), T2-weighted,\ndiffusion-weighted imaging (DWI), and post-contrast dynamic imaging\nafter the administration of gadolinium-based contrast agent.\n\n**Detailed Findings:** The liver demonstrates enlargement with\nmeasurements consistent with the recent ultrasound: 18.1 cm in the\nmid-clavicular line (MCL), 18.5 cm in the maximum cranial-caudal\ndiameter (CCD), and 20.2 cm along the anterior line (AL).\n\nThe liver parenchyma is mostly homogenous. However, there is a region in\nthe anterolateral segment demonstrating T2 hyperintensity and\nhypointensity on T1-weighted images. The aforementioned region in the\nanterolateral segment demonstrates restricted diffusion, suggestive of\nincreased cellular density. After gadolinium administration, there is\nperipheral enhancement of the lesion in the arterial phase, followed by\nprogressive central filling in portal venous and delayed phases. This\npattern is suggestive of a focal nodular hyperplasia (FNH) or atypical\nhemangioma. The intrahepatic and extrahepatic bile ducts are not\ndilated. No evidence of any obstructing lesion. The hepatic arteries,\nportal vein, and hepatic veins appear patent with no evidence of\nthrombosis or stenosis. The gallbladder, pancreas, spleen, and adjacent\nsegments of the bowel appear normal. No lymphadenopathy is noted in the\nporta hepatis or celiac axis.\n\n**Impression:** Enlarged liver with a suspicious lesion in the\nanterolateral segment demonstrating characteristics that might be\nconsistent with focal nodular hyperplasia or atypical hemangioma. No\nindication of lymphomatous involvement of the liver.\n\n**Discussion: **\n\nGiven her positive response to the treatment so far, we intend to\ncontinue with the current regimen, with careful monitoring of her side\neffects and symptomatology.\n\nWe deeply appreciate your continued involvement in Mrs. Sample\\'s\nhealthcare journey. Collaborative care is paramount, especially in cases\nas complex as hers. Should you have any recommendations, insights, or if\nyou require additional information, please do not hesitate to reach out.\n\n**Medication at discharge: **\n\nAspirin 100mg: Take 1 tablet in the morning; Atorvastatin 40mg: Take 1\ntablet at bedtime; Sertraline 50mg: Take 2 tablets in the morning;\nLorazepam 1mg: Take as needed; Melatonin (sustained-release) 2mg: Take 1\ntablet at bedtime; Fingolimod 0.5mg: Take 1 capsule at bedtime/take a\nbreak as directed; Hydromorphone hydrochloride (extended-release) 2mg:\nTake 2 capsules in the morning and 2 capsules at bedtime; Pregabalin\n75mg: Take 1 capsule in the morning and 1 capsule at bedtime; Baclofen\n10mg: Take 1 tablet three times a day; MoviCOL®: Mix 1 packet with water\nand take orally three times a day; Pantoprazole 40mg: Take 1 tablet in\nthe morning; Colecalciferol (Vitamin D3) 20000 I.U.: Take 1 capsule on\nMonday and Thursday; Dimenhydrinate (sustained-release) 150mg: Take as\nneeded for nausea, up to 2 capsules daily.\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 135 - 145 mEq/L\n Potassium 4.1 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 17 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 124 U/L 40 - 129 U/L\n Total Bilirubin 0.4 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 75 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 39 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 36 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 342 U/L \\< 244 U/L\n Uric Acid 3.8 mg/dL 3 - 7 mg/dL\n Calcium 9.12 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>62 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 67 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 1.8 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 105% 70 - 120%\n INR 0.98 N/A\n aPTT 28 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- --------------- ---------------------\n WBC 11.9 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 3.1 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.4 g/dL 14 - 18 g/dL\n Hematocrit 26% 40 - 48%\n MCH 27.8 pg 27 - 32 pg\n MCV 84 fL 82 - 92 fL\n MCHC 33 g/dL 32 - 36 g/dL\n Platelets 263 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 73% 40 - 70%\n Lymphocytes 7% 25 - 40%\n Monocytes 16% 4 - 10%\n Eosinophils 1% 2 - 4%\n Basophils 0.5% 0 - 1%\n", "title": "text_1" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n\n\n\n\nHere is the query:\nWhat abnormality was observed in Mr. Nilsson's ECG on July 2nd 2008?\n\nChoose the correct answer from the following options:\nA. Complete heart block\nB. ST depression and T-wave positivity\nC. Ventricular tachycardia\nD. Prolonged QT interval\nE. Left bundle branch block\n\n\nYour response:\n", "role": "user" }, { "content": "ST depression and T-wave positivity", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n\n\n\n\nHere is the query:\nWhen was Mr. Hurley's Myelodysplastic Syndrome diagnosed as having ring sideroblasts?\n\nChoose the correct answer from the following options:\nA. Jul 10\nB. Aug 20\nC. Dec 19\nD. Jan 20\nE. Jul 21\n\n\nYour response:\n", "role": "user" }, { "content": "Aug 20", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n\n\n\n\nHere is the query:\nHow many biopsies were taken in Mr. Rudolph during the ureterorenoscopy?\n\nChoose the correct answer from the following options:\nA. 5\nB. 6\nC. 8\nD. 10\nE. 12\n\n\nYour response:\n", "role": "user" }, { "content": "8", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nHerewith we report on Mr. John Williams, born 08/08/1956, inpatient from\n10/03/2015 to 10/06/2015.\n\n**Diagnosis:**\n\nMultiple Myeloma IgG kappa.\n\n**Staging and Initial Diagnosis:**\n\nDate: 03/2015\n\nStage: IIA based on the Salmon and Durie scale, ISS II.\n\n- CT whole body 03/11/2015: Osteolysis detected in the seventh\n thoracic vertebra (T7); pathologic fracture observed in the first\n lumbar vertebra (L1).\n\n- Bone marrow infiltration: Initial histological evaluation showed\n 22%; cytomorphological assessment revealed 28%.\n\n**Histological Findings:**\n\nDate: 03/2015\n\n**FISH (Fluorescence In Situ Hybridization) Results:** Detected an\nadditional signal for both CCND1 and CCND3. Presence of one trisomy or\ntetrasomy 9. Additional signals observed for 5p15- and 5q31- as well as\n19p13- and 19q13-. 46, XY with a detected ASxL1 mutation.\n\n**Treatment Timeline:**\n\n**01-02/15:** Administered 2 cycles of\nCyclophosphamide-Bortezomib-Dexamethasone (CyBorD). Resulted in stable\ndisease but caused prolonged pancytopenia.\n\n**03/15 - 06/15:** Administered 3 cycles of a combination treatment\nincluding Carfilzomib, Lenalidomide, and Dexamethasone.\n\n**07/15:** Underwent stem cell mobilization using cyclophosphamide.\n\n**07-08/15:** Experienced extended pancytopenia and regeneration. Bone\nmarrow puncture showed progressive disease with a significant increase\nin plasma cell infiltration, reaching 92%.\n\n**09/02/15:** Received the first dosage of daratumumab at 16mg/kg.\nSubsequently developed thrombocytopenia. Treatment did not include\nRevlimid.\n\n**Histopathological report: **\n\nMultiple myeloma, IgG kappa. The evaluation is for myelodysplastic\nsyndrome in the presence of tricytopenia and an ASXL1 mutation.\n\n**Methods:** Hematoxylin and eosin (HE), periodic acid-Schiff (PAS),\niron, Giemsa, Gomori, chloroacetate esterase, step sections,\ndecalcification, and 1 block.\n\n**Microscopic Examination:**\n\nThe sample is a 2 cm long bone marrow biopsy core that contains more\nthan ten medullary canals. The cellularity is around 20-30%, which is\nconsidered normocellular for the patient\\'s age. There is evidence of\nbone marrow edema and heightened hemosiderosis. Recent stromal\nhemorrhages are also observed. There is a relative increase in\nerythropoiesis with a ratio of erythropoiesis to granulopoiesis being\napproximately 2:1. Erythropoiesis is present in well-defined zones with\nregular maturation. Only minimal nuclear rounding is observed.\nGranulopoiesis matures into segmented granulocytes. PAS staining reveals\nsome morphologically normal megakaryocytes. Occasionally there are bare\nnuclei and possible microforms. Scattered mature plasma cells are\nobserved with no signs of atypical proliferation. The argyrophilic\nfibrous network is fine, and no fibrosis is detected.\n\n**Preliminary Findings:**\n\nThe bone marrow biopsy is normocellular for the age with a relative\nincrease in erythropoiesis that shows only minimal cytological atypia.\nGranulopoiesis is slightly reduced, while megakaryopoiesis is\nnormocellular with a few cells that are hypolobulated.There is bone\nmarrow edema and enhanced hemosiderosis. Scattered mature plasma cells\nare also noted.\n\nBased solely on histomorphologic observations, it is not enough to\nconfirm a diagnosis of myelodysplastic syndrome (MDS), which is the\nsuspected clinical diagnosis. For a more thorough evaluation of\npotential atypicalities in the megakaryopoiesis (like\nmicromegakaryocytes), further immunohistochemical examination is\nrecommended. Assessing the blast content is also advised. There is no\nevidence currently of manifest infiltrates from the previously diagnosed\nmultiple myeloma.\n\n**Immunohistochemical Additional Findings (Dated 10/04/2015):**\n\n**Immunohistochemistry Stains Used:** CD3, CD79a, CD34, CD117, MUM-1,\nKappa, lambda, CyclinD1, CD61.\n\nBlast cells positive for CD34 and CD117 are below 5% of the total. CD3\nstains scattered T lymphocytes, and CD79a identifies sporadic B\nlymphocytes and some plasma cells. Plasma cells are also positive for\nMUM-1 and exhibit polytypic expression of kappa and lambda light chains.\nThere is no co-expression with CyclinD1. CD61 highlights the previously\ndescribed megakaryocytes, and no micromegakaryocytes are observed.\n\n**Final Report:**\n\nThe bone marrow biopsy is representative and normocellular for the\npatient\\'s age. There is a relative increase in erythropoiesis that\nshows only minor cytological atypia. Granulopoiesis appears slightly\nreduced, while megakaryopoiesis presents with a few hypolobulated cell\nforms. Evidence of bone marrow edema and increased hemosiderosis is\nnoted, along with scattered mature plasma cells.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe hereby report on Mr. Williams, John, born 08/08/1956, inpatient from\n11/30/2015 to 12/28/2015.\n\n**Oncological Diagnosis**:\n\nMultiple myeloma IgG kappa.\n\nInitial diagnosis 03/15: Stage IIA (Salmon and Durie), ISS II.\n\n**Sites**:\n\nOsteolysis in T7 vertebra, fracture in T1 vertebra.\n\nBone marrow: 22% histological, 28% cytomorphologic infiltration.\n\n**Histology**:\n\nBone marrow biopsy 11/16: FISH: Additional signals for CCND1, CCND3;\nTrisomy 3, 9; Additional signals on chromosomes 5 and 19. Chromosomal\nanalysis: 46, XY with ASxL1 mutation.\n\n**Treatment**:\n\n01-02/15: 2 cycles Cyclophosphamide-Bortezomib-Dexamethasone -\\>\nStable disease, prolonged low blood counts.\n\n03/15 - 06/15: 3 cycles Carfilzomib/Lenolidomide/Dexamethasone.\n\n07/15: Stem cell mobilization with Cyclophosphamide.\n\n07-08/15: Extended low blood count. Bone marrow biopsy: 92% plasma cell\ninfiltration.\n\n09/02/15: Darzalex 16mg/kg initial dose, with platelet count drop. No\nLenalidomide.\n\n09/04/15: 10 cycles of Darzalex, 1 cycle with Lenalidomide due to\nrenewed low platelet and white blood cell counts.\n\n11-12/15: Conditioning chemo with Fludarabine/Treosulfan, then\nallogeneic stem cell transplant from HLA-matched unrelated donor.\nImmunosuppression with ATG, cyclosporine, Mycophenolate Mofetil.\n\n**Complications**:\n\nMucositis, central line infection, gastrointestinal symptoms, urinary\ninfections with E. faecium and E.coli, JC virus bladder infection.\n\n**Secondary Diagnoses**:\n\nDry eye syndrome, Type 2 diabetes managed with oral meds, Hypertension.\n\n**Treatment Plan**:\n\nGradual reduction of immunosuppression based on graft vs. host disease\nsigns.\n\n**Radiology**:\n\nCT Whole Body: 12/01/15: Various areas of bone osteolysis. Degeneration\nof spine.\n\nCT Chest 12/02/15 and 12/03/15: Changes in lungs and some fluid\naccumulation.\n\n**Medication**:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------- ---------------\n Mycophenolic Acid (Myfortic) 360 mg Twice Daily\n Cyclosporine (Sandimmune) 200 mg Daily\n Artificial Tears As directed 3x Daily\n Candesartan (Atacand) 8 mg Daily\n Tamsulosin (Flomax) 0.4 mg Daily\n Pantoprazole (Protonix) 40 mg Daily\n Amlodipine (Norvasc) 5 mg Twice Daily\n Cotrimoxazole (Bactrim) 960 mg Mon/Wed/Fri\n Valacyclovir (Valtrex) 500 mg Twice Daily\n\n**Summary**:\n\nMr. Williams was admitted on 11/30/2015 for treatment related to his\nMultiple Myeloma. He underwent conditioning chemotherapy,\nimmunosuppressive therapy, and stem cell transplantation. He experienced\ncomplications, including infections and symptoms affecting multiple\nsystems. Close monitoring of blood pressure and glucose is recommended.\nHe was discharged on 12/28/2015 in good condition and will be followed\nup in the outpatient clinic. If there are worsening symptoms, he should\nvisit the emergency department immediately.\n\n**Dear Mr. Williams,**\n\nWe report on your outpatient treatment on 02/15/2016.\n\n**Diagnoses:**\n\n1. **Multiple Myeloma** IgG kappa, diagnosed 03/2015.\n\n Stage IIA as per Salmon and Durie, stage II as per ISS.\n\n Osteolysis at T7 vertebra, fracture at T1 vertebra.\n\n Bone marrow infiltration: 22% histologically, 28% cytologically.\n\n FISH: Indications of additional CCND1 and CCND3 signals; Trisomy 3,\n additional signals at various chromosomes.\n\n Chromosome analysis: 46, XY \\[20\\].\n\n**Secondary diagnoses:**\n\nType 2 diabetes mellitus\n\nHypertension\n\nCataract (surgery 06/2018)\n\nNodular goiter\n\nRSV pneumonia (03/2018)\n\n**Summary:**\n\nMr. Williams presents in good general health to our bone marrow\ntransplant (BMT) outpatient clinic. There are no signs of infection or\nchronic graft rejection. He has shown significant improvement in\nresilience and does not have any complaints. Vital signs are stable.\nBlood tests showed ongoing regeneration with normal light chains and\npersistent positive immunofixation. There is no need for\nmyeloma-specific therapy at present, but close monitoring of the\nparaprotein is required.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ---------------------- -------------------------------------------------------\n Tamsulosin (Flomax) 0.4 mg Daily in the morning\n Candesartan (Atacand) 8 mg Twice Daily\n Metformin (Glucophage) 1000 mg 0.5 tablet in the morning, 1.5 tablets in the evening\n Pantoprazole (Protonix) 20 mg Daily in the morning\n Vitamin D3 (various brands) 20,000 IU Once a week\n Allopurinol (Zyloprim) 100 mg Daily in the morning\n Insulin (various types) As per sliding scale As per sliding scale\n\nWith kind regards\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are providing an update on our shared patient, Mr. John Williams, who\nconsulted with us on June 15, 2018.\n\n**Consultation Summary:**\n\n8. **Multiple Myeloma**\n\n **Kidney biopsy scheduled for tomorrow.**\n\n **Prostate cancer**\n\n**Current Status:**\n\nAcute renal failure accompanied by proteinuria due to the recent\ndiagnosis of multiple myeloma.\n\nMultiple osteolytic lesions, including at the T4, T7, L1 vertebra and\nthe ribs.\n\n**Diagnosis:**\n\nMultiple myeloma.\n\nProstate cancer\n\n**Clinical Presentation:**\n\nOsteolytic lesion presenting as thoracic pain.\n\n**Imaging Findings:**\n\nOsteolytic lesion at T4 vertebra with involvement of the posterior edge.\n\n**Planned Procedures:**\n\nRestricted bed rest.\n\nWhole spine MRI with STIR sequences, to be presented in the upcoming\ntumor board meeting for deciding further course of action.\n\n**Previous Diagnoses:**\n\nMay, 2018, Nephrology: Enlarged kidneys noted bilaterally.\n\nJanuary, 2018, Urology: Prostate cancer\n\nDecember, 2015, Internal Medicine: Multiple myeloma without evidence of\ncomplete remission.\n\n**Previous Procedures:**\n\nTransrectal biopsy of the prostate.\n\n**Histology Report, Date: June 13, 2018:**\n\nSuspected plasmacytoma with paraproteinemia.\n\nWBC 6.47; Hb 10.8; Platelets 251,000.\n\nBone marrow biopsy: Cellularity approximated at 48%, indicating slightly\nincreased cellularity. Amidst reduced hematopoiesis, there is\nproliferation of plasmacytoid cells with certain features.\n\n**Preliminary Report:**\n\nThe bone marrow sample indicates possible infiltration due to plasma\ncell myeloma. Additional tests will be conducted to confirm and further\nelucidate this finding.\n\n**Supplementary Findings:**\n\nImmunohistochemical staining: CD138, Kappa, Lambda, CD20.\n\nMicroscopic findings confirm the presence of nodular infiltrates with\ncertain features.\n\n**Final Report:**\n\nBone marrow sample indicates infiltration by a plasma cell myeloma with\nkappa light chain restriction. Additionally, regular trilinear\nhematopoiesis is significantly reduced.\n\n\n\n### text_3\n**Dear colleague, **\n\nI wish to provide an update on our mutual patient, Mr. John Williams,\nborn 08/08/1956, who presented at our clinic at 08/20/2018.\n\n**Diagnosis:**\n\nPresent condition: Multiple Myeloma IgG type, coded under ICD-10.\n\nStage: II B based on Durie and Salmon criteria; determined from Hb 9.1,\nCreatinine 4.5 mg/dL.\n\n**Histology:**\n\nBone marrow biopsy presents a strong indication of interstitial and\nfocal nodular invasion of the marrow space by plasma cell myeloma,\npredominantly of high to intermediate maturity.\n\n**Immunohistochemistry:**\n\nThe nodular infiltrates were found positive for CD138 with a kappa-light\nchain restriction (infiltration rate at 62%).\n\nCytological findings align with high-grade bone marrow infiltration by\nmultiple myeloma.\n\n**Tumor Localization:**\n\nMRI of the entire spine conducted on 06/20/2018 reveals disseminated\nbone lesions throughout the spine without any soft tissue involvement.\nThere is noted anterior vertebral body involvement at T4.\n\n**Secondary Diagnoses:**\n\nCysts in the right kidney.\n\nAs of 01/2018, a diagnosis of Prostate cancer with a Gleason score of 8\nand a PSA reading of 10.02.\n\nPrevious rib fracture, which may be associated with the multiple\nmyeloma.\n\nChronic renal failure, with ongoing dialysis treatment.\n\nDocumented mitral valve surgery in 2015.\n\nHistory of Deep Vein Thrombosis in 1999.\n\n**Prior Treatments:**\n\nInitial diagnosis of multiple myeloma IgG kappa in 2015.\n\nProstate cancer was diagnosed in 01/2018 following spontaneous rib\nfractures, Gleason score of 8.\n\nA PSMA-PET-CT scan in 05/18 showed multiple bone lesions, notably\npronounced at Th4.\n\nTumor board review in 06/2018 concluded treatment strategies for\nurological tumors, encompassing radiation therapy targeting Th4 and\nantiandrogen therapy for the identified prostate cancer, using a GnRH\nanalog.\n\nThe progression of multiple myeloma required the commencement of\nsystemic treatment with Velcade and Dexamethasone.\n\n**Study**: PSMA-PET-CT Scan\n\n**Date of Study**: 05/2018\n\n**Clinical Information**: Prostate cancer diagnosed in 01/2018 following\nspontaneous rib fractures. Gleason score of 8.\n\n**Technique**:\n\nWhole body positron emission tomography/computed tomography (PET/CT) was\nperformed following the intravenous administration of PSMA-radiotracer.\nCoronal, sagittal, and axial images were acquired and reviewed.\n\n**Findings**:\n\nBone: Notably increased PSMA uptake is seen at the level of T4 vertebral\nbody consistent with metastatic involvement. The lesion has caused\ncortical erosion and expansion with potential involvement of the\nanterior spinal canal. Multiple rib lesions are identified,\ncorresponding with the clinical history of spontaneous rib fractures.\nThese lesions exhibit no increased PSMA uptake. No other foci of\nincreased PSMA uptake throughout the axial and appendicular skeleton.\n\n**Prostate**:\n\n12. The prostate gland demonstrates diffusely increased uptake, which is\n consistent with primary prostate malignancy, especially given the\n known clinical history.\n\n**Thorax/Abdomen: **\n\n13. No abnormal PSMA avid soft tissue masses or lymphadenopathies were\n noted in the visualized fields. No pulmonary nodules or masses\n suggestive of metastatic disease were identified. Liver, spleen,\n kidneys, and adrenal glands appear unremarkable with no evidence of\n metastatic lesions.\n\n**Impression**:\n\nOsseous metastasis from prostate cancer with involvement of the T4\nvertebral body. No evidence of soft tissue, lymph node, or pulmonary\nmetastases in the visualized fields. Prostate gland showing evidence\nconsistent with primary malignancy.\n\n**Current Radiation Therapy:**\n\n**Indication:** Radiotherapy became a consideration due to a sizable\nosteolytic lesion at T4, both for pain alleviation and stabilization.\nConcurrent treatment of the aching ribs on the right side (7th-9th) was\nalso performed.\n\n**Technique:** 6 MeV photons from a linear accelerator, administering a\ncumulative dose of 30 Gy to thoracic vertebra 4 and 20 Gy to the ribs\nwith respective daily doses.\n\n1. **Treatment Duration:**\n\n Th4: 08/21/2018 to 08/27/2018\n\n Rib area: 08/21/2018 to 08/27/2018\n\n**Clinical Update:**\n\nThroughout the therapy period, Mr. Williams remained admitted to our\nOncology ward for ongoing reduced dosage chemotherapy using Velcade. He\nhas reported a decline in pain sensations during this timeframe. The\noverall health status appeared satisfactory, with no skin irritation\nobserved at the irradiated sites.\n\n**Subsequent Actions:**\n\nGuidance on skincare and potential adverse effects have been provided to\nMr. Williams. The intensity of the chemotherapy will soon be escalated.\nA radio-oncological assessment has been scheduled in our outpatient\nfacility for 09/05/2018 at 12:00 PM. I kindly request the most recent\ntest results by this date.\n\n**Note:** In compliance with the Radiation Protection Act, we shall\nundertake regular evaluations and request updates on the patient\\'s\ncondition. Mr. Williams has been apprised of the necessity for\nconsistent oncological check-ups.\n\nWarm regards,\n\n\n\n### text_4\n**Dear colleague, **\n\nWe wish to update you on our mutual patient, Mr. John Williams.\n\n**Diagnosis:**\n\nCurrent multiple myeloma IgG type\n\n**Tumor Localization:**\n\nBased on a whole spine MRI dated June 20, 2018:\n\nMultiple intraosseous lesions throughout the spine without soft tissue\ninvolvement.\n\nKnown intrusion of the T4 cover plate.\n\n**Secondary Diagnoses:**\n\nRight kidney cysts\n\nDiagnosed prostate carcinoma in January 2018, Gleason score 8, initial\nPSA at 10.02.\n\nHistory of a spontaneous rib fracture related to the multiple myeloma.\n\nChronic renal insufficiency; he remains on dialysis.\n\nHistory of mitral valve reconstruction in 2015.\n\nHistory of deep vein thrombosis in 1999.\n\n**Treatment Overview:**\n\nDiagnosed with multiple myeloma type kappa in 2015 with initially normal\nrenal function.\n\nDiagnosed with prostate carcinoma in January 2018 due to spontaneous rib\nfractures, Gleason score 8.\n\nTreatment decisions in 2018 included radiation for vertebral lesions and\nhormone therapy for prostate cancer using a GnRH analogue.\n\nSystemic therapy with Velcade and Dexamethasone initiated due to\nprogressive myeloma.\n\nRadiation therapy in August 2018 for vertebral and rib lesions.\n\n**Summary:**\n\nMr. Williams had a radio-oncological follow-up on September 29, 2018.\nHis general health has improved. He remains on thrice-weekly dialysis.\nRecent CT scans show extensive osteolysis of the spine with several\nvertebral collapses. Currently, we see no urgent fracture risk or need\nfor additional radiation therapy. We have planned regular clinical\ncheck-ups with Mr. Williams. His next follow-up is scheduled in three\nmonths.\n\n**Oncologic treatment: **\n\nDaratumumab/lenalidomide/dexamethasone regimen:\n\nDaratumumab 16mg/kg: Days 1, 8, 15, 22 for cycles 1 & 2 (every 28 days\nfor 8 weeks).\n\nDays 1, 15 for cycles 3-6 (every 28 days for 16 weeks).\n\nDay 1 for subsequent cycles (every 28 days).\n\nDexamethasone 20mg on Daratumumab days, with an additional 20mg the day\nafter (totaling 40mg/week).\n\nLenalidomide 5mg from day 1-21 (every 28 days).\n\nBondronate every 4 weeks (last administered on 12/13/2016).\n\nRe-evaluation of hemodialysis and autologous peripheral blood stem cell\ntransplant (PBSCT) after 2 cycles of daratumumab.\n\n**CT Spine scan (09/30/2018): **\n\n**Technique**: Contrast-enhanced computed tomography (Omnipaque 240) of\nthe thoracic and lumbar spine was performed with axial slices, and\nmultiplanar reconstructions in sagittal and coronal orientations.\n\n**Findings**:\n\n**Thoracic Spine**:\n\nExtensive osteolytic lesions are identified in multiple thoracic\nvertebrae. Specifically, vertebral collapses are noted at T4, T7, T9,\nT11. No significant bony destruction of pedicles, lamina and spinous\nprocesses. No evidence of paravertebral or epidural soft tissue masses.\n\n**Lumbar Spine**:\n\nProminent osteolytic changes are seen in L1 (with fracture) and L4\nvertebral bodies. However, there is no significant vertebral collapse.\nPreserved pedicles, lamina, and spinous Processes without significant\nosteolysis. No evidence of abnormal masses or lymphadenopathy.\n\nNo significant central canal stenosis or neural foraminal narrowing. The\nintervertebral discs are preserved without significant discopathies.\n\n**Impression**:\n\nExtensive osteolysis in multiple vertebral bodies, specifically in the\nthoracic and lumbar spine, with vertebral collapses at levels T4, T7,\nT9, and T11 as well as L1. Also, osteolytic changes in L4 of the lumbar\nspine.\n\nCurrently, based on imaging, there does not appear to be an urgent\nfracture risk, and no radiologic signs suggesting a need for imminent\nradiation therapy. No soft tissue abnormalities identified in the\nexamined regions.\n\n**Medication: **\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ----------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg In the morning (day after Daratumumab)\n Pantoprazole (Protonix) 40 mg Daily in the morning\n Cotrimoxazole (Bactrim) 480 mg Thrice weekly (Mon, Wed, Fri)\n Valacyclovir (Valtrex) 500 mg Daily in the morning\n Acetaminophen (Tylenol) 500 mg Orally, three times daily\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly (4-week depot) subcutaneously\n Pregabalin (Lyrica) 25 mg Twice a day\n Amlodipine (Norvasc) 5 mg Daily in the morning\n Bisoprolol (Zebeta) 5 mg Daily in the morning\n Lenalidomide (Revlimid) 5 mg Nightly\n Ondansetron (Zofran) 8 mg As needed, up to twice daily\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are updating you on Mr. John Williams\\' outpatient visit on December\n13, 2018.\n\n**Diagnosis:**\n\nFebrile respiratory infection.\n\n**Underlying Conditions:**\n\nMultiple myeloma, kappa light chain, stage IIIB as classified by Salmon\nand Durie.\n\nChronic kidney disease requiring hemodialysis.\n\nProstate cancer.\n\n**Summary:**\n\nMr. Williams came to the emergency room with fever and dry cough during\nhis multiple myeloma treatment with Darzalex, Revlimid, and\nDexamethasone. His vital signs were recorded, and laboratory tests\nshowed signs of infection and confirmed chronic kidney disease. Chest\nX-ray indicated possible inflammation. Given these findings, Mr.\nWilliams was admitted for antibiotic therapy. Further observations and\ntreatments were documented.\n\n\n\n### text_6\n**Dear colleague, **\n\nThis letter pertains to Mr. John Williams, who was hospitalized from\nDecember 14 to 21st, 2018.\n\n**Oncological Diagnosis:**\n\nMultiple myeloma, kappa light chain, initially diagnosed in June 2018 as\nstage IIIB per Durie and Salmon criteria.\n\n**Treatment Details:**\n\nHe underwent various treatment regimens for multiple myeloma over the\ncourse of the year. His current condition indicates an\ninfluenza-positive pneumonia, likely with a bacterial superinfection. He\ncontinues hemodialysis thrice a week.\n\n**Secondary Diagnoses:**\n\nSeveral renal complications were documented in June 2018.\n\n**Plan of Care:**\n\nMr. Williams\\' therapy plan was discussed in a tumor board meeting. He\nremains on a regimen of Darzalex, Revlimid, and Dexamethasone.\n\n**Summary:**\n\nMr. Williams came to the emergency room on December 13, 2018, with cough\nand fever. Further details about his history can be found in previous\ncommunications. On admission, he showed signs of a respiratory\ninfection, confirmed by a chest X-ray. He was treated with antibiotics,\nwhich were later escalated. He also tested positive for influenza A and\nwas given Tamiflu. After a short in-patient stay, he has shown\nimprovement. He is scheduled to continue his therapy in our clinic on\nDecember 22, 2018. In case of any complications, he has been advised to\nreturn to our emergency room immediately.\n\nFor future consultations, please provide a referral slip for each new\nquarter.\n\nWarm regards\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to inform you about Mr. John Williams, who was an\ninpatient in our clinic from March 1, 2019, to March 3, 2019.\n\nOncological diagnosis:\n\nMr. Williams was diagnosed with Multiple Myeloma light chain kappa. He\nreceived his follow-up diagnosis in June 2018, which was at stage IIIB\nper the Durie and Salmon staging system.\n\nTreatment:\n\nIn June 2018, he was given VelDex due to impaired renal function.\nSubsequently, he received Carfilzomib (15mg/m2 on days 1-2, 8-9, 15-16),\nLenalidomide (5 mg, on days 1-21), and Dexamethasone (40mg, on days 1,\n8, 15-16, 22). In addition, he was treated with Pomalidomide (4mg on\ndays 1-21), Doxorubicin (9mg/m2 on days 1, 4), and Dexamethasone (40mg,\non days 1, 8, 15, 22). He underwent radiation therapy to T4 of the rib\nthorax in August. Between August to October 2018, he had three cycles of\nPomalidomide, Doxorubicin, and Dexamethasone, after which the disease\nprogressed. From November 2018 to February 2019, he had four cycles of\nDaratumumab, Lenalidomide, and Dexamethasone.\n\n**Outcome:**\n\nThe response to the treatment was very good partial remission (VGPR).\n\n**Present Treatment:**\n\nHe underwent mobilization chemotherapy with cyclophosphamide, with a\ndosage adjusted due to his requirement for dialysis (1500mg/m^2^ on day\n1 and 1000mg/m^2^ on day 2). He received dialysis on March 2 in our\nnephrology department.\n\n**Secondary diagnoses:**\n\nIn March 2018, he developed renal insufficiency requiring thrice-weekly\ndialysis. In January 2018, he was diagnosed with prostate carcinoma and\nwas treated with an androgen blockade using Enantone.\n\n**Future Therapy Plan:**\n\nThe tumor board\\'s decision from March 3, 2019 was to continue with\nDaratumumab, Revlimid, and Dexamethasone due to the good response. He\nwill undergo stem cell mobilization and high-dose therapy with\nautologous stem cell transplant. Monitoring is scheduled for March 14,\n2019, followed by dialysis at our dialysis center on Mondays,\nWednesdays, and Fridays.\n\n**Medications:**\n\nHis current medications include:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------------ ---------------------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL For dialysis\n Dexamethasone (Decadron) 8 mg On March 4 and 5\n Pantoprazole (Protonix) 40 mg \n Cotrimoxazole (Bactrim) 480 mg Thrice weekly on Mondays, Wednesdays, and Fridays\n Valacyclovir (Valtrex) 500 mg \n Ibandronate (Boniva) 2 mg Every four weeks\n Leuprorelin (Lupron Depot) 3.75 mg Every four weeks\n Pregabalin (Lyrica) 25 mg \n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg \n Filgrastim (Neupogen/Granix) 48 million IU \n\n**Summary:**\n\nMr. Williams was admitted on March 1, 2019, for mobilization\nchemotherapy with cyclophosphamide. Please refer to our previous letters\nfor a detailed history. His last treatment was with daratumumab,\nRevlimid, and dexamethasone. Fortunately, this treatment showed a very\ngood response. He is dialyzed three times a week at our clinic due to\nchronic renal insufficiency. He was discharged on March 3, 2019, and we\nrequest the administration of filgrastim as per the medication plan\nstarting March 6, 2019. CD34+ monitoring is scheduled for March 14,\n2019. Depending on the CD34+ count, stem cell collection may need to be\nscheduled on a dialysis-free day. We have coordinated with our\ncolleagues at the dialysis center for the collection via the atrial\ncatheter. A follow-up for blood count and Ibandronate administration has\nbeen scheduled for March 10, 2017. If his condition deteriorates or if\nhe shows signs of infection, bleeding, or any other complications, he\nshould immediately be brought to our emergency department. Please\nremember to bring a referral form during your initial visit each\nquarter.\n\nTherapy recommendation based on Transthoracic echocardiography findings:\n\nMr. Williams has a normally sized left ventricle with standard global\nfunction. There\\'s no evidence of any regional wall motion\nabnormalities. The right ventricle is also of normal size with standard\nfunction. The left atrium is not dilated. There\\'s marked concentric\nleft ventricular hypertrophy. His aortic valve shows insufficiency of I°\n(PHT 520 ms), while the mitral and tricuspid valves appear normal. There\nis no significant pericardial effusion. Overall, he has a standard left\nventricular function with no significant valvular diseases or pulmonary\nhypertension.\n\n**Surgery Report:**\n\nDiagnosis: Terminal renal failure.\n\nProcedure: Creation of a right upper arm brachialis-basilica fistula\nwith the anterior movement of the right basilic vein.\n\n**Report:**\n\nMr. Williams required dialysis due to terminal renal insufficiency. For\nthis purpose, an arteriovenous (AV) fistula was created as a dialysis\naccess. Previously, dialysis was performed using a right atrial\ncatheter. After mapping, only the basilic vein on the right arm seemed\nsuitable. Hence, a brachialis-basilica fistula was created with anterior\ntransposition of the basilica vein. A partial mobilization of the\nbasilica vein was performed. Afterward, a brachialis-basilica\nanastomosis was carried out. The operation was uncomplicated.\n\nYour collaboration has been instrumental in managing this patient\neffectively. If you have any further queries or require additional\ndetails, please do not hesitate to contact our office.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------- ------------------ ------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Change every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg Morning on 03/05 & 03/06\n Pantoprazole (Protonix) 40 mg Morning\n Cotrimoxazole (Bactrim Forte) 480 mg Morning 3x weekly on Mon, Wed, Fri\n Valacyclovir (Valtrex) 500 mg Half tablet in the morning\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly subcutaneous (Morning)\n Pregabalin (Lyrica) 25 mg Morning and Evening\n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg Morning and Evening\n Filgrastim (Neupogen/Granix) 48 million IU Morning and Evening\n\nBest regards,\n\n\n\n### text_8\n**Dear colleague, **\n\nI am writing to provide you with a detailed report on Mr. John Williams,\nwho was admitted to our facility from May 8, 2020, to May 28, 2020.\n\n**Diagnoses:**\n\nHistory of acute mitral valve endocarditis in March 2020.\n\nSubsequent re-operation entailing mitral valve replacement using a\nBioprosthesis (29 mm) coupled with the resection of all infected tissue\nfrom the mitral valve\\'s supporting apparatus on March 24, 2020.\n\nThe origin remains uncertain, but potential associations include Demers\ncatheter infection and port catheter infection (confirmed presence of\nStaphylococcus epidermidis).\n\nSurgical removal was conducted on March 21, 2020, with no findings at\nthe catheter tips.\n\n14. Antibiotic regimen included:\n\n Meropenem from April 2, 2020, to April 23, 2020.\n\n Linezolid 600 mg from April 3, 2020, to April 19, 2020.\n\n Daptomycin from April 3, 2020, to May 27, 2020.\n\n Fosfomycin from April 19, 2020, to May 28, 2020.\n\nHistory of mitral valve reconstruction via minithoracotomy in 2015.\n\nRight-side vision loss due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia in the caput nuclei caudati/lenticular nuclei\non April 5, 2020, possibly embolic in origin from mitral valve\nendocarditis.\n\nHistory of brainstem transient ischemic attack (TIA) on March 11, 2020,\npotentially embolic in relation to mitral valve endocarditis.\n\nJugular vein thrombosis.\n\n20. Hematological/oncological diagnoses comprise:\n\n Multiple myeloma with lambda light chains, stage IIIB according to\n the Salmon and Durie criteria, first diagnosed in 2015. This was\n accompanied by multiple osteolysis occurrences, history of radiation\n to Th4 and rib thorax, and treatment with Daratumumab. Current\n treatment has been paused due to remission.\n\n A prostate carcinoma diagnosis in January 2018\n\n**Other medical conditions include:**\n\n-Chronic kidney failure necessitating dialysis since 2018, history of a\nDemer catheter with explantation on March 2020, and angioplasty on the\nright V. basilica and V. brachialis due to stenosis-related shunt\ndysfunction.\n\n-History of brainstem TIA in April 2019.\n\n-Sensations of tingling paresthesias in both lower legs.\n\n-History of bilateral deep vein thrombosis.\n\n-Frequent calf muscle cramps.\n\n**Medical History Overview:**\n\nMr. Williams\\'s latest admission on May 8, 2020, was to assess remission\nstatus and determine if continuation of treatment for his known multiple\nmyeloma was necessary. Previously, until March 2020 he was under a\nDaratumumab monotherapy (as he could not tolerate Revlimid), which\nshowed stable disease progression. Prior to this, he was treated at our\nlocal hospital for mitral valve endocarditis which had a complex\ntrajectory. At the time of admission, Mr. Williams felt generally weak\nbut was otherwise in stable condition. Upon discontinuation of the\nfentanyl patch, his back pain increased. He exhibited no fevers and had\nno known allergies. His appetite was low, and he reported no nausea.\nSince his heart surgery, he has experienced numbness in his left heel\nand toes. His residual urine output was about 190 mL per day, and he was\nundergoing regular dialysis.\n\n**Physical Examination:**\n\nThe patient was alert, responsive, and fully oriented. The examination\nof the head, neck, and lungs was unremarkable. Cardiac auscultation\nrevealed clear and rhythmic heart sounds without any abnormal findings.\nThere was a non-irritated sternotomy scar. Examination of his back\nrevealed decubitus ulcers. Abdominal examination showed a soft,\nnon-tender abdomen with normal bowel sounds. Extremity examination\nrevealed minor edema.\n\n**Diagnostic Imaging and Tests:**\n\nA series of diagnostic tests, including sonography, whole body CT scan,\nophthalmological exams, and histology were conducted. The results are\ndetailed within this report. In summary, the findings indicate:\n\n-Limited abnormalities in the heart\\'s echocardiography, with potential\nmitral valve issues to monitor.\n\n-Bone scans revealed extensive osteopenia and other abnormalities\nrelated to his known multiple myeloma, but no evidence of new\nosteolysis.\n\n-Eye examinations confirmed the previously noted vision issues,\npotentially stemming from the mitral valve endocarditis, but provided no\nclear solutions.\n\n-Histological evaluation of bone marrow samples indicates largely\nregular hematopoiesis but confirms infiltration from the known multiple\nmyeloma.\n\n**Summary and Recommendations:**\n\nMr. John Williams is a 63-year-old male with a complex medical history\ninvolving multiple organ systems. His most recent admission was in\nrelation to his multiple myeloma, for which he has been in remission and\nwill be monitored closely. His mitral valve endocarditis from earlier\nthis year has been resolved and treated appropriately. Due to the\nmultiple comorbidities, it is crucial for any treating facility or\nphysician to be fully aware of his history to provide optimal care.\nContinual monitoring of his cardiovascular and renal systems is\nessential. The importance of maintaining strict adherence to his\ndialysis regimen and potential antibiotic prophylaxis is emphasized.\nGiven his weakened general condition and chronic pain, palliative care\nmight also be a suitable approach to consider, focusing on enhancing his\nquality of life and addressing his pain management needs.\n\nPlease refer to the attached files for further details and a complete\nbreakdown of tests and findings. I trust this report will help guide the\nappropriate medical care for Mr. John Williams.\n\nSincerely,\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- -------------------- -----------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Morning\n Enoxaparin (Lovenox) 0.2 mL s.c. Evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Morning and Evening\n Leuprorelin (Lupron Depot) Monthly depot Every 4 weeks via subcutaneous injection\n Fentanyl Transdermal System 12 μg/hour Changed every 3 days\n Pantoprazole (Protonix) 40 mg Morning\n Sevelamer (Renagel) 800 mg Morning\n Multivitamin One tablet Morning\n Torsemide (Torem) 200 mg Morning\n Vitamin D3 20,000 IU Once weekly\n Sodium bicarbonate (Bicanorm) One tablet Morning\n Calcitriol (Rocaltrol) 0.25 μg Morning\n Valacyclovir (Valtrex) 500 mg half-tablet Morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Morning on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Morning on day 1 and day 2 following daratumumab administration\n\n\n\n### text_9\n**Dear colleague, **\n\nI am writing to provide an update on the medical condition and treatment\nof Mr. John Williams, who has been undergoing inpatient treatment in our\nfacility since September 30, 2021.\n\n**Diagnoses**:\n\n**Present**: Acute impairment of the visual field.\n\n**Oncological Diagnosis**:\n\n1. Diagnosis of Multiple Myeloma with kappa light chains, staged at\n IIIB as per the Salmon and Durie criteria\n\n Observable multiple osteolyses.\n\n History of radiation to the T4 and thoracic rib.\n\n Starting from 2018, he required dialysis due to renal insufficiency,\n scheduled on Mondays, Wednesdays, and Fridays in our local clinic.\n\n 2018: Treatment involved Bortezomib and Dexamethasone, but he was\n refractory to this combination. The regimen of Carfilzomib,\n Lenalidomide, and Dexamethasone was also found to be ineffective.\n\n Radiation was administered to the T4 (totaling 30 Gy) and the\n thoracic rib (totaling 20 Gy) in August 2018.\n\n Between August and October 2018: Mr. Williams underwent three cycles\n of Pomalidomide, Doxorubicin, and Dexamethasone, but the disease\n showed progression.\n\n November 2018 to February 2019: He received four treatments of\n Daratumumab, Lenalidomide, and Dexamethasone, which led to a very\n good partial response (VGPR).\n\n In March 2019, he underwent stem cell mobilization due to RSV\n pneumonia complications and then started on Daratumumab monotherapy\n (VGPR was last noted in May 2018).\n\n He continued with Daratumumab treatment until November 2019, after\n which there was a pause until March 2020 due to remission (VGPR) and\n a diagnosis of endocarditis.\n\n A whole body CT scan conducted in March 2020 did not show any new\n osteolyses.\n\n By May 2020, there was an increase in LK values, prompting the\n resumption of Daratumumab, which led to a decrease in free light\n chains.\n\n As of June 2020, there was a noted increase in light chain kappa\n values to 102 mg/L.\n\n In July 2020, therapy was escalated to include Daratumumab, Revlimid\n (5 mg), and Dexamethasone.\n\n By September 2020, a further increase in light chains was observed,\n prompting a planned switch to Elotuzumab, Pomalidomide, and\n Dexamethasone.\n\n**For his heart condition:**\n\nAcute mitral valve endocarditis was diagnosed in March 2020. He\nunderwent a re-operation for mitral valve replacement with a\nbioprosthesis (29 mm). This procedure, performed in March, 2020,\ninvolved the resection of all infected tissue from the mitral valve\\'s\nholding apparatus. The cause is presumed to be associated with a Demers\ncatheter infection or possibly related to a port catheter infection\n(Staphylococcus epidermidis was found). The catheter was surgically\nremoved in March 2020. He was on a series of antibiotics, including\nMeropenem, Linezolid, Daptomycin, and Fosfomycin.\n\n**Other pertinent medical events include:**\n\nA history of radiation treatment using a minithoracotomy technique for\nmitral valve reconstruction in 2015.\n\nRight eye amaurosis due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia diagnosed in April 2020, possibly due to\nemboli from the mitral valve endocarditis.\n\nA transient ischemic attack (TIA) in the brainstem observed on in March\n2020, which could be related to emboli from the mitral valve\nendocarditis.\n\nJugular vein thrombosis.\n\nProstate cancer diagnosed in 2018.\n\nChronic renal failure necessitating dialysis since 2018.\n\nPrevious procedures include Demers catheter placement (removed on March\n2020) and angioplasty on the right basilic vein and brachial vein due to\nstenosis causing shunt dysfunction.\n\nHistory of transient ischemic attacks.\n\nBilateral tingling paresthesias in the lower legs, history of deep vein\nthrombosis, recurrent calf cramps, and hypothyroidism.\n\nPlease let me know if you require any further information on Mr.\nWilliams. I am confident that this detailed account will assist you in\nunderstanding his medical history and ensuring optimal care.\n\n**Therapy: **\n\nTherapy schedule: Daratumumab s.c. 1800mg abs. weekly in week 1-8,\n2-weekly in week 9-24, every 4 weeks from week 25. Continuation of\nBondronat. Regular monitoring and optimal adjustment of cardiovascular\nrisk factors.\n\nMedication:\n\nPlavix (Clopidogrel) 75 mg; once daily in the morning\n\nLovenox (Enoxaparin) 0.2 ml subcutaneously; once daily in the evening on\nnon-dialysis days\n\nMarinol (Dronabinol) drops; four drops in the morning and four drops in\nthe evening\n\nDuragesic (Fentanyl transdermal patch) 12 μg/hour; change every 3 days\n\nProtonix (Pantoprazole) 40 mg; dosing: Once daily in the morning and\nonce daily in the evening for 2 weeks, then once daily in the morning\n\nRenvela 800 mg; dosing: Once daily in the morning\n\nTorem 200 mg; once daily in the morning\n\nVitamin D3 20,000 IU; once weekly\n\nCalcijex (Calcitriol) 0.25 mcg; once daily in the morning\n\nValtrex (Valacyclovir) 500 mg; dosing: Half a tablet (250 mg) once daily\nin the morning\n\nBactrim (Cotrimoxazole or trimethoprim/sulfamethoxazole) 480 mg, once\ndaily\n\nWarm regards,\n\n**Clinical Update, 11/12/2022**\n\nMr. John Williams, a 66-year-old male with a known history of multiple\nmyeloma and associated complications, presented again to our facility\nwith worsening symptoms over the past three weeks.\n\n**Symptoms**:\n\nPersistent fatigue\n\nShortness of breath on minimal exertion\n\nBilateral pitting edema in the lower extremities up to the mid-calf\n\n**Preliminary Findings**:\n\n**Physical Examination**:\n\n1. Jugular venous distention\n\n Decreased breath sounds bilaterally with mild basilar crackles\n\n S3 gallop on cardiac auscultation\n\n**Chest X-ray**:\n\n4. Cardiomegaly with an enlarged cardiac silhouette. Mild pulmonary\n edema evident.\n\n**Echocardiogram**:\n\n5. Reduced left ventricular ejection fraction (LVEF) of 35% (normal \\>\n 55%)\n\n Mild mitral regurgitation\n\n**Lab Results**:\n\n7. B-type natriuretic peptide (BNP): 890 pg/mL (Normal: \\<100 pg/mL)\n\n Serum Sodium: 130 mEq/L (Normal: 135-145 mEq/L)\n\n Serum Potassium: 5.8 mEq/L (Normal: 3.5-5.1 mEq/L)\n\n Blood Urea Nitrogen (BUN): 38 mg/dL (Normal: 7-20 mg/dL)\n\n Creatinine: 2.1 mg/dL (Normal: 0.8-1.3 mg/dL)\n\n GFR: 35 mL/min (Reduced)\n\n**Diagnosis**:\n\nCongestive Heart Failure (CHF) with reduced ejection fraction\n\nRenal insufficiency\n\nMultiple Myeloma (primary diagnosis 2015)\n\nProstate cancer\n\n**Treatment Administered**:\n\nIntravenous furosemide was administered to relieve fluid overload,\nresulting in a significant reduction in edema and improvement in\nbreathlessness over the subsequent 48 hours. Lisinopril was initiated\ncautiously to manage CHF and to potentially provide renal protection.\nMetoprolol was started at a low dose, with close monitoring of blood\npressure and heart rate. Potassium levels were closely monitored given\ninitial hyperkalemia; diet and medications were adjusted accordingly.\nDietary consult emphasized a low-sodium, moderate protein, and\npotassium-restricted diet. Close monitoring of fluid balance\n(input-output) was maintained throughout the stay.\n\n**Progress**:\n\nMr. Williams showed consistent improvement over his two-week admission.\nSerial echocardiograms indicated a slight improvement in LVEF to 39%.\nThe edema receded notably, and his shortness of breath on exertion\nreduced significantly. Labs before discharge showed:\n\nSerum Sodium: 134 mEq/L\n\nSerum Potassium: 4.9 mEq/L\n\nBUN: 32 mg/dL\n\nCreatinine: 1.9 mg/dL\n\nBNP: 550 pg/mL\n\n**Discharge Recommendations**:\n\nOutpatient cardiology follow-up in two weeks and then monthly to monitor\nLVEF and adjust medications. Nephrology consultation to keep an eye on\nrenal function, given his increased susceptibility to kidney damage.\nContinue with dietary restrictions and modifications as advised.\nCommence an outpatient cardiac rehabilitation program for supervised\nexercise and lifestyle modifications. Weekly blood tests for the first\nmonth to monitor electrolytes and kidney function.\n\nMr. Williams remains at risk due to multiple comorbidities. It is\nessential to address each condition holistically while ensuring no\nsingle treatment exacerbates another condition. A collaborative and\nvigilant approach is imperative for his ongoing health management.\n\nWarm regards,\n\n --------------------------- ---------------- ---------------------\n **Parameter** **Value** **Reference Range**\n **Blood Count** \n White Blood Cells (WBC) 5.8 x 10^9^/L 4-11 x 10^9^/L\n Red Blood Cells (RBC) 3.9 x 10^12^/L 4.5-5.5 x 10^12^/L\n Hemoglobin (Hb) 9.8 g/dL 13-18 g/dL for men\n Platelets (Plt) 150 x 10^9^/L 150-450 x 10^9^/L\n \n **Biochemistry** \n Creatinine 2.8 mg/dL 0.6-1.3 mg/dL\n Blood Urea Nitrogen (BUN) 40 mg/dL 7-20 mg/dL\n Glucose 98 mg/dL 70-100 mg/dL\n \n **Electrolytes** \n Sodium (Na) 137 mEq/L 135-145 mEq/L\n Potassium (K) 5.1 mEq/L 3.5-5.0 mEq/L\n Calcium 8.6 mg/dL 8.5-10.5 mg/dL\n Phosphate 4.5 mg/dL 2.5-4.5 mg/dL\n \n **Oncologic Markers** \n Free light chain kappa 692 mg/L 3.3-19.4 mg/L\n Free light chain lambda 12 mg/L 5.7-26.3 mg/L\n \n **Other Values** \n LDL cholesterol 80 mg/dL \\<100 mg/dL\n HbA1c 6.2% \\<5.7%\n --------------------------- ---------------- ---------------------\n\n\n\n\nHere is the query:\nWhich sequence of events, as presented in Mr. Williams's detailed medical report, is accurate?\n\nChoose the correct answer from the following options:\nA. Mitral valve reconstruction via minithoracotomy in 2015, multiple myeloma diagnosis in 2015, prostate carcinoma diagnosis in January 2018, followed by brainstem transient ischemic attack (TIA) in March 2020.\nB. Multiple myeloma diagnosis in 2015, acute mitral valve endocarditis in March 2020, mitral valve reconstruction in 2015, followed by prostate carcinoma diagnosis in January 2018.\nC. Mitral valve endocarditis in March 2020, prostate carcinoma diagnosis in January 2018, mitral valve reconstruction in 2015, followed by the first diagnosis of multiple myeloma in 2015.\nD. Prostate carcinoma diagnosis in January 2018, acute mitral valve endocarditis in March 2020, multiple myeloma diagnosis in 2015, followed by mitral valve reconstruction in 2015.\nE. First diagnosis of multiple myeloma in 2015, mitral valve reconstruction in 2015, prostate carcinoma diagnosis in January 2018, and then acute mitral valve endocarditis in March 2020.\n\n\nYour response:\n", "role": "user" }, { "content": "First diagnosis of multiple myeloma in 2015, mitral valve reconstruction in 2015, prostate carcinoma diagnosis in January 2018, and then acute mitral valve endocarditis in March 2020.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nHerewith we report on Mr. John Williams, born 08/08/1956, inpatient from\n10/03/2015 to 10/06/2015.\n\n**Diagnosis:**\n\nMultiple Myeloma IgG kappa.\n\n**Staging and Initial Diagnosis:**\n\nDate: 03/2015\n\nStage: IIA based on the Salmon and Durie scale, ISS II.\n\n- CT whole body 03/11/2015: Osteolysis detected in the seventh\n thoracic vertebra (T7); pathologic fracture observed in the first\n lumbar vertebra (L1).\n\n- Bone marrow infiltration: Initial histological evaluation showed\n 22%; cytomorphological assessment revealed 28%.\n\n**Histological Findings:**\n\nDate: 03/2015\n\n**FISH (Fluorescence In Situ Hybridization) Results:** Detected an\nadditional signal for both CCND1 and CCND3. Presence of one trisomy or\ntetrasomy 9. Additional signals observed for 5p15- and 5q31- as well as\n19p13- and 19q13-. 46, XY with a detected ASxL1 mutation.\n\n**Treatment Timeline:**\n\n**01-02/15:** Administered 2 cycles of\nCyclophosphamide-Bortezomib-Dexamethasone (CyBorD). Resulted in stable\ndisease but caused prolonged pancytopenia.\n\n**03/15 - 06/15:** Administered 3 cycles of a combination treatment\nincluding Carfilzomib, Lenalidomide, and Dexamethasone.\n\n**07/15:** Underwent stem cell mobilization using cyclophosphamide.\n\n**07-08/15:** Experienced extended pancytopenia and regeneration. Bone\nmarrow puncture showed progressive disease with a significant increase\nin plasma cell infiltration, reaching 92%.\n\n**09/02/15:** Received the first dosage of daratumumab at 16mg/kg.\nSubsequently developed thrombocytopenia. Treatment did not include\nRevlimid.\n\n**Histopathological report: **\n\nMultiple myeloma, IgG kappa. The evaluation is for myelodysplastic\nsyndrome in the presence of tricytopenia and an ASXL1 mutation.\n\n**Methods:** Hematoxylin and eosin (HE), periodic acid-Schiff (PAS),\niron, Giemsa, Gomori, chloroacetate esterase, step sections,\ndecalcification, and 1 block.\n\n**Microscopic Examination:**\n\nThe sample is a 2 cm long bone marrow biopsy core that contains more\nthan ten medullary canals. The cellularity is around 20-30%, which is\nconsidered normocellular for the patient\\'s age. There is evidence of\nbone marrow edema and heightened hemosiderosis. Recent stromal\nhemorrhages are also observed. There is a relative increase in\nerythropoiesis with a ratio of erythropoiesis to granulopoiesis being\napproximately 2:1. Erythropoiesis is present in well-defined zones with\nregular maturation. Only minimal nuclear rounding is observed.\nGranulopoiesis matures into segmented granulocytes. PAS staining reveals\nsome morphologically normal megakaryocytes. Occasionally there are bare\nnuclei and possible microforms. Scattered mature plasma cells are\nobserved with no signs of atypical proliferation. The argyrophilic\nfibrous network is fine, and no fibrosis is detected.\n\n**Preliminary Findings:**\n\nThe bone marrow biopsy is normocellular for the age with a relative\nincrease in erythropoiesis that shows only minimal cytological atypia.\nGranulopoiesis is slightly reduced, while megakaryopoiesis is\nnormocellular with a few cells that are hypolobulated.There is bone\nmarrow edema and enhanced hemosiderosis. Scattered mature plasma cells\nare also noted.\n\nBased solely on histomorphologic observations, it is not enough to\nconfirm a diagnosis of myelodysplastic syndrome (MDS), which is the\nsuspected clinical diagnosis. For a more thorough evaluation of\npotential atypicalities in the megakaryopoiesis (like\nmicromegakaryocytes), further immunohistochemical examination is\nrecommended. Assessing the blast content is also advised. There is no\nevidence currently of manifest infiltrates from the previously diagnosed\nmultiple myeloma.\n\n**Immunohistochemical Additional Findings (Dated 10/04/2015):**\n\n**Immunohistochemistry Stains Used:** CD3, CD79a, CD34, CD117, MUM-1,\nKappa, lambda, CyclinD1, CD61.\n\nBlast cells positive for CD34 and CD117 are below 5% of the total. CD3\nstains scattered T lymphocytes, and CD79a identifies sporadic B\nlymphocytes and some plasma cells. Plasma cells are also positive for\nMUM-1 and exhibit polytypic expression of kappa and lambda light chains.\nThere is no co-expression with CyclinD1. CD61 highlights the previously\ndescribed megakaryocytes, and no micromegakaryocytes are observed.\n\n**Final Report:**\n\nThe bone marrow biopsy is representative and normocellular for the\npatient\\'s age. There is a relative increase in erythropoiesis that\nshows only minor cytological atypia. Granulopoiesis appears slightly\nreduced, while megakaryopoiesis presents with a few hypolobulated cell\nforms. Evidence of bone marrow edema and increased hemosiderosis is\nnoted, along with scattered mature plasma cells.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe hereby report on Mr. Williams, John, born 08/08/1956, inpatient from\n11/30/2015 to 12/28/2015.\n\n**Oncological Diagnosis**:\n\nMultiple myeloma IgG kappa.\n\nInitial diagnosis 03/15: Stage IIA (Salmon and Durie), ISS II.\n\n**Sites**:\n\nOsteolysis in T7 vertebra, fracture in T1 vertebra.\n\nBone marrow: 22% histological, 28% cytomorphologic infiltration.\n\n**Histology**:\n\nBone marrow biopsy 11/16: FISH: Additional signals for CCND1, CCND3;\nTrisomy 3, 9; Additional signals on chromosomes 5 and 19. Chromosomal\nanalysis: 46, XY with ASxL1 mutation.\n\n**Treatment**:\n\n01-02/15: 2 cycles Cyclophosphamide-Bortezomib-Dexamethasone -\\>\nStable disease, prolonged low blood counts.\n\n03/15 - 06/15: 3 cycles Carfilzomib/Lenolidomide/Dexamethasone.\n\n07/15: Stem cell mobilization with Cyclophosphamide.\n\n07-08/15: Extended low blood count. Bone marrow biopsy: 92% plasma cell\ninfiltration.\n\n09/02/15: Darzalex 16mg/kg initial dose, with platelet count drop. No\nLenalidomide.\n\n09/04/15: 10 cycles of Darzalex, 1 cycle with Lenalidomide due to\nrenewed low platelet and white blood cell counts.\n\n11-12/15: Conditioning chemo with Fludarabine/Treosulfan, then\nallogeneic stem cell transplant from HLA-matched unrelated donor.\nImmunosuppression with ATG, cyclosporine, Mycophenolate Mofetil.\n\n**Complications**:\n\nMucositis, central line infection, gastrointestinal symptoms, urinary\ninfections with E. faecium and E.coli, JC virus bladder infection.\n\n**Secondary Diagnoses**:\n\nDry eye syndrome, Type 2 diabetes managed with oral meds, Hypertension.\n\n**Treatment Plan**:\n\nGradual reduction of immunosuppression based on graft vs. host disease\nsigns.\n\n**Radiology**:\n\nCT Whole Body: 12/01/15: Various areas of bone osteolysis. Degeneration\nof spine.\n\nCT Chest 12/02/15 and 12/03/15: Changes in lungs and some fluid\naccumulation.\n\n**Medication**:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------- ---------------\n Mycophenolic Acid (Myfortic) 360 mg Twice Daily\n Cyclosporine (Sandimmune) 200 mg Daily\n Artificial Tears As directed 3x Daily\n Candesartan (Atacand) 8 mg Daily\n Tamsulosin (Flomax) 0.4 mg Daily\n Pantoprazole (Protonix) 40 mg Daily\n Amlodipine (Norvasc) 5 mg Twice Daily\n Cotrimoxazole (Bactrim) 960 mg Mon/Wed/Fri\n Valacyclovir (Valtrex) 500 mg Twice Daily\n\n**Summary**:\n\nMr. Williams was admitted on 11/30/2015 for treatment related to his\nMultiple Myeloma. He underwent conditioning chemotherapy,\nimmunosuppressive therapy, and stem cell transplantation. He experienced\ncomplications, including infections and symptoms affecting multiple\nsystems. Close monitoring of blood pressure and glucose is recommended.\nHe was discharged on 12/28/2015 in good condition and will be followed\nup in the outpatient clinic. If there are worsening symptoms, he should\nvisit the emergency department immediately.\n\n**Dear Mr. Williams,**\n\nWe report on your outpatient treatment on 02/15/2016.\n\n**Diagnoses:**\n\n1. **Multiple Myeloma** IgG kappa, diagnosed 03/2015.\n\n Stage IIA as per Salmon and Durie, stage II as per ISS.\n\n Osteolysis at T7 vertebra, fracture at T1 vertebra.\n\n Bone marrow infiltration: 22% histologically, 28% cytologically.\n\n FISH: Indications of additional CCND1 and CCND3 signals; Trisomy 3,\n additional signals at various chromosomes.\n\n Chromosome analysis: 46, XY \\[20\\].\n\n**Secondary diagnoses:**\n\nType 2 diabetes mellitus\n\nHypertension\n\nCataract (surgery 06/2018)\n\nNodular goiter\n\nRSV pneumonia (03/2018)\n\n**Summary:**\n\nMr. Williams presents in good general health to our bone marrow\ntransplant (BMT) outpatient clinic. There are no signs of infection or\nchronic graft rejection. He has shown significant improvement in\nresilience and does not have any complaints. Vital signs are stable.\nBlood tests showed ongoing regeneration with normal light chains and\npersistent positive immunofixation. There is no need for\nmyeloma-specific therapy at present, but close monitoring of the\nparaprotein is required.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ---------------------- -------------------------------------------------------\n Tamsulosin (Flomax) 0.4 mg Daily in the morning\n Candesartan (Atacand) 8 mg Twice Daily\n Metformin (Glucophage) 1000 mg 0.5 tablet in the morning, 1.5 tablets in the evening\n Pantoprazole (Protonix) 20 mg Daily in the morning\n Vitamin D3 (various brands) 20,000 IU Once a week\n Allopurinol (Zyloprim) 100 mg Daily in the morning\n Insulin (various types) As per sliding scale As per sliding scale\n\nWith kind regards\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are providing an update on our shared patient, Mr. John Williams, who\nconsulted with us on June 15, 2018.\n\n**Consultation Summary:**\n\n8. **Multiple Myeloma**\n\n **Kidney biopsy scheduled for tomorrow.**\n\n **Prostate cancer**\n\n**Current Status:**\n\nAcute renal failure accompanied by proteinuria due to the recent\ndiagnosis of multiple myeloma.\n\nMultiple osteolytic lesions, including at the T4, T7, L1 vertebra and\nthe ribs.\n\n**Diagnosis:**\n\nMultiple myeloma.\n\nProstate cancer\n\n**Clinical Presentation:**\n\nOsteolytic lesion presenting as thoracic pain.\n\n**Imaging Findings:**\n\nOsteolytic lesion at T4 vertebra with involvement of the posterior edge.\n\n**Planned Procedures:**\n\nRestricted bed rest.\n\nWhole spine MRI with STIR sequences, to be presented in the upcoming\ntumor board meeting for deciding further course of action.\n\n**Previous Diagnoses:**\n\nMay, 2018, Nephrology: Enlarged kidneys noted bilaterally.\n\nJanuary, 2018, Urology: Prostate cancer\n\nDecember, 2015, Internal Medicine: Multiple myeloma without evidence of\ncomplete remission.\n\n**Previous Procedures:**\n\nTransrectal biopsy of the prostate.\n\n**Histology Report, Date: June 13, 2018:**\n\nSuspected plasmacytoma with paraproteinemia.\n\nWBC 6.47; Hb 10.8; Platelets 251,000.\n\nBone marrow biopsy: Cellularity approximated at 48%, indicating slightly\nincreased cellularity. Amidst reduced hematopoiesis, there is\nproliferation of plasmacytoid cells with certain features.\n\n**Preliminary Report:**\n\nThe bone marrow sample indicates possible infiltration due to plasma\ncell myeloma. Additional tests will be conducted to confirm and further\nelucidate this finding.\n\n**Supplementary Findings:**\n\nImmunohistochemical staining: CD138, Kappa, Lambda, CD20.\n\nMicroscopic findings confirm the presence of nodular infiltrates with\ncertain features.\n\n**Final Report:**\n\nBone marrow sample indicates infiltration by a plasma cell myeloma with\nkappa light chain restriction. Additionally, regular trilinear\nhematopoiesis is significantly reduced.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nI wish to provide an update on our mutual patient, Mr. John Williams,\nborn 08/08/1956, who presented at our clinic at 08/20/2018.\n\n**Diagnosis:**\n\nPresent condition: Multiple Myeloma IgG type, coded under ICD-10.\n\nStage: II B based on Durie and Salmon criteria; determined from Hb 9.1,\nCreatinine 4.5 mg/dL.\n\n**Histology:**\n\nBone marrow biopsy presents a strong indication of interstitial and\nfocal nodular invasion of the marrow space by plasma cell myeloma,\npredominantly of high to intermediate maturity.\n\n**Immunohistochemistry:**\n\nThe nodular infiltrates were found positive for CD138 with a kappa-light\nchain restriction (infiltration rate at 62%).\n\nCytological findings align with high-grade bone marrow infiltration by\nmultiple myeloma.\n\n**Tumor Localization:**\n\nMRI of the entire spine conducted on 06/20/2018 reveals disseminated\nbone lesions throughout the spine without any soft tissue involvement.\nThere is noted anterior vertebral body involvement at T4.\n\n**Secondary Diagnoses:**\n\nCysts in the right kidney.\n\nAs of 01/2018, a diagnosis of Prostate cancer with a Gleason score of 8\nand a PSA reading of 10.02.\n\nPrevious rib fracture, which may be associated with the multiple\nmyeloma.\n\nChronic renal failure, with ongoing dialysis treatment.\n\nDocumented mitral valve surgery in 2015.\n\nHistory of Deep Vein Thrombosis in 1999.\n\n**Prior Treatments:**\n\nInitial diagnosis of multiple myeloma IgG kappa in 2015.\n\nProstate cancer was diagnosed in 01/2018 following spontaneous rib\nfractures, Gleason score of 8.\n\nA PSMA-PET-CT scan in 05/18 showed multiple bone lesions, notably\npronounced at Th4.\n\nTumor board review in 06/2018 concluded treatment strategies for\nurological tumors, encompassing radiation therapy targeting Th4 and\nantiandrogen therapy for the identified prostate cancer, using a GnRH\nanalog.\n\nThe progression of multiple myeloma required the commencement of\nsystemic treatment with Velcade and Dexamethasone.\n\n**Study**: PSMA-PET-CT Scan\n\n**Date of Study**: 05/2018\n\n**Clinical Information**: Prostate cancer diagnosed in 01/2018 following\nspontaneous rib fractures. Gleason score of 8.\n\n**Technique**:\n\nWhole body positron emission tomography/computed tomography (PET/CT) was\nperformed following the intravenous administration of PSMA-radiotracer.\nCoronal, sagittal, and axial images were acquired and reviewed.\n\n**Findings**:\n\nBone: Notably increased PSMA uptake is seen at the level of T4 vertebral\nbody consistent with metastatic involvement. The lesion has caused\ncortical erosion and expansion with potential involvement of the\nanterior spinal canal. Multiple rib lesions are identified,\ncorresponding with the clinical history of spontaneous rib fractures.\nThese lesions exhibit no increased PSMA uptake. No other foci of\nincreased PSMA uptake throughout the axial and appendicular skeleton.\n\n**Prostate**:\n\n12. The prostate gland demonstrates diffusely increased uptake, which is\n consistent with primary prostate malignancy, especially given the\n known clinical history.\n\n**Thorax/Abdomen: **\n\n13. No abnormal PSMA avid soft tissue masses or lymphadenopathies were\n noted in the visualized fields. No pulmonary nodules or masses\n suggestive of metastatic disease were identified. Liver, spleen,\n kidneys, and adrenal glands appear unremarkable with no evidence of\n metastatic lesions.\n\n**Impression**:\n\nOsseous metastasis from prostate cancer with involvement of the T4\nvertebral body. No evidence of soft tissue, lymph node, or pulmonary\nmetastases in the visualized fields. Prostate gland showing evidence\nconsistent with primary malignancy.\n\n**Current Radiation Therapy:**\n\n**Indication:** Radiotherapy became a consideration due to a sizable\nosteolytic lesion at T4, both for pain alleviation and stabilization.\nConcurrent treatment of the aching ribs on the right side (7th-9th) was\nalso performed.\n\n**Technique:** 6 MeV photons from a linear accelerator, administering a\ncumulative dose of 30 Gy to thoracic vertebra 4 and 20 Gy to the ribs\nwith respective daily doses.\n\n1. **Treatment Duration:**\n\n Th4: 08/21/2018 to 08/27/2018\n\n Rib area: 08/21/2018 to 08/27/2018\n\n**Clinical Update:**\n\nThroughout the therapy period, Mr. Williams remained admitted to our\nOncology ward for ongoing reduced dosage chemotherapy using Velcade. He\nhas reported a decline in pain sensations during this timeframe. The\noverall health status appeared satisfactory, with no skin irritation\nobserved at the irradiated sites.\n\n**Subsequent Actions:**\n\nGuidance on skincare and potential adverse effects have been provided to\nMr. Williams. The intensity of the chemotherapy will soon be escalated.\nA radio-oncological assessment has been scheduled in our outpatient\nfacility for 09/05/2018 at 12:00 PM. I kindly request the most recent\ntest results by this date.\n\n**Note:** In compliance with the Radiation Protection Act, we shall\nundertake regular evaluations and request updates on the patient\\'s\ncondition. Mr. Williams has been apprised of the necessity for\nconsistent oncological check-ups.\n\nWarm regards,\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe wish to update you on our mutual patient, Mr. John Williams.\n\n**Diagnosis:**\n\nCurrent multiple myeloma IgG type\n\n**Tumor Localization:**\n\nBased on a whole spine MRI dated June 20, 2018:\n\nMultiple intraosseous lesions throughout the spine without soft tissue\ninvolvement.\n\nKnown intrusion of the T4 cover plate.\n\n**Secondary Diagnoses:**\n\nRight kidney cysts\n\nDiagnosed prostate carcinoma in January 2018, Gleason score 8, initial\nPSA at 10.02.\n\nHistory of a spontaneous rib fracture related to the multiple myeloma.\n\nChronic renal insufficiency; he remains on dialysis.\n\nHistory of mitral valve reconstruction in 2015.\n\nHistory of deep vein thrombosis in 1999.\n\n**Treatment Overview:**\n\nDiagnosed with multiple myeloma type kappa in 2015 with initially normal\nrenal function.\n\nDiagnosed with prostate carcinoma in January 2018 due to spontaneous rib\nfractures, Gleason score 8.\n\nTreatment decisions in 2018 included radiation for vertebral lesions and\nhormone therapy for prostate cancer using a GnRH analogue.\n\nSystemic therapy with Velcade and Dexamethasone initiated due to\nprogressive myeloma.\n\nRadiation therapy in August 2018 for vertebral and rib lesions.\n\n**Summary:**\n\nMr. Williams had a radio-oncological follow-up on September 29, 2018.\nHis general health has improved. He remains on thrice-weekly dialysis.\nRecent CT scans show extensive osteolysis of the spine with several\nvertebral collapses. Currently, we see no urgent fracture risk or need\nfor additional radiation therapy. We have planned regular clinical\ncheck-ups with Mr. Williams. His next follow-up is scheduled in three\nmonths.\n\n**Oncologic treatment: **\n\nDaratumumab/lenalidomide/dexamethasone regimen:\n\nDaratumumab 16mg/kg: Days 1, 8, 15, 22 for cycles 1 & 2 (every 28 days\nfor 8 weeks).\n\nDays 1, 15 for cycles 3-6 (every 28 days for 16 weeks).\n\nDay 1 for subsequent cycles (every 28 days).\n\nDexamethasone 20mg on Daratumumab days, with an additional 20mg the day\nafter (totaling 40mg/week).\n\nLenalidomide 5mg from day 1-21 (every 28 days).\n\nBondronate every 4 weeks (last administered on 12/13/2016).\n\nRe-evaluation of hemodialysis and autologous peripheral blood stem cell\ntransplant (PBSCT) after 2 cycles of daratumumab.\n\n**CT Spine scan (09/30/2018): **\n\n**Technique**: Contrast-enhanced computed tomography (Omnipaque 240) of\nthe thoracic and lumbar spine was performed with axial slices, and\nmultiplanar reconstructions in sagittal and coronal orientations.\n\n**Findings**:\n\n**Thoracic Spine**:\n\nExtensive osteolytic lesions are identified in multiple thoracic\nvertebrae. Specifically, vertebral collapses are noted at T4, T7, T9,\nT11. No significant bony destruction of pedicles, lamina and spinous\nprocesses. No evidence of paravertebral or epidural soft tissue masses.\n\n**Lumbar Spine**:\n\nProminent osteolytic changes are seen in L1 (with fracture) and L4\nvertebral bodies. However, there is no significant vertebral collapse.\nPreserved pedicles, lamina, and spinous Processes without significant\nosteolysis. No evidence of abnormal masses or lymphadenopathy.\n\nNo significant central canal stenosis or neural foraminal narrowing. The\nintervertebral discs are preserved without significant discopathies.\n\n**Impression**:\n\nExtensive osteolysis in multiple vertebral bodies, specifically in the\nthoracic and lumbar spine, with vertebral collapses at levels T4, T7,\nT9, and T11 as well as L1. Also, osteolytic changes in L4 of the lumbar\nspine.\n\nCurrently, based on imaging, there does not appear to be an urgent\nfracture risk, and no radiologic signs suggesting a need for imminent\nradiation therapy. No soft tissue abnormalities identified in the\nexamined regions.\n\n**Medication: **\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ----------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg In the morning (day after Daratumumab)\n Pantoprazole (Protonix) 40 mg Daily in the morning\n Cotrimoxazole (Bactrim) 480 mg Thrice weekly (Mon, Wed, Fri)\n Valacyclovir (Valtrex) 500 mg Daily in the morning\n Acetaminophen (Tylenol) 500 mg Orally, three times daily\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly (4-week depot) subcutaneously\n Pregabalin (Lyrica) 25 mg Twice a day\n Amlodipine (Norvasc) 5 mg Daily in the morning\n Bisoprolol (Zebeta) 5 mg Daily in the morning\n Lenalidomide (Revlimid) 5 mg Nightly\n Ondansetron (Zofran) 8 mg As needed, up to twice daily\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are updating you on Mr. John Williams\\' outpatient visit on December\n13, 2018.\n\n**Diagnosis:**\n\nFebrile respiratory infection.\n\n**Underlying Conditions:**\n\nMultiple myeloma, kappa light chain, stage IIIB as classified by Salmon\nand Durie.\n\nChronic kidney disease requiring hemodialysis.\n\nProstate cancer.\n\n**Summary:**\n\nMr. Williams came to the emergency room with fever and dry cough during\nhis multiple myeloma treatment with Darzalex, Revlimid, and\nDexamethasone. His vital signs were recorded, and laboratory tests\nshowed signs of infection and confirmed chronic kidney disease. Chest\nX-ray indicated possible inflammation. Given these findings, Mr.\nWilliams was admitted for antibiotic therapy. Further observations and\ntreatments were documented.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nThis letter pertains to Mr. John Williams, who was hospitalized from\nDecember 14 to 21st, 2018.\n\n**Oncological Diagnosis:**\n\nMultiple myeloma, kappa light chain, initially diagnosed in June 2018 as\nstage IIIB per Durie and Salmon criteria.\n\n**Treatment Details:**\n\nHe underwent various treatment regimens for multiple myeloma over the\ncourse of the year. His current condition indicates an\ninfluenza-positive pneumonia, likely with a bacterial superinfection. He\ncontinues hemodialysis thrice a week.\n\n**Secondary Diagnoses:**\n\nSeveral renal complications were documented in June 2018.\n\n**Plan of Care:**\n\nMr. Williams\\' therapy plan was discussed in a tumor board meeting. He\nremains on a regimen of Darzalex, Revlimid, and Dexamethasone.\n\n**Summary:**\n\nMr. Williams came to the emergency room on December 13, 2018, with cough\nand fever. Further details about his history can be found in previous\ncommunications. On admission, he showed signs of a respiratory\ninfection, confirmed by a chest X-ray. He was treated with antibiotics,\nwhich were later escalated. He also tested positive for influenza A and\nwas given Tamiflu. After a short in-patient stay, he has shown\nimprovement. He is scheduled to continue his therapy in our clinic on\nDecember 22, 2018. In case of any complications, he has been advised to\nreturn to our emergency room immediately.\n\nFor future consultations, please provide a referral slip for each new\nquarter.\n\nWarm regards\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about Mr. John Williams, who was an\ninpatient in our clinic from March 1, 2019, to March 3, 2019.\n\nOncological diagnosis:\n\nMr. Williams was diagnosed with Multiple Myeloma light chain kappa. He\nreceived his follow-up diagnosis in June 2018, which was at stage IIIB\nper the Durie and Salmon staging system.\n\nTreatment:\n\nIn June 2018, he was given VelDex due to impaired renal function.\nSubsequently, he received Carfilzomib (15mg/m2 on days 1-2, 8-9, 15-16),\nLenalidomide (5 mg, on days 1-21), and Dexamethasone (40mg, on days 1,\n8, 15-16, 22). In addition, he was treated with Pomalidomide (4mg on\ndays 1-21), Doxorubicin (9mg/m2 on days 1, 4), and Dexamethasone (40mg,\non days 1, 8, 15, 22). He underwent radiation therapy to T4 of the rib\nthorax in August. Between August to October 2018, he had three cycles of\nPomalidomide, Doxorubicin, and Dexamethasone, after which the disease\nprogressed. From November 2018 to February 2019, he had four cycles of\nDaratumumab, Lenalidomide, and Dexamethasone.\n\n**Outcome:**\n\nThe response to the treatment was very good partial remission (VGPR).\n\n**Present Treatment:**\n\nHe underwent mobilization chemotherapy with cyclophosphamide, with a\ndosage adjusted due to his requirement for dialysis (1500mg/m^2^ on day\n1 and 1000mg/m^2^ on day 2). He received dialysis on March 2 in our\nnephrology department.\n\n**Secondary diagnoses:**\n\nIn March 2018, he developed renal insufficiency requiring thrice-weekly\ndialysis. In January 2018, he was diagnosed with prostate carcinoma and\nwas treated with an androgen blockade using Enantone.\n\n**Future Therapy Plan:**\n\nThe tumor board\\'s decision from March 3, 2019 was to continue with\nDaratumumab, Revlimid, and Dexamethasone due to the good response. He\nwill undergo stem cell mobilization and high-dose therapy with\nautologous stem cell transplant. Monitoring is scheduled for March 14,\n2019, followed by dialysis at our dialysis center on Mondays,\nWednesdays, and Fridays.\n\n**Medications:**\n\nHis current medications include:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------------ ---------------------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL For dialysis\n Dexamethasone (Decadron) 8 mg On March 4 and 5\n Pantoprazole (Protonix) 40 mg \n Cotrimoxazole (Bactrim) 480 mg Thrice weekly on Mondays, Wednesdays, and Fridays\n Valacyclovir (Valtrex) 500 mg \n Ibandronate (Boniva) 2 mg Every four weeks\n Leuprorelin (Lupron Depot) 3.75 mg Every four weeks\n Pregabalin (Lyrica) 25 mg \n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg \n Filgrastim (Neupogen/Granix) 48 million IU \n\n**Summary:**\n\nMr. Williams was admitted on March 1, 2019, for mobilization\nchemotherapy with cyclophosphamide. Please refer to our previous letters\nfor a detailed history. His last treatment was with daratumumab,\nRevlimid, and dexamethasone. Fortunately, this treatment showed a very\ngood response. He is dialyzed three times a week at our clinic due to\nchronic renal insufficiency. He was discharged on March 3, 2019, and we\nrequest the administration of filgrastim as per the medication plan\nstarting March 6, 2019. CD34+ monitoring is scheduled for March 14,\n2019. Depending on the CD34+ count, stem cell collection may need to be\nscheduled on a dialysis-free day. We have coordinated with our\ncolleagues at the dialysis center for the collection via the atrial\ncatheter. A follow-up for blood count and Ibandronate administration has\nbeen scheduled for March 10, 2017. If his condition deteriorates or if\nhe shows signs of infection, bleeding, or any other complications, he\nshould immediately be brought to our emergency department. Please\nremember to bring a referral form during your initial visit each\nquarter.\n\nTherapy recommendation based on Transthoracic echocardiography findings:\n\nMr. Williams has a normally sized left ventricle with standard global\nfunction. There\\'s no evidence of any regional wall motion\nabnormalities. The right ventricle is also of normal size with standard\nfunction. The left atrium is not dilated. There\\'s marked concentric\nleft ventricular hypertrophy. His aortic valve shows insufficiency of I°\n(PHT 520 ms), while the mitral and tricuspid valves appear normal. There\nis no significant pericardial effusion. Overall, he has a standard left\nventricular function with no significant valvular diseases or pulmonary\nhypertension.\n\n**Surgery Report:**\n\nDiagnosis: Terminal renal failure.\n\nProcedure: Creation of a right upper arm brachialis-basilica fistula\nwith the anterior movement of the right basilic vein.\n\n**Report:**\n\nMr. Williams required dialysis due to terminal renal insufficiency. For\nthis purpose, an arteriovenous (AV) fistula was created as a dialysis\naccess. Previously, dialysis was performed using a right atrial\ncatheter. After mapping, only the basilic vein on the right arm seemed\nsuitable. Hence, a brachialis-basilica fistula was created with anterior\ntransposition of the basilica vein. A partial mobilization of the\nbasilica vein was performed. Afterward, a brachialis-basilica\nanastomosis was carried out. The operation was uncomplicated.\n\nYour collaboration has been instrumental in managing this patient\neffectively. If you have any further queries or require additional\ndetails, please do not hesitate to contact our office.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------- ------------------ ------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Change every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg Morning on 03/05 & 03/06\n Pantoprazole (Protonix) 40 mg Morning\n Cotrimoxazole (Bactrim Forte) 480 mg Morning 3x weekly on Mon, Wed, Fri\n Valacyclovir (Valtrex) 500 mg Half tablet in the morning\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly subcutaneous (Morning)\n Pregabalin (Lyrica) 25 mg Morning and Evening\n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg Morning and Evening\n Filgrastim (Neupogen/Granix) 48 million IU Morning and Evening\n\nBest regards,\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nI am writing to provide you with a detailed report on Mr. John Williams,\nwho was admitted to our facility from May 8, 2020, to May 28, 2020.\n\n**Diagnoses:**\n\nHistory of acute mitral valve endocarditis in March 2020.\n\nSubsequent re-operation entailing mitral valve replacement using a\nBioprosthesis (29 mm) coupled with the resection of all infected tissue\nfrom the mitral valve\\'s supporting apparatus on March 24, 2020.\n\nThe origin remains uncertain, but potential associations include Demers\ncatheter infection and port catheter infection (confirmed presence of\nStaphylococcus epidermidis).\n\nSurgical removal was conducted on March 21, 2020, with no findings at\nthe catheter tips.\n\n14. Antibiotic regimen included:\n\n Meropenem from April 2, 2020, to April 23, 2020.\n\n Linezolid 600 mg from April 3, 2020, to April 19, 2020.\n\n Daptomycin from April 3, 2020, to May 27, 2020.\n\n Fosfomycin from April 19, 2020, to May 28, 2020.\n\nHistory of mitral valve reconstruction via minithoracotomy in 2015.\n\nRight-side vision loss due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia in the caput nuclei caudati/lenticular nuclei\non April 5, 2020, possibly embolic in origin from mitral valve\nendocarditis.\n\nHistory of brainstem transient ischemic attack (TIA) on March 11, 2020,\npotentially embolic in relation to mitral valve endocarditis.\n\nJugular vein thrombosis.\n\n20. Hematological/oncological diagnoses comprise:\n\n Multiple myeloma with lambda light chains, stage IIIB according to\n the Salmon and Durie criteria, first diagnosed in 2015. This was\n accompanied by multiple osteolysis occurrences, history of radiation\n to Th4 and rib thorax, and treatment with Daratumumab. Current\n treatment has been paused due to remission.\n\n A prostate carcinoma diagnosis in January 2018\n\n**Other medical conditions include:**\n\n-Chronic kidney failure necessitating dialysis since 2018, history of a\nDemer catheter with explantation on March 2020, and angioplasty on the\nright V. basilica and V. brachialis due to stenosis-related shunt\ndysfunction.\n\n-History of brainstem TIA in April 2019.\n\n-Sensations of tingling paresthesias in both lower legs.\n\n-History of bilateral deep vein thrombosis.\n\n-Frequent calf muscle cramps.\n\n**Medical History Overview:**\n\nMr. Williams\\'s latest admission on May 8, 2020, was to assess remission\nstatus and determine if continuation of treatment for his known multiple\nmyeloma was necessary. Previously, until March 2020 he was under a\nDaratumumab monotherapy (as he could not tolerate Revlimid), which\nshowed stable disease progression. Prior to this, he was treated at our\nlocal hospital for mitral valve endocarditis which had a complex\ntrajectory. At the time of admission, Mr. Williams felt generally weak\nbut was otherwise in stable condition. Upon discontinuation of the\nfentanyl patch, his back pain increased. He exhibited no fevers and had\nno known allergies. His appetite was low, and he reported no nausea.\nSince his heart surgery, he has experienced numbness in his left heel\nand toes. His residual urine output was about 190 mL per day, and he was\nundergoing regular dialysis.\n\n**Physical Examination:**\n\nThe patient was alert, responsive, and fully oriented. The examination\nof the head, neck, and lungs was unremarkable. Cardiac auscultation\nrevealed clear and rhythmic heart sounds without any abnormal findings.\nThere was a non-irritated sternotomy scar. Examination of his back\nrevealed decubitus ulcers. Abdominal examination showed a soft,\nnon-tender abdomen with normal bowel sounds. Extremity examination\nrevealed minor edema.\n\n**Diagnostic Imaging and Tests:**\n\nA series of diagnostic tests, including sonography, whole body CT scan,\nophthalmological exams, and histology were conducted. The results are\ndetailed within this report. In summary, the findings indicate:\n\n-Limited abnormalities in the heart\\'s echocardiography, with potential\nmitral valve issues to monitor.\n\n-Bone scans revealed extensive osteopenia and other abnormalities\nrelated to his known multiple myeloma, but no evidence of new\nosteolysis.\n\n-Eye examinations confirmed the previously noted vision issues,\npotentially stemming from the mitral valve endocarditis, but provided no\nclear solutions.\n\n-Histological evaluation of bone marrow samples indicates largely\nregular hematopoiesis but confirms infiltration from the known multiple\nmyeloma.\n\n**Summary and Recommendations:**\n\nMr. John Williams is a 63-year-old male with a complex medical history\ninvolving multiple organ systems. His most recent admission was in\nrelation to his multiple myeloma, for which he has been in remission and\nwill be monitored closely. His mitral valve endocarditis from earlier\nthis year has been resolved and treated appropriately. Due to the\nmultiple comorbidities, it is crucial for any treating facility or\nphysician to be fully aware of his history to provide optimal care.\nContinual monitoring of his cardiovascular and renal systems is\nessential. The importance of maintaining strict adherence to his\ndialysis regimen and potential antibiotic prophylaxis is emphasized.\nGiven his weakened general condition and chronic pain, palliative care\nmight also be a suitable approach to consider, focusing on enhancing his\nquality of life and addressing his pain management needs.\n\nPlease refer to the attached files for further details and a complete\nbreakdown of tests and findings. I trust this report will help guide the\nappropriate medical care for Mr. John Williams.\n\nSincerely,\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- -------------------- -----------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Morning\n Enoxaparin (Lovenox) 0.2 mL s.c. Evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Morning and Evening\n Leuprorelin (Lupron Depot) Monthly depot Every 4 weeks via subcutaneous injection\n Fentanyl Transdermal System 12 μg/hour Changed every 3 days\n Pantoprazole (Protonix) 40 mg Morning\n Sevelamer (Renagel) 800 mg Morning\n Multivitamin One tablet Morning\n Torsemide (Torem) 200 mg Morning\n Vitamin D3 20,000 IU Once weekly\n Sodium bicarbonate (Bicanorm) One tablet Morning\n Calcitriol (Rocaltrol) 0.25 μg Morning\n Valacyclovir (Valtrex) 500 mg half-tablet Morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Morning on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Morning on day 1 and day 2 following daratumumab administration\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nI am writing to provide an update on the medical condition and treatment\nof Mr. John Williams, who has been undergoing inpatient treatment in our\nfacility since September 30, 2021.\n\n**Diagnoses**:\n\n**Present**: Acute impairment of the visual field.\n\n**Oncological Diagnosis**:\n\n1. Diagnosis of Multiple Myeloma with kappa light chains, staged at\n IIIB as per the Salmon and Durie criteria\n\n Observable multiple osteolyses.\n\n History of radiation to the T4 and thoracic rib.\n\n Starting from 2018, he required dialysis due to renal insufficiency,\n scheduled on Mondays, Wednesdays, and Fridays in our local clinic.\n\n 2018: Treatment involved Bortezomib and Dexamethasone, but he was\n refractory to this combination. The regimen of Carfilzomib,\n Lenalidomide, and Dexamethasone was also found to be ineffective.\n\n Radiation was administered to the T4 (totaling 30 Gy) and the\n thoracic rib (totaling 20 Gy) in August 2018.\n\n Between August and October 2018: Mr. Williams underwent three cycles\n of Pomalidomide, Doxorubicin, and Dexamethasone, but the disease\n showed progression.\n\n November 2018 to February 2019: He received four treatments of\n Daratumumab, Lenalidomide, and Dexamethasone, which led to a very\n good partial response (VGPR).\n\n In March 2019, he underwent stem cell mobilization due to RSV\n pneumonia complications and then started on Daratumumab monotherapy\n (VGPR was last noted in May 2018).\n\n He continued with Daratumumab treatment until November 2019, after\n which there was a pause until March 2020 due to remission (VGPR) and\n a diagnosis of endocarditis.\n\n A whole body CT scan conducted in March 2020 did not show any new\n osteolyses.\n\n By May 2020, there was an increase in LK values, prompting the\n resumption of Daratumumab, which led to a decrease in free light\n chains.\n\n As of June 2020, there was a noted increase in light chain kappa\n values to 102 mg/L.\n\n In July 2020, therapy was escalated to include Daratumumab, Revlimid\n (5 mg), and Dexamethasone.\n\n By September 2020, a further increase in light chains was observed,\n prompting a planned switch to Elotuzumab, Pomalidomide, and\n Dexamethasone.\n\n**For his heart condition:**\n\nAcute mitral valve endocarditis was diagnosed in March 2020. He\nunderwent a re-operation for mitral valve replacement with a\nbioprosthesis (29 mm). This procedure, performed in March, 2020,\ninvolved the resection of all infected tissue from the mitral valve\\'s\nholding apparatus. The cause is presumed to be associated with a Demers\ncatheter infection or possibly related to a port catheter infection\n(Staphylococcus epidermidis was found). The catheter was surgically\nremoved in March 2020. He was on a series of antibiotics, including\nMeropenem, Linezolid, Daptomycin, and Fosfomycin.\n\n**Other pertinent medical events include:**\n\nA history of radiation treatment using a minithoracotomy technique for\nmitral valve reconstruction in 2015.\n\nRight eye amaurosis due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia diagnosed in April 2020, possibly due to\nemboli from the mitral valve endocarditis.\n\nA transient ischemic attack (TIA) in the brainstem observed on in March\n2020, which could be related to emboli from the mitral valve\nendocarditis.\n\nJugular vein thrombosis.\n\nProstate cancer diagnosed in 2018.\n\nChronic renal failure necessitating dialysis since 2018.\n\nPrevious procedures include Demers catheter placement (removed on March\n2020) and angioplasty on the right basilic vein and brachial vein due to\nstenosis causing shunt dysfunction.\n\nHistory of transient ischemic attacks.\n\nBilateral tingling paresthesias in the lower legs, history of deep vein\nthrombosis, recurrent calf cramps, and hypothyroidism.\n\nPlease let me know if you require any further information on Mr.\nWilliams. I am confident that this detailed account will assist you in\nunderstanding his medical history and ensuring optimal care.\n\n**Therapy: **\n\nTherapy schedule: Daratumumab s.c. 1800mg abs. weekly in week 1-8,\n2-weekly in week 9-24, every 4 weeks from week 25. Continuation of\nBondronat. Regular monitoring and optimal adjustment of cardiovascular\nrisk factors.\n\nMedication:\n\nPlavix (Clopidogrel) 75 mg; once daily in the morning\n\nLovenox (Enoxaparin) 0.2 ml subcutaneously; once daily in the evening on\nnon-dialysis days\n\nMarinol (Dronabinol) drops; four drops in the morning and four drops in\nthe evening\n\nDuragesic (Fentanyl transdermal patch) 12 μg/hour; change every 3 days\n\nProtonix (Pantoprazole) 40 mg; dosing: Once daily in the morning and\nonce daily in the evening for 2 weeks, then once daily in the morning\n\nRenvela 800 mg; dosing: Once daily in the morning\n\nTorem 200 mg; once daily in the morning\n\nVitamin D3 20,000 IU; once weekly\n\nCalcijex (Calcitriol) 0.25 mcg; once daily in the morning\n\nValtrex (Valacyclovir) 500 mg; dosing: Half a tablet (250 mg) once daily\nin the morning\n\nBactrim (Cotrimoxazole or trimethoprim/sulfamethoxazole) 480 mg, once\ndaily\n\nWarm regards,\n\n**Clinical Update, 11/12/2022**\n\nMr. John Williams, a 66-year-old male with a known history of multiple\nmyeloma and associated complications, presented again to our facility\nwith worsening symptoms over the past three weeks.\n\n**Symptoms**:\n\nPersistent fatigue\n\nShortness of breath on minimal exertion\n\nBilateral pitting edema in the lower extremities up to the mid-calf\n\n**Preliminary Findings**:\n\n**Physical Examination**:\n\n1. Jugular venous distention\n\n Decreased breath sounds bilaterally with mild basilar crackles\n\n S3 gallop on cardiac auscultation\n\n**Chest X-ray**:\n\n4. Cardiomegaly with an enlarged cardiac silhouette. Mild pulmonary\n edema evident.\n\n**Echocardiogram**:\n\n5. Reduced left ventricular ejection fraction (LVEF) of 35% (normal \\>\n 55%)\n\n Mild mitral regurgitation\n\n**Lab Results**:\n\n7. B-type natriuretic peptide (BNP): 890 pg/mL (Normal: \\<100 pg/mL)\n\n Serum Sodium: 130 mEq/L (Normal: 135-145 mEq/L)\n\n Serum Potassium: 5.8 mEq/L (Normal: 3.5-5.1 mEq/L)\n\n Blood Urea Nitrogen (BUN): 38 mg/dL (Normal: 7-20 mg/dL)\n\n Creatinine: 2.1 mg/dL (Normal: 0.8-1.3 mg/dL)\n\n GFR: 35 mL/min (Reduced)\n\n**Diagnosis**:\n\nCongestive Heart Failure (CHF) with reduced ejection fraction\n\nRenal insufficiency\n\nMultiple Myeloma (primary diagnosis 2015)\n\nProstate cancer\n\n**Treatment Administered**:\n\nIntravenous furosemide was administered to relieve fluid overload,\nresulting in a significant reduction in edema and improvement in\nbreathlessness over the subsequent 48 hours. Lisinopril was initiated\ncautiously to manage CHF and to potentially provide renal protection.\nMetoprolol was started at a low dose, with close monitoring of blood\npressure and heart rate. Potassium levels were closely monitored given\ninitial hyperkalemia; diet and medications were adjusted accordingly.\nDietary consult emphasized a low-sodium, moderate protein, and\npotassium-restricted diet. Close monitoring of fluid balance\n(input-output) was maintained throughout the stay.\n\n**Progress**:\n\nMr. Williams showed consistent improvement over his two-week admission.\nSerial echocardiograms indicated a slight improvement in LVEF to 39%.\nThe edema receded notably, and his shortness of breath on exertion\nreduced significantly. Labs before discharge showed:\n\nSerum Sodium: 134 mEq/L\n\nSerum Potassium: 4.9 mEq/L\n\nBUN: 32 mg/dL\n\nCreatinine: 1.9 mg/dL\n\nBNP: 550 pg/mL\n\n**Discharge Recommendations**:\n\nOutpatient cardiology follow-up in two weeks and then monthly to monitor\nLVEF and adjust medications. Nephrology consultation to keep an eye on\nrenal function, given his increased susceptibility to kidney damage.\nContinue with dietary restrictions and modifications as advised.\nCommence an outpatient cardiac rehabilitation program for supervised\nexercise and lifestyle modifications. Weekly blood tests for the first\nmonth to monitor electrolytes and kidney function.\n\nMr. Williams remains at risk due to multiple comorbidities. It is\nessential to address each condition holistically while ensuring no\nsingle treatment exacerbates another condition. A collaborative and\nvigilant approach is imperative for his ongoing health management.\n\nWarm regards,\n\n --------------------------- ---------------- ---------------------\n **Parameter** **Value** **Reference Range**\n **Blood Count** \n White Blood Cells (WBC) 5.8 x 10^9^/L 4-11 x 10^9^/L\n Red Blood Cells (RBC) 3.9 x 10^12^/L 4.5-5.5 x 10^12^/L\n Hemoglobin (Hb) 9.8 g/dL 13-18 g/dL for men\n Platelets (Plt) 150 x 10^9^/L 150-450 x 10^9^/L\n \n **Biochemistry** \n Creatinine 2.8 mg/dL 0.6-1.3 mg/dL\n Blood Urea Nitrogen (BUN) 40 mg/dL 7-20 mg/dL\n Glucose 98 mg/dL 70-100 mg/dL\n \n **Electrolytes** \n Sodium (Na) 137 mEq/L 135-145 mEq/L\n Potassium (K) 5.1 mEq/L 3.5-5.0 mEq/L\n Calcium 8.6 mg/dL 8.5-10.5 mg/dL\n Phosphate 4.5 mg/dL 2.5-4.5 mg/dL\n \n **Oncologic Markers** \n Free light chain kappa 692 mg/L 3.3-19.4 mg/L\n Free light chain lambda 12 mg/L 5.7-26.3 mg/L\n \n **Other Values** \n LDL cholesterol 80 mg/dL \\<100 mg/dL\n HbA1c 6.2% \\<5.7%\n --------------------------- ---------------- ---------------------\n", "title": "text_9" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_3\n**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n\nHere is the query:\nWhich neuropsychological test did Mr. Davies perform poorly on in terms of reaction time?\n\nChoose the correct answer from the following options:\nA. Divided attention\nB. Wechsler Memory Scale\nC. Verbal Learning and Memory Test\nD. Alertness\nE. Multiple-Choice Vocabulary Intelligence Test\n\n\nYour response:\n", "role": "user" }, { "content": "Alertness", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953. He was under our inpatient care from 04/19/2009 to\n04/28/2009.\n\n**Diagnoses:**\n\n- Progressive deterioration of renal transplant function (creeping\n creatinine) without evidence of biopsy-proven rejection\n\n- Isovolumetric tubular epithelial vacuolization\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Mr. Fisher was admitted for a renal transplant\nbiopsy due to progressive deterioration of transplant function (creeping\ncreatinine). His recent creatinine values had increased to around 1.4 --\n1.6 mg/dL, while they had previously been around 1.1 mg/dL.\n\n**Therapy and Progression:** Following appropriate preparation and\ninformed consent, a complication-free transplant puncture was performed.\nThe biopsy showed isometric tubular epithelial vacuolization without\nsignificant findings. This was followed by adjustment of Cyclosporin-A\nlevels and the addition of a lymphocyte proliferation inhibitor to the\nexisting immunosuppressive dual therapy. There was a significant\nincrease in Cyclosporin-A levels at one point due to accidental double\ndosing by the patient, but levels returned to the target range. This\nmight explain the current rise in creatinine. Another explanation could\nbe recurrent hypotensive blood pressure dysregulations, leading to the\ndiscontinuation of Minoxidile medication. For chronic atrial\nfibrillation, anticoagulation therapy with Marcumar was restarted during\nhospitalization and should be continued as an outpatient according to\nthe target INR. Low molecular weight heparin administration could be\ndiscontinued.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No dyspnea. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable.\n\nLungs: Normal chest shape, moderately mobile, resonant percussion sound,\nvesicular breath sounds bilaterally, no wheezing or crackles heard.\n\nHeart: Irregular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, markedly obese, no tenderness, no palpable\nmasses, liver and spleen not palpable due to limited access, non-tender\nkidneys. Large reducible incisional hernia on the right side following\nnephrectomy.\n\nExtremities: Occluded fistula on the right forearm. Normal peripheral\npulses; joints freely movable. Strength, motor function, and sensation\nare unremarkable.\n\n**Kidney Biopsy on 04/19/2009:** Complication-free biopsy of the\ntransplant kidney.\n\nFindings: Erythematous macules.\n\nRecommendation: Follow-up in 3 months.\n\n**Ultrasound of Transplant Kidney on 04/20/2009:** Transplant kidney\nwell visualized, located in the left iliac fossa, measurable,\noval-shaped. Parenchymal echogenicity normal, normal corticomedullary\ndifferentiation. No evidence of arteriovenous fistula or hematoma after\nkidney biopsy.\n\n**Pathological-anatomical assessment on 04/19/2009:**\n\n**Macroscopic Findings:** Singular Nodule Identified: Dimensions\nmeasuring 8 mm.\n\n**Microscopic Examination:**\n\nSampled Tissue: Renal cortex\n\nIdentified Components:\n\n- Glomeruli: Nine observed\n\n- Interlobular Artery: One segment present\n\n- Absence of medullary tissue\n\n**Diagnostic Observations:** There were no signs of inflammation or\nscarring in the renal cortex. The glomeruli appeared normocellular, and\nno signs of inflammation or pathological changes were observed in them.\nThe peritubular capillaries were free of inflammation, and the specific\ntest for C4d staining yielded negative results. The arterioles within\nthe tissue had thin walls, and there was no evidence of inflammation in\nthis vascular component.\n\nThe interlobular artery was also thin-walled and showed no evidence of\ninflammation.\n\nA notable finding was extensive damage to the tubular epithelium. The\ndamage was characterized by isometric microvesicular cytoplasmic\ntransformation, which exceeded 80%. Importantly, there was no evidence\nof cell necrosis and only minimal flattening of cells was observed. In\naddition, no pathological imprints, microcalcifications, or nuclear\ninclusion bodies were observed in the tubular epithelium.\n\n**Summary:** The predominant pathological finding in this case is\nsubstantial tubular damage. Consequently, it is highly advisable to\nclosely monitor immunosuppression levels in the patient\\'s management.\nFurther comprehensive evaluation is strongly recommended to determine\nthe underlying cause of the observed tubular damage and to address the\nclinical question concerning the presence of Chronic Allograft\nNephropathy or the potential involvement of an infection in the clinical\npresentation.\n\n**Chest X-ray (2 views) on 04/22/2009:**\n\n[Findings]{.underline}: No pneumothorax, no effusion. No evidence of\npneumonia. No focal findings. Left-biased heart without decompensation.\nMediastinum centrally positioned, not widened. Unremarkable depiction of\ncentral hilar structures. Thoracic hyperkyphosis.\n\n**Current Recommenations:** We request regular outpatient monitoring of\nretention parameters (initially every 2-3 weeks) and are available for\nfurther questions at the provided telephone number.\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 144 mEq/L 134-145 mEq/L\n Potassium 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium 9.48 mg/dL 8.6-10.6 mg/dL\n Chloride 106 mEq/L 95-112 mEq/L\n Phosphorus 2.88 mg/dL 2.5-4.5 mg/dL\n Transferrin Saturation 20 % 16-45 %\n Magnesium 1.9 mg/dL 1.8-2.6 mg/dL\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n Glomerular Filtration Rate 36 mL/min \\>90 mL/min\n BUN (Blood Urea Nitrogen) 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n C-Reactive Protein 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 ng/mL 30-300 ng/mL\n ALT (Alanine Aminotransferase) 17 U/L \\<45 U/L\n AST (Aspartate Aminotransferase) 20 U/L \\<50 U/L\n Alkaline Phosphatase 119 U/L 40-129 U/L\n GGT (Gamma-Glutamyltransferase) 94 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n TSH (Thyroid-Stimulating Hormone) 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43% 40-52%\n Red Blood Cells 4.60 M/uL 4.6-6.2 M/uL\n White Blood Cells 8.78 K/uL 4.5-11.0 K/uL\n Platelets 205 K/uL 150-400 K/uL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/uL 1.8-7.7 K/uL\n Lymphocytes 2.37 K/uL 1.4-3.7 K/uL\n Monocytes 0.93 K/uL 0.2-1.0 K/uL\n Eosinophils 1.67 K/uL \\<0.7 K/uL\n Basophils 0.09 K/uL 0.01-0.10 K/uL\n Nucleated Red Blood Cells Negative \\<0.01 K/uL\n APTT (Activated Partial Thromboplastin Time) 45.1 sec 26-40 sec\n Antithrombin Activity 85 % 80-120 %\n\n**Medication upon discharge**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Cyclosporine (Neoral) 1 mg 1-0-1\n Mycophenolic Acid (Myfortic) 180 mg 1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0\n Aspirin 81 mg 1-0-0\n Candesartan (Atacand) 16 mg 0-0-1\n Metoprolol (Lopressor) 50 mg 1-1-1-1\n Isosorbide Dinitrate (Isordil) 60 mg 1-0-0\n Torsemide (Demadex) 10 mg As directed\n Ranitidine (Zantac) 300 mg 0-0-1\n Fluvastatin (Lescol) 20 mg 0-0-1\n Allopurinol (Zyloprim) 100 mg 0-1-0\n Tamsulosin (Flomax) 0.4 mg 1-0-0\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide an update on our patient, Mr. Alan Fisher,\nborn on 12/09/1953.\n\nHe was under our inpatient care from 10/02/2018 to 10/03/2018.\n\n**Diagnoses:**\n\n- Urosepsis\n\n- Acute postrenal kidney failure\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Previous Surgeries:** Previous prostate vesiculectomy with regional\nlymphadenectomy\n\n**Planned procedure:** Urethro-cystoscopy with catheter placement for\nurethral stricture\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by the outpatient urologist due to suspicion of\na urethral stricture. Mr. Fisher reports a worsening urinary retention\nfor approximately 6 months. Despite multiple unsuccessful attempts at\ncatheter placement, ureterocystoscopy with catheter insertion was\nperformed. Intraoperatively, purulent cystitis and a bladder outlet\nobstruction were observed.\n\nMr. Fisher regularly attends follow-up examinations for his history of\nkidney transplantation in 1995 and previous prostate vesiculectomy with\nregional lymphadenectomy in 01/2018.\n\n**Physical Examination:** Neurology: RASS 0, alert, CAM-ICU negative, no\nnew focal neurology\n\nLungs: Bilateral air entry, no rales or wheezing, sufficient gas\nexchange on 2L/O2 Cardiovascular: Normal sinus rhythm, normotensive on\n0.01 µg/kg/min NA\n\nAbdomen: Soft, no guarding, sparse peristalsis, advanced oral diet,\nregular bowel movements\n\nDiuresis: Normal urine output, retention values within normal range,\ngoal: balanced fluid status\n\nSkin/Wounds: Non-irritated, no peripheral edema\n\n**Therapy and Progression**: We received Mr. Fisher, who was awake and\nspontaneously breathing under a 2L O2 mask via nasal cannula, to our\nintensive care unit due to urosepsis. To maintain an adequate\ncirculation, low-dose catecholamine therapy was required but could be\ndiscontinued on the first postoperative day. Pulmonary function remained\nstable with intensive non-invasive ventilation and breathing training.\n\nGiven his immunosuppression, we escalated the intraoperatively initiated\nanti-infective therapy from Ceftriaxone to Piperacillin/Tazobactam.\nPneumococcal and Legionella rapid tests were negative. Following\nappropriate volume resuscitation and diuretic therapy with Furosemide,\ndiuresis became sufficient. Oral diet progression occurred without\ncomplications. Anticoagulation was initially in prophylactic dosing with\nHeparin and later switched to therapeutic dosing with Enoxaparin.\n\n**Current Recommendations:**\n\n- Switch unfractionated Heparin to Fragmin\n\n- baseline Crea 2mg/dL, target CyA level: 50-60ng/mL, Myfortic\n continued.\n\n- Urological care of the stricture in progress, leave catheter until\n then.\n\n- Mobilization\n\n**Medication upon Discharge:**\n\n **Medication (Brand)** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Torsemide (Demadex) 10 mg 1-1-0-0\n Prednisone (Deltasone) 5 mg 1-1-0-0\n Pantoprazole (Protonix) 20 mg 1-1-0-0\n Mycophenolate Mofetil (CellCept) 360 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 100 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Candesartan (Atacand) 16 mg 0-0.5-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Allopurinol (Zyloprim) 100 mg 1-0-0-0\n Aspirin 81 mg 1-0-0-0\n Paracetamol (Tylenol) 500 mg As needed\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. Alan Fisher, born on\n12/09/1953.\n\nHe was under our inpatient care from 11/04/2018 to 11/12/2018.\n\n**Current Symptoms:** Decreased diuresis, rising creatinine, frustrating\ncatheterization.\n\n**Diagnoses:**\n\n- Acute on chronic graft failure\n\n<!-- -->\n\n- Creatinine increased from 1.56 mg/dL to a maximum of 2.35 mg/dL.\n\n- Likely postrenal origin due to urethral stricture; sonographically,\n Grade II urinary stasis with urinary retention and residual urine\n formation.\n\n- Frustrating catheterization due to urethral stricture\n\n- Urethro-cystoscopy with bougie and catheter placement\n\n- Parainfectious component in purulent cystitis with urosepsis\n\n- Discharged with indwelling catheter\n\n- Inpatient readmission to the colleagues in Urology for internal\n urethrotomy\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by an outpatient urologist due to suspected\nurethral stricture. Mr. Fisher reports increasing difficulty urinating\nfor approximately 6 months. He has to \\\"squeeze out\\\" his bladder\ncompletely. Frustrating catheterization was performed due to urinary\nretention. Intraoperatively, purulent cystitis and bladder outlet\nstenosis were observed. Mr. Fisher regularly undergoes follow-up\nexaminations for a history of kidney transplantation in 1995 and a\nprostate vesiculectomy with regional lymphadenectomy in 01/2018.\n\n**Vegetative Findings:** The patient had a bowel movement 4 days ago,\nindwelling catheter irritation (3L of diuresis the previous day), no\nnausea/vomiting, no fever or night sweats, weight loss of 30kg from\nFebruary to April 2020.\n\n**Physical Capacity:** Limited, can still climb 2 stairs but needs to\ntake a break due to shortness of breath.\n\n**Physical Examination:** Temperature 37.4°C, Blood pressure 128/72\nmmHg; Pulse 72/min; Respiratory rate 15/min, O2 saturation under 2L O2:\n96%\n\nAwake, alert, cooperative, oriented to time, place, person, and\nsituation.\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; Clear paranasal\nsinuses; moist and pink mucous membranes; unremarkable dentition; moist\nand glossy tongue; non-palpable thyroid enlargement.\n\n[Chest]{.underline}: Normal configuration; Non-tender spine; free renal\nbeds bilaterally.\n\n[Heart]{.underline}: Rhythmic, clear heart sounds, normal rate, no\nsplitting; non-distended jugular veins. [Lungs]{.underline}: Vesicular\nbreath sounds; Resonant percussion note; no adventitious sounds; no\nstridor; normal chest expansion.\n\n[Abdomen]{.underline}: Protuberant, known incisional hernia, normal\nperistalsis in all quadrants; soft; no pathological resistance; no\ntenderness; liver palpable below the costal margin; spleen not palpable.\n\n[Lymph nodes:]{.underline} No pathologically enlarged cervical nodes\npalpable; axillary and inguinal nodes not palpable.\n\nSkin: No pathological skin findings.\n\n[Extremities:]{.underline} Warm; mild bilateral ankle edema.\n\n[Pulse status (right/left):]{.underline} A. carotis +/+, A. radialis\n+/+, A. femoralis +/+, A. tibialis post. +/+, A. dorsalis ped. +/+\n\n[Neurological]{.underline}: Oriented and unremarkable.\n\n**Therapy and Progression:** The patient was admitted through our\nemergency department upon referral by an outpatient urologist due to\nsuspected urethral stricture, which had been causing increasingly\ndifficult urination for approximately 6 months. Sonography showed Grade\nII urinary stasis with urinary retention and residual urine. Frustrating\ncatheterization was performed, followed by ureterocystoscopy with bougie\nand catheter placement. Intraoperatively, purulent cystitis and bladder\noutlet stenosis were observed. Laboratory tests revealed acute kidney\ntransplant failure, with creatinine increasing from 1.56 mg/dL to 2.35\nmg/dL, along with significantly elevated infection parameters: CRP up to\n186 mg/dL, PCT 12.82 µg/L, and leukocytosis of 21.6/nL. After obtaining\nblood cultures, empirical antibiotic therapy with Ceftriaxone was\ninitiated. Upon detecting Pseudomonas aeruginosa, therapy was switched\nto Piperacillin/Tazobactam on 12/06/20 and continued until 12/13/20.\nUnder this treatment, infection parameters significantly improved, and\nMr. Fisher remained afebrile. Kidney retention parameters also decreased\nto a discharge creatinine of 2.05 mg/dL. Regarding the urethral\nstricture, he was initially discharged with an indwelling catheter. A\nfollow-up appointment for internal urethrotomy and potentially Allium\nstent placement was scheduled for 4 weeks later. During the hospital\nstay, ciclosporin levels remained within the target range. Following\nprostate vesiculectomy earlier in the year, anticoagulation was switched\nfrom Enoxaparin to Apixaban 2.5 mg twice daily, and Aspirin therapy was\ndiscontinued.\n\n**Recommendations**: We recommend regular monitoring of kidney retention\nparameters and infection parameters. Regarding the urethral stricture,\nthe patient will be discharged with an indwelling catheter. We scheduled\na follow-up with colleagues in Urology for internal urethrotomy and\npotentially Allium stent placement. Pause oral anticoagulation with\nApixaban one day before inpatient admission.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Candesartan (Atacand) 8 mg 0-1-0-0\n Torsemide (Demadex) 10 mg 1-1-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU Pause\n Magnesium Oxide 400 mg 1-0-0-0\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under outpatient care on 07/01/2019.\n\n**Current Symptoms:** Pain on the left side at rib level**,** Dyspnea\n\n**Diagnoses:**\n\n- Infection of unclear origin\n\n - CT Thorax and Abdomen showed no focus\n\n - Urine dipstick and cultures were bland\n\n - Antibiotics: Meropenem from 06/11/2019 to 06/19/2019\n\n- Acute Transplant Dysfunction\n\n - Serum Creatinine: 2.4 -\\> 4.5 -\\> 2.6 mg/dl\n\n - Renal ultrasound: 123 x 54 x 24 mm, not dilated, some areas of\n increased echogenicity, no twinkling, no acoustic shadowing, no\n signs of urolithiasis.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Initial presentation was at the local emergency\ndepartment on referral from the primary care physician for suspected\nacute coronary syndrome. Mr. Fisher described left-sided rib pain, which\nwas related to breathing and pressure, as well as dyspnea for a few\ndays. Laboratory tests showed acute-on-chronic kidney failure and\nelevated infection parameters. A urine dipstick test was negative for\nnitrites and leukocytes. Chest CT ruled out pulmonary pathology, and\nacute coronary syndrome was also excluded. Mr. Fisher reported a urinary\ntract infection about 4 weeks ago, which was treated with antibiotics as\nan outpatient.\n\n**Physical Examination:** Alert, oriented, cooperative, and responsive\nto time, place, person, and situation\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; clear nasal\nsinuses; moist pink mucous membranes; unremarkable dental status; moist\ntongue\n\n[Chest]{.underline}: Normal configuration; no tenderness in the spine;\nboth renal beds free\n\n[Heart]{.underline}: Arrhythmic heart sounds, pure, tachycardic, not\nsplit\n\n[Lungs]{.underline}: Vesicular breath sounds; somewhat decreased breath\nsounds bilaterally; no adventitious sounds; no stridor\n\n[Abdomen]{.underline}: Regular peristalsis in all quadrants; soft; right\nlower abdomen notably distended with increased vascular markings, liver\nand spleen not palpable, transplant kidney non-tender\n\n[Lymph Nodes:]{.underline} No pathologically enlarged cervical lymph\nnodes palpable\n\n[Skin]{.underline}: No pathological skin findings\n\n[Extremities:]{.underline} Warm; no edema; cyanosis of toes bilaterally\nafter prolonged leg dependency\n\n- Pulse status (right/left): Carotid artery +/+, Radial artery +/+,\n Posterior tibial artery +/+\n\n- Neurology: Normal cranial nerves; round, moderately dilated pupils;\n prompt bilateral pupillary light reflex; no sensory or motor\n deficits; ubiquitous muscle strength 5/5\n\n**Therapy and Progression:** We admitted the patient for further\ndiagnosis and treatment. Initially suspected acute coronary syndrome was\nruled out. Laboratory results showed elevated retention and infection\nparameters. With volume substitution, we achieved baseline creatinine\nlevels again. The transplant kidney appeared non-dilated and\nwell-perfused. For the infection, the patient received the mentioned\nimaging studies, which did not reveal any definitive findings. Our urine\nanalyses and cultures also showed bland results. It should be noted that\nprior outpatient treatment for suspected urinary tract infection was\nlikely with cotrimoxazole. Ultimately, considering the recent\nantibiograms, we decided on a calculated antibiotic therapy with\nMeropenem. This led to a significant improvement in infection\nparameters. The last measured Ciclosporin level was slightly\nsubtherapeutic, so we adjusted the dosage accordingly. We recommend\nfollow-up with the primary care physician.\n\n**Chest CT on 06/10/2019:**\n\n[Clinical Information, Question, Justification]{.underline}: Patient\nwith a history of kidney transplantation. Bursting pain on both sides at\nthe ribcage. Cough. Elevated inflammatory markers. Question about\ninfiltrates, pleural effusion, congestion.\n\n[Technique]{.underline}: Digital overview radiographs. Plain 80-line CT\nof the chest. MPR (Multiplanar reconstruction). DLP (Dose-Length\nProduct) 120.6 mGy\\*cm.\n\n[Findings]{.underline}: No previous images available for comparison.\nSymmetric thyroid. Minimal pericardial effusion, accentuated at the\nbase, measuring up to 8 mm in width (Series 5, Image 293). Coronary\natherosclerosis. No pathologically enlarged lymph nodes in the\nmediastinum, axilla, or hilum on plain images. Multisegmental calcified\n(micro)nodules. No suspicious pulmonary nodules indicative of\nmalignancy. No pneumonic infiltrates. No pleural effusions. No\npneumothorax. No pulmonary venous congestion. Delicate scar tissue at\nthe bases bilaterally. Small axial hiatal hernia. Rounded soft tissue\nstructure in the right adrenal space (Series 5, measuring 411 x 10 mm).\nIncidentally captured at the image margins is a shrunken left kidney.\nSpondylosis deformans of the thoracic spine. Interpretation: No\npneumonic infiltrates. No pleural effusions. No pulmonary venous\ncongestion. Minimal pericardial effusion. Multisegmental calcified\n(micro)nodules, likely post-inflammatory.\n\n**Abdomen/Pelvis CT on 06/14/2019:**\n\n[Clinical Information, Question, Justification:]{.underline} Acute\nkidney failure. Question regarding kidney or ureteral stones.\n\n[Technique]{.underline}: Plain 80-line CT of the abdomen. MPR. DLP 947\nmGy\\*cm. Findings and [Interpretation:]{.underline}\n\nThe left transplant kidney shows pelvic dilation with an expanded renal\npelvis and ureter (hydronephrosis grade II) but no evidence of stones.\nStatus post-right nephrectomy. Shrunken left kidney. Known large,\nbroad-based right-sided abdominal wall weakness with prolapsed\nintestinal loops and mesenteric fat tissue without evidence of\nincarceration. No ileus. Diverticulosis of the sigmoid colon. Small\naxial hiatal hernia. No free or encapsulated fluid or free air in the\nabdomen with the right diaphragmatic dome not fully visualized.\n\nCholecystolithiasis. No cholestasis. Vascular sclerosis. No\nlymphadenopathy. Bilaterally aerated lung bases captured without change.\nUnchanged irregularly thickened and coarsely structured right iliac\nbone, consistent with Paget\\'s disease.\n\n**Recommendations:**\n\nCiclosporin level monitoring\n\n**Medication upon discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Candesartan Cilexetil (Atacand) 8 mg 0-1-0-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU 1 x/week\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 70-0-70-0\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under our inpatient care from 02/19/2020 to\n03/01/2020.\n\n**Current Symptoms:** Decreased general condition, weakness,\ndecompensation\n\n**Diagnosis**: Acute episode of recurrent urinary tract infection with\ndetection of E. faecalis, E. faecium, and Enterobacter cloacae in urine\n(blood cultures sterile).\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our internal\nmedicine emergency department. He presented with worsening general\ncondition and increasing weakness, following the recommendation of our\nlocal nephrological telemedicine. He particularly noticed the increasing\nweakness when getting up, describing his legs as feeling like rubber. He\nalso experienced shortness of breath. His walking distance was greater\nthan 100 meters. There was no fever, chills, nausea, vomiting, dysuria,\nor changes in bowel movements. Before the outpatient visit, the patient\nhad collected urine for 24 hours, totaling 1700 ml, with a fluid intake\nof approximately 2 liters. His blood pressure at home was approximately\n120/60 mmHg. In the emergency department, he had negative urinary\ndipstick results and a non-specific chest X-ray. Blood and urine\ncultures were obtained, and he was subsequently transferred to our\ngeneral ward. No angina pectoris symptoms. The patient had normal bowel\nmovements, specifically no melena, and no blood-tinged stools. Urine was\ndescribed as clear and light.\n\n**Physical Examination:** Alert, oriented, cooperative, oriented to\ntime, place, person, and situation. Height 179 cm; Weight 114 kg\n\n[Head/neck:]{.underline} No tender nerve exit points; Clear nasal\nsinuses; No tenderness over the skull; Mucous membranes pink and moist;\nDental status is rehabilitated; Tongue moist and glossy\n[Thorax]{.underline}: Normally shaped; Spine without tenderness; Renal\nregions free of tenderness\n\n[Heart]{.underline}: Heart sounds are faint, arrhythmic, clear, regular\nrate, no splitting of heart sounds; Jugular veins are not distended\n\n[Lungs]{.underline}: Faint vesicular breath sounds; Resonant percussion\nnote; Dullness on the left, no added sounds; No stridor; Normal breath\nexcursion\n\n[Abdomen]{.underline}: Large right abdominal wall hernia, normal\nperistalsis in all quadrants; Soft; No pathological resistances; No\ntenderness (especially not over the left lower abdomen)\n\n[Skin status:]{.underline} No pathological skin findings\n\nExtremities: Warm; Mild edema.\n\n[Neurology:]{.underline} Alert. No focal deficits\n\n**Treatment and Progression:** The patient was admitted through our\nemergency department due to a decrease in general condition and\nweakness, accompanied by significantly elevated laboratory infection\nparameters and slightly worsened retention parameters (Creatinine max\n3.4 mg/dL compared to the current baseline of 3 mg/dL). Upon admission,\napart from a known and persistent leukocyturia since 2020, there were no\nindications of any other infectious focus. We were able to detect\nEnterobacter cloacae and Enterococcus faecalis in the urine, and we\ninitially treated the patient with intravenous Tazobactam. Blood\ncultures remained sterile. The patient\\'s general condition improved\nwithin a few days, along with a regression of infection parameters.\n\nFor further investigation of recurrent urinary tract infections (UTIs)\nand in the context of a history of urethral stricture treatment in\nFebruary 2021 with bougienage of the urethra one year ago, a urological\nconsultation was arranged. During this consultation, there was suspicion\nof a recurrence of the urethral stricture due to a significant residual\nurine volume of 175 ml. A scheduled readmission for repeat surgical\nmanagement was set for May 16, 2022. Due to the lack of normalization of\nelevated infection parameters and significant residual urine, a urinary\ncatheter was inserted. Subsequently, Enterococcus faecium was detected,\nand we continued treatment with oral Linezolid after the completion of\nintravenous antibiotic therapy.\n\nThe antibiotic treatment was planned to continue on an outpatient basis\nfor a total of 10 days. We kindly request an outpatient follow-up to\nmonitor infection parameters next week. The urinary catheter will be\nmaintained until the urological follow-up appointment, and the patient\nhas been provided with a prescription for medication.\n\nFurthermore, the patient exhibited atrial tachyarrhythmia. We reduced\nthe heart rate using Digoxin, as the patient was already on maximum\nbeta-blocker therapy. The atrial tachyarrhythmia significantly improved\nunder this treatment.\n\nAdditionally, there was a non-puncture-worthy pleural effusion and a\nchronic pericardial effusion, which was not hemodynamically relevant.\nThere were no clinical indications of pericarditis.\n\n**Current Recommendations:**\n\n1. Inpatient admission to Urology Department.\n\n2. Outpatient laboratory monitoring and referral issuance by the\n primary care physician.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on mutual patient, Mr. Alan Fisher, born on 12/09/1953,\nwho was under our inpatient care from 03/14/2020 to 03/15/2020.\n\n**Diagnoses**: Anastomotic stricture following history of prostatectomy\nand history of urethrotomy interna.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Procedure**:\n\n- Urethrotomy interna according to Sachse\n\n- Calculated intravenous antibiotic therapy with Meropenem starting on\n 03/14/2020\n\n- Extension of therapy to include antifungal treatment with\n Fluconazole on 03/15/2020\n\n**Medical History:** The patient presents with a recurrence of\nsymptomatic urethral stricture at the anastomosis site following\nprostatectomy. The main symptoms are frequent urination, dysuria, and\nresidual urine formation up to 175 ml. In January 2019, urethrotomy\ninterna was already performed. Since the last hospitalization due to a\nurinary tract infection, the patient has had a continuous\ncatheterization.\n\n**Physical Examination:** Patient in a reduced general condition and\nobese nutritional status. The abdomen is soft, without signs of\nresistance or pain. Kidney beds on both sides are indolent.\n\n**Urine Diagnostics**: Urine dipstick: Leukocytes 500, Nitrite negative,\nErythrocytes 50\n\n**Microbiology**: Candida in urine, collected by the general\npractitioner on 03/11/2020.\n\n**Chest X-ray in two planes on 02/19/2020:**\n\n[Clinical Information, Question, Justification for the\nExamination]{.underline}: Deterioration of general condition. History of\nrecurrent sepsis. History of lung transplantation. Infiltrates?\n\n**Findings**: The heart is shifted to the left and has a mitral\nconfiguration. No signs of acute congestion. The mediastinum shows no\nsigns of emphysema, is centrally located, and of normal width. No active\npneumonia in the ventilated lung regions. Progressive costophrenic angle\neffusion on the left. No pleural effusion on the right, as far as can be\nassessed. No pneumothorax. Degenerative changes in the spine.\nHyperkyphosis of the thoracic spine.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complication. Scar tissue at the level of the bladder sphincter\nwas incised. The postoperative course was uneventful. The transurethral\nindwelling catheter was removed on the 19th postoperative day. At the\ntime of discharge, the patient could urinate without residual urine with\na good urinary stream. We discharged the patient on 03/19/2020 for\nfurther outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------------- ------------------- ------------------\n Magnesium Oxide 400 mg 1-0-0-0\n Atorvastatin (Lipitor) 43.3 mg 0-0-1-0\n Candesartan Cilexetil (Atacand) 16 mg 1-1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol, oily) 20,000 IU 1x every 2 weeks\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 385 mg 1-0-1-0\n Pantoprazole (Protonix) 22.6 mg 1-0-0-0\n Piperacillin/Tazobactam (Zosyn) 4.17 g and 0.54 g 1-1-1-0\n Cyclosporine, microemulsified (Neoral) 10 mg 1-0-1-0\n Cyclosporine, microemulsified (Neoral) 50 mg 1-0-1-0\n Torsemide (Demadex) 10 mg 2-1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------------ ---------------------\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 3.02 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 19 mL/min/1.73m² \\-\n Total Bilirubin 0.73 mg/dL \\< 1.20 mg/dL\n Direct Bilirubin 0.41 mg/dL \\< 0.30 mg/dL\n C-reactive Protein 78.3 mg/dL \\< 5.0 mg/dL\n Alanine Aminotransferase 35 U/L \\< 41 U/L\n Aspartate Aminotransferase 33 U/L \\< 50 U/L\n Alkaline Phosphatase 273 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 184 U/L 8-61 U/L\n Lipase 102 U/L 13-60 U/L\n Hemoglobin 12.3 g/dL 12.5-17.2 g/dL\n Hematocrit 39.0% 37.0-49.0%\n Red Blood Cells 4.2 M/uL 4.0-5.6 M/uL\n White Blood Cells 10.41 K/uL 3.90-10.50 K/uL\n Platelets 488 K/uL 150-370 K/uL\n Mean Corpuscular Volume 92.4 fL 80.0-101.0 fL\n Mean Corpuscular Hemoglobin 29.1 pg 27.0-34.0 pg\n Mean Corpuscular Hemoglobin Concentration 31.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.3 fL 7.0-12.0 fL\n Red Cell Distribution Width 13.5% 11.5-15.0%\n\n\n\n\nHere is the query:\nWhich of Mr. Fisher's medications present in November 2018 is absent from the discharge list in July 2019?\n\nChoose the correct answer from the following options:\nA. Metoprolol Succinate (Toprol-XL)\nB. Pantoprazole (Protonix)\nC. Torsemide (Demadex)\nD. Prednisone (Deltasone)\nE. Vitamin D3 (Cholecalciferol)\n\n\nYour response:\n", "role": "user" }, { "content": "Torsemide (Demadex)", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953. He was under our inpatient care from 04/19/2009 to\n04/28/2009.\n\n**Diagnoses:**\n\n- Progressive deterioration of renal transplant function (creeping\n creatinine) without evidence of biopsy-proven rejection\n\n- Isovolumetric tubular epithelial vacuolization\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Mr. Fisher was admitted for a renal transplant\nbiopsy due to progressive deterioration of transplant function (creeping\ncreatinine). His recent creatinine values had increased to around 1.4 --\n1.6 mg/dL, while they had previously been around 1.1 mg/dL.\n\n**Therapy and Progression:** Following appropriate preparation and\ninformed consent, a complication-free transplant puncture was performed.\nThe biopsy showed isometric tubular epithelial vacuolization without\nsignificant findings. This was followed by adjustment of Cyclosporin-A\nlevels and the addition of a lymphocyte proliferation inhibitor to the\nexisting immunosuppressive dual therapy. There was a significant\nincrease in Cyclosporin-A levels at one point due to accidental double\ndosing by the patient, but levels returned to the target range. This\nmight explain the current rise in creatinine. Another explanation could\nbe recurrent hypotensive blood pressure dysregulations, leading to the\ndiscontinuation of Minoxidile medication. For chronic atrial\nfibrillation, anticoagulation therapy with Marcumar was restarted during\nhospitalization and should be continued as an outpatient according to\nthe target INR. Low molecular weight heparin administration could be\ndiscontinued.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No dyspnea. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable.\n\nLungs: Normal chest shape, moderately mobile, resonant percussion sound,\nvesicular breath sounds bilaterally, no wheezing or crackles heard.\n\nHeart: Irregular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, markedly obese, no tenderness, no palpable\nmasses, liver and spleen not palpable due to limited access, non-tender\nkidneys. Large reducible incisional hernia on the right side following\nnephrectomy.\n\nExtremities: Occluded fistula on the right forearm. Normal peripheral\npulses; joints freely movable. Strength, motor function, and sensation\nare unremarkable.\n\n**Kidney Biopsy on 04/19/2009:** Complication-free biopsy of the\ntransplant kidney.\n\nFindings: Erythematous macules.\n\nRecommendation: Follow-up in 3 months.\n\n**Ultrasound of Transplant Kidney on 04/20/2009:** Transplant kidney\nwell visualized, located in the left iliac fossa, measurable,\noval-shaped. Parenchymal echogenicity normal, normal corticomedullary\ndifferentiation. No evidence of arteriovenous fistula or hematoma after\nkidney biopsy.\n\n**Pathological-anatomical assessment on 04/19/2009:**\n\n**Macroscopic Findings:** Singular Nodule Identified: Dimensions\nmeasuring 8 mm.\n\n**Microscopic Examination:**\n\nSampled Tissue: Renal cortex\n\nIdentified Components:\n\n- Glomeruli: Nine observed\n\n- Interlobular Artery: One segment present\n\n- Absence of medullary tissue\n\n**Diagnostic Observations:** There were no signs of inflammation or\nscarring in the renal cortex. The glomeruli appeared normocellular, and\nno signs of inflammation or pathological changes were observed in them.\nThe peritubular capillaries were free of inflammation, and the specific\ntest for C4d staining yielded negative results. The arterioles within\nthe tissue had thin walls, and there was no evidence of inflammation in\nthis vascular component.\n\nThe interlobular artery was also thin-walled and showed no evidence of\ninflammation.\n\nA notable finding was extensive damage to the tubular epithelium. The\ndamage was characterized by isometric microvesicular cytoplasmic\ntransformation, which exceeded 80%. Importantly, there was no evidence\nof cell necrosis and only minimal flattening of cells was observed. In\naddition, no pathological imprints, microcalcifications, or nuclear\ninclusion bodies were observed in the tubular epithelium.\n\n**Summary:** The predominant pathological finding in this case is\nsubstantial tubular damage. Consequently, it is highly advisable to\nclosely monitor immunosuppression levels in the patient\\'s management.\nFurther comprehensive evaluation is strongly recommended to determine\nthe underlying cause of the observed tubular damage and to address the\nclinical question concerning the presence of Chronic Allograft\nNephropathy or the potential involvement of an infection in the clinical\npresentation.\n\n**Chest X-ray (2 views) on 04/22/2009:**\n\n[Findings]{.underline}: No pneumothorax, no effusion. No evidence of\npneumonia. No focal findings. Left-biased heart without decompensation.\nMediastinum centrally positioned, not widened. Unremarkable depiction of\ncentral hilar structures. Thoracic hyperkyphosis.\n\n**Current Recommenations:** We request regular outpatient monitoring of\nretention parameters (initially every 2-3 weeks) and are available for\nfurther questions at the provided telephone number.\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 144 mEq/L 134-145 mEq/L\n Potassium 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium 9.48 mg/dL 8.6-10.6 mg/dL\n Chloride 106 mEq/L 95-112 mEq/L\n Phosphorus 2.88 mg/dL 2.5-4.5 mg/dL\n Transferrin Saturation 20 % 16-45 %\n Magnesium 1.9 mg/dL 1.8-2.6 mg/dL\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n Glomerular Filtration Rate 36 mL/min \\>90 mL/min\n BUN (Blood Urea Nitrogen) 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n C-Reactive Protein 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 ng/mL 30-300 ng/mL\n ALT (Alanine Aminotransferase) 17 U/L \\<45 U/L\n AST (Aspartate Aminotransferase) 20 U/L \\<50 U/L\n Alkaline Phosphatase 119 U/L 40-129 U/L\n GGT (Gamma-Glutamyltransferase) 94 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n TSH (Thyroid-Stimulating Hormone) 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43% 40-52%\n Red Blood Cells 4.60 M/uL 4.6-6.2 M/uL\n White Blood Cells 8.78 K/uL 4.5-11.0 K/uL\n Platelets 205 K/uL 150-400 K/uL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/uL 1.8-7.7 K/uL\n Lymphocytes 2.37 K/uL 1.4-3.7 K/uL\n Monocytes 0.93 K/uL 0.2-1.0 K/uL\n Eosinophils 1.67 K/uL \\<0.7 K/uL\n Basophils 0.09 K/uL 0.01-0.10 K/uL\n Nucleated Red Blood Cells Negative \\<0.01 K/uL\n APTT (Activated Partial Thromboplastin Time) 45.1 sec 26-40 sec\n Antithrombin Activity 85 % 80-120 %\n\n**Medication upon discharge**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Cyclosporine (Neoral) 1 mg 1-0-1\n Mycophenolic Acid (Myfortic) 180 mg 1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0\n Aspirin 81 mg 1-0-0\n Candesartan (Atacand) 16 mg 0-0-1\n Metoprolol (Lopressor) 50 mg 1-1-1-1\n Isosorbide Dinitrate (Isordil) 60 mg 1-0-0\n Torsemide (Demadex) 10 mg As directed\n Ranitidine (Zantac) 300 mg 0-0-1\n Fluvastatin (Lescol) 20 mg 0-0-1\n Allopurinol (Zyloprim) 100 mg 0-1-0\n Tamsulosin (Flomax) 0.4 mg 1-0-0\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient, Mr. Alan Fisher,\nborn on 12/09/1953.\n\nHe was under our inpatient care from 10/02/2018 to 10/03/2018.\n\n**Diagnoses:**\n\n- Urosepsis\n\n- Acute postrenal kidney failure\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Previous Surgeries:** Previous prostate vesiculectomy with regional\nlymphadenectomy\n\n**Planned procedure:** Urethro-cystoscopy with catheter placement for\nurethral stricture\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by the outpatient urologist due to suspicion of\na urethral stricture. Mr. Fisher reports a worsening urinary retention\nfor approximately 6 months. Despite multiple unsuccessful attempts at\ncatheter placement, ureterocystoscopy with catheter insertion was\nperformed. Intraoperatively, purulent cystitis and a bladder outlet\nobstruction were observed.\n\nMr. Fisher regularly attends follow-up examinations for his history of\nkidney transplantation in 1995 and previous prostate vesiculectomy with\nregional lymphadenectomy in 01/2018.\n\n**Physical Examination:** Neurology: RASS 0, alert, CAM-ICU negative, no\nnew focal neurology\n\nLungs: Bilateral air entry, no rales or wheezing, sufficient gas\nexchange on 2L/O2 Cardiovascular: Normal sinus rhythm, normotensive on\n0.01 µg/kg/min NA\n\nAbdomen: Soft, no guarding, sparse peristalsis, advanced oral diet,\nregular bowel movements\n\nDiuresis: Normal urine output, retention values within normal range,\ngoal: balanced fluid status\n\nSkin/Wounds: Non-irritated, no peripheral edema\n\n**Therapy and Progression**: We received Mr. Fisher, who was awake and\nspontaneously breathing under a 2L O2 mask via nasal cannula, to our\nintensive care unit due to urosepsis. To maintain an adequate\ncirculation, low-dose catecholamine therapy was required but could be\ndiscontinued on the first postoperative day. Pulmonary function remained\nstable with intensive non-invasive ventilation and breathing training.\n\nGiven his immunosuppression, we escalated the intraoperatively initiated\nanti-infective therapy from Ceftriaxone to Piperacillin/Tazobactam.\nPneumococcal and Legionella rapid tests were negative. Following\nappropriate volume resuscitation and diuretic therapy with Furosemide,\ndiuresis became sufficient. Oral diet progression occurred without\ncomplications. Anticoagulation was initially in prophylactic dosing with\nHeparin and later switched to therapeutic dosing with Enoxaparin.\n\n**Current Recommendations:**\n\n- Switch unfractionated Heparin to Fragmin\n\n- baseline Crea 2mg/dL, target CyA level: 50-60ng/mL, Myfortic\n continued.\n\n- Urological care of the stricture in progress, leave catheter until\n then.\n\n- Mobilization\n\n**Medication upon Discharge:**\n\n **Medication (Brand)** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Torsemide (Demadex) 10 mg 1-1-0-0\n Prednisone (Deltasone) 5 mg 1-1-0-0\n Pantoprazole (Protonix) 20 mg 1-1-0-0\n Mycophenolate Mofetil (CellCept) 360 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 100 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Candesartan (Atacand) 16 mg 0-0.5-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Allopurinol (Zyloprim) 100 mg 1-0-0-0\n Aspirin 81 mg 1-0-0-0\n Paracetamol (Tylenol) 500 mg As needed\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. Alan Fisher, born on\n12/09/1953.\n\nHe was under our inpatient care from 11/04/2018 to 11/12/2018.\n\n**Current Symptoms:** Decreased diuresis, rising creatinine, frustrating\ncatheterization.\n\n**Diagnoses:**\n\n- Acute on chronic graft failure\n\n<!-- -->\n\n- Creatinine increased from 1.56 mg/dL to a maximum of 2.35 mg/dL.\n\n- Likely postrenal origin due to urethral stricture; sonographically,\n Grade II urinary stasis with urinary retention and residual urine\n formation.\n\n- Frustrating catheterization due to urethral stricture\n\n- Urethro-cystoscopy with bougie and catheter placement\n\n- Parainfectious component in purulent cystitis with urosepsis\n\n- Discharged with indwelling catheter\n\n- Inpatient readmission to the colleagues in Urology for internal\n urethrotomy\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by an outpatient urologist due to suspected\nurethral stricture. Mr. Fisher reports increasing difficulty urinating\nfor approximately 6 months. He has to \\\"squeeze out\\\" his bladder\ncompletely. Frustrating catheterization was performed due to urinary\nretention. Intraoperatively, purulent cystitis and bladder outlet\nstenosis were observed. Mr. Fisher regularly undergoes follow-up\nexaminations for a history of kidney transplantation in 1995 and a\nprostate vesiculectomy with regional lymphadenectomy in 01/2018.\n\n**Vegetative Findings:** The patient had a bowel movement 4 days ago,\nindwelling catheter irritation (3L of diuresis the previous day), no\nnausea/vomiting, no fever or night sweats, weight loss of 30kg from\nFebruary to April 2020.\n\n**Physical Capacity:** Limited, can still climb 2 stairs but needs to\ntake a break due to shortness of breath.\n\n**Physical Examination:** Temperature 37.4°C, Blood pressure 128/72\nmmHg; Pulse 72/min; Respiratory rate 15/min, O2 saturation under 2L O2:\n96%\n\nAwake, alert, cooperative, oriented to time, place, person, and\nsituation.\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; Clear paranasal\nsinuses; moist and pink mucous membranes; unremarkable dentition; moist\nand glossy tongue; non-palpable thyroid enlargement.\n\n[Chest]{.underline}: Normal configuration; Non-tender spine; free renal\nbeds bilaterally.\n\n[Heart]{.underline}: Rhythmic, clear heart sounds, normal rate, no\nsplitting; non-distended jugular veins. [Lungs]{.underline}: Vesicular\nbreath sounds; Resonant percussion note; no adventitious sounds; no\nstridor; normal chest expansion.\n\n[Abdomen]{.underline}: Protuberant, known incisional hernia, normal\nperistalsis in all quadrants; soft; no pathological resistance; no\ntenderness; liver palpable below the costal margin; spleen not palpable.\n\n[Lymph nodes:]{.underline} No pathologically enlarged cervical nodes\npalpable; axillary and inguinal nodes not palpable.\n\nSkin: No pathological skin findings.\n\n[Extremities:]{.underline} Warm; mild bilateral ankle edema.\n\n[Pulse status (right/left):]{.underline} A. carotis +/+, A. radialis\n+/+, A. femoralis +/+, A. tibialis post. +/+, A. dorsalis ped. +/+\n\n[Neurological]{.underline}: Oriented and unremarkable.\n\n**Therapy and Progression:** The patient was admitted through our\nemergency department upon referral by an outpatient urologist due to\nsuspected urethral stricture, which had been causing increasingly\ndifficult urination for approximately 6 months. Sonography showed Grade\nII urinary stasis with urinary retention and residual urine. Frustrating\ncatheterization was performed, followed by ureterocystoscopy with bougie\nand catheter placement. Intraoperatively, purulent cystitis and bladder\noutlet stenosis were observed. Laboratory tests revealed acute kidney\ntransplant failure, with creatinine increasing from 1.56 mg/dL to 2.35\nmg/dL, along with significantly elevated infection parameters: CRP up to\n186 mg/dL, PCT 12.82 µg/L, and leukocytosis of 21.6/nL. After obtaining\nblood cultures, empirical antibiotic therapy with Ceftriaxone was\ninitiated. Upon detecting Pseudomonas aeruginosa, therapy was switched\nto Piperacillin/Tazobactam on 12/06/20 and continued until 12/13/20.\nUnder this treatment, infection parameters significantly improved, and\nMr. Fisher remained afebrile. Kidney retention parameters also decreased\nto a discharge creatinine of 2.05 mg/dL. Regarding the urethral\nstricture, he was initially discharged with an indwelling catheter. A\nfollow-up appointment for internal urethrotomy and potentially Allium\nstent placement was scheduled for 4 weeks later. During the hospital\nstay, ciclosporin levels remained within the target range. Following\nprostate vesiculectomy earlier in the year, anticoagulation was switched\nfrom Enoxaparin to Apixaban 2.5 mg twice daily, and Aspirin therapy was\ndiscontinued.\n\n**Recommendations**: We recommend regular monitoring of kidney retention\nparameters and infection parameters. Regarding the urethral stricture,\nthe patient will be discharged with an indwelling catheter. We scheduled\na follow-up with colleagues in Urology for internal urethrotomy and\npotentially Allium stent placement. Pause oral anticoagulation with\nApixaban one day before inpatient admission.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Candesartan (Atacand) 8 mg 0-1-0-0\n Torsemide (Demadex) 10 mg 1-1-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU Pause\n Magnesium Oxide 400 mg 1-0-0-0\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under outpatient care on 07/01/2019.\n\n**Current Symptoms:** Pain on the left side at rib level**,** Dyspnea\n\n**Diagnoses:**\n\n- Infection of unclear origin\n\n - CT Thorax and Abdomen showed no focus\n\n - Urine dipstick and cultures were bland\n\n - Antibiotics: Meropenem from 06/11/2019 to 06/19/2019\n\n- Acute Transplant Dysfunction\n\n - Serum Creatinine: 2.4 -\\> 4.5 -\\> 2.6 mg/dl\n\n - Renal ultrasound: 123 x 54 x 24 mm, not dilated, some areas of\n increased echogenicity, no twinkling, no acoustic shadowing, no\n signs of urolithiasis.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Initial presentation was at the local emergency\ndepartment on referral from the primary care physician for suspected\nacute coronary syndrome. Mr. Fisher described left-sided rib pain, which\nwas related to breathing and pressure, as well as dyspnea for a few\ndays. Laboratory tests showed acute-on-chronic kidney failure and\nelevated infection parameters. A urine dipstick test was negative for\nnitrites and leukocytes. Chest CT ruled out pulmonary pathology, and\nacute coronary syndrome was also excluded. Mr. Fisher reported a urinary\ntract infection about 4 weeks ago, which was treated with antibiotics as\nan outpatient.\n\n**Physical Examination:** Alert, oriented, cooperative, and responsive\nto time, place, person, and situation\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; clear nasal\nsinuses; moist pink mucous membranes; unremarkable dental status; moist\ntongue\n\n[Chest]{.underline}: Normal configuration; no tenderness in the spine;\nboth renal beds free\n\n[Heart]{.underline}: Arrhythmic heart sounds, pure, tachycardic, not\nsplit\n\n[Lungs]{.underline}: Vesicular breath sounds; somewhat decreased breath\nsounds bilaterally; no adventitious sounds; no stridor\n\n[Abdomen]{.underline}: Regular peristalsis in all quadrants; soft; right\nlower abdomen notably distended with increased vascular markings, liver\nand spleen not palpable, transplant kidney non-tender\n\n[Lymph Nodes:]{.underline} No pathologically enlarged cervical lymph\nnodes palpable\n\n[Skin]{.underline}: No pathological skin findings\n\n[Extremities:]{.underline} Warm; no edema; cyanosis of toes bilaterally\nafter prolonged leg dependency\n\n- Pulse status (right/left): Carotid artery +/+, Radial artery +/+,\n Posterior tibial artery +/+\n\n- Neurology: Normal cranial nerves; round, moderately dilated pupils;\n prompt bilateral pupillary light reflex; no sensory or motor\n deficits; ubiquitous muscle strength 5/5\n\n**Therapy and Progression:** We admitted the patient for further\ndiagnosis and treatment. Initially suspected acute coronary syndrome was\nruled out. Laboratory results showed elevated retention and infection\nparameters. With volume substitution, we achieved baseline creatinine\nlevels again. The transplant kidney appeared non-dilated and\nwell-perfused. For the infection, the patient received the mentioned\nimaging studies, which did not reveal any definitive findings. Our urine\nanalyses and cultures also showed bland results. It should be noted that\nprior outpatient treatment for suspected urinary tract infection was\nlikely with cotrimoxazole. Ultimately, considering the recent\nantibiograms, we decided on a calculated antibiotic therapy with\nMeropenem. This led to a significant improvement in infection\nparameters. The last measured Ciclosporin level was slightly\nsubtherapeutic, so we adjusted the dosage accordingly. We recommend\nfollow-up with the primary care physician.\n\n**Chest CT on 06/10/2019:**\n\n[Clinical Information, Question, Justification]{.underline}: Patient\nwith a history of kidney transplantation. Bursting pain on both sides at\nthe ribcage. Cough. Elevated inflammatory markers. Question about\ninfiltrates, pleural effusion, congestion.\n\n[Technique]{.underline}: Digital overview radiographs. Plain 80-line CT\nof the chest. MPR (Multiplanar reconstruction). DLP (Dose-Length\nProduct) 120.6 mGy\\*cm.\n\n[Findings]{.underline}: No previous images available for comparison.\nSymmetric thyroid. Minimal pericardial effusion, accentuated at the\nbase, measuring up to 8 mm in width (Series 5, Image 293). Coronary\natherosclerosis. No pathologically enlarged lymph nodes in the\nmediastinum, axilla, or hilum on plain images. Multisegmental calcified\n(micro)nodules. No suspicious pulmonary nodules indicative of\nmalignancy. No pneumonic infiltrates. No pleural effusions. No\npneumothorax. No pulmonary venous congestion. Delicate scar tissue at\nthe bases bilaterally. Small axial hiatal hernia. Rounded soft tissue\nstructure in the right adrenal space (Series 5, measuring 411 x 10 mm).\nIncidentally captured at the image margins is a shrunken left kidney.\nSpondylosis deformans of the thoracic spine. Interpretation: No\npneumonic infiltrates. No pleural effusions. No pulmonary venous\ncongestion. Minimal pericardial effusion. Multisegmental calcified\n(micro)nodules, likely post-inflammatory.\n\n**Abdomen/Pelvis CT on 06/14/2019:**\n\n[Clinical Information, Question, Justification:]{.underline} Acute\nkidney failure. Question regarding kidney or ureteral stones.\n\n[Technique]{.underline}: Plain 80-line CT of the abdomen. MPR. DLP 947\nmGy\\*cm. Findings and [Interpretation:]{.underline}\n\nThe left transplant kidney shows pelvic dilation with an expanded renal\npelvis and ureter (hydronephrosis grade II) but no evidence of stones.\nStatus post-right nephrectomy. Shrunken left kidney. Known large,\nbroad-based right-sided abdominal wall weakness with prolapsed\nintestinal loops and mesenteric fat tissue without evidence of\nincarceration. No ileus. Diverticulosis of the sigmoid colon. Small\naxial hiatal hernia. No free or encapsulated fluid or free air in the\nabdomen with the right diaphragmatic dome not fully visualized.\n\nCholecystolithiasis. No cholestasis. Vascular sclerosis. No\nlymphadenopathy. Bilaterally aerated lung bases captured without change.\nUnchanged irregularly thickened and coarsely structured right iliac\nbone, consistent with Paget\\'s disease.\n\n**Recommendations:**\n\nCiclosporin level monitoring\n\n**Medication upon discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Candesartan Cilexetil (Atacand) 8 mg 0-1-0-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU 1 x/week\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 70-0-70-0\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under our inpatient care from 02/19/2020 to\n03/01/2020.\n\n**Current Symptoms:** Decreased general condition, weakness,\ndecompensation\n\n**Diagnosis**: Acute episode of recurrent urinary tract infection with\ndetection of E. faecalis, E. faecium, and Enterobacter cloacae in urine\n(blood cultures sterile).\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our internal\nmedicine emergency department. He presented with worsening general\ncondition and increasing weakness, following the recommendation of our\nlocal nephrological telemedicine. He particularly noticed the increasing\nweakness when getting up, describing his legs as feeling like rubber. He\nalso experienced shortness of breath. His walking distance was greater\nthan 100 meters. There was no fever, chills, nausea, vomiting, dysuria,\nor changes in bowel movements. Before the outpatient visit, the patient\nhad collected urine for 24 hours, totaling 1700 ml, with a fluid intake\nof approximately 2 liters. His blood pressure at home was approximately\n120/60 mmHg. In the emergency department, he had negative urinary\ndipstick results and a non-specific chest X-ray. Blood and urine\ncultures were obtained, and he was subsequently transferred to our\ngeneral ward. No angina pectoris symptoms. The patient had normal bowel\nmovements, specifically no melena, and no blood-tinged stools. Urine was\ndescribed as clear and light.\n\n**Physical Examination:** Alert, oriented, cooperative, oriented to\ntime, place, person, and situation. Height 179 cm; Weight 114 kg\n\n[Head/neck:]{.underline} No tender nerve exit points; Clear nasal\nsinuses; No tenderness over the skull; Mucous membranes pink and moist;\nDental status is rehabilitated; Tongue moist and glossy\n[Thorax]{.underline}: Normally shaped; Spine without tenderness; Renal\nregions free of tenderness\n\n[Heart]{.underline}: Heart sounds are faint, arrhythmic, clear, regular\nrate, no splitting of heart sounds; Jugular veins are not distended\n\n[Lungs]{.underline}: Faint vesicular breath sounds; Resonant percussion\nnote; Dullness on the left, no added sounds; No stridor; Normal breath\nexcursion\n\n[Abdomen]{.underline}: Large right abdominal wall hernia, normal\nperistalsis in all quadrants; Soft; No pathological resistances; No\ntenderness (especially not over the left lower abdomen)\n\n[Skin status:]{.underline} No pathological skin findings\n\nExtremities: Warm; Mild edema.\n\n[Neurology:]{.underline} Alert. No focal deficits\n\n**Treatment and Progression:** The patient was admitted through our\nemergency department due to a decrease in general condition and\nweakness, accompanied by significantly elevated laboratory infection\nparameters and slightly worsened retention parameters (Creatinine max\n3.4 mg/dL compared to the current baseline of 3 mg/dL). Upon admission,\napart from a known and persistent leukocyturia since 2020, there were no\nindications of any other infectious focus. We were able to detect\nEnterobacter cloacae and Enterococcus faecalis in the urine, and we\ninitially treated the patient with intravenous Tazobactam. Blood\ncultures remained sterile. The patient\\'s general condition improved\nwithin a few days, along with a regression of infection parameters.\n\nFor further investigation of recurrent urinary tract infections (UTIs)\nand in the context of a history of urethral stricture treatment in\nFebruary 2021 with bougienage of the urethra one year ago, a urological\nconsultation was arranged. During this consultation, there was suspicion\nof a recurrence of the urethral stricture due to a significant residual\nurine volume of 175 ml. A scheduled readmission for repeat surgical\nmanagement was set for May 16, 2022. Due to the lack of normalization of\nelevated infection parameters and significant residual urine, a urinary\ncatheter was inserted. Subsequently, Enterococcus faecium was detected,\nand we continued treatment with oral Linezolid after the completion of\nintravenous antibiotic therapy.\n\nThe antibiotic treatment was planned to continue on an outpatient basis\nfor a total of 10 days. We kindly request an outpatient follow-up to\nmonitor infection parameters next week. The urinary catheter will be\nmaintained until the urological follow-up appointment, and the patient\nhas been provided with a prescription for medication.\n\nFurthermore, the patient exhibited atrial tachyarrhythmia. We reduced\nthe heart rate using Digoxin, as the patient was already on maximum\nbeta-blocker therapy. The atrial tachyarrhythmia significantly improved\nunder this treatment.\n\nAdditionally, there was a non-puncture-worthy pleural effusion and a\nchronic pericardial effusion, which was not hemodynamically relevant.\nThere were no clinical indications of pericarditis.\n\n**Current Recommendations:**\n\n1. Inpatient admission to Urology Department.\n\n2. Outpatient laboratory monitoring and referral issuance by the\n primary care physician.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on mutual patient, Mr. Alan Fisher, born on 12/09/1953,\nwho was under our inpatient care from 03/14/2020 to 03/15/2020.\n\n**Diagnoses**: Anastomotic stricture following history of prostatectomy\nand history of urethrotomy interna.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Procedure**:\n\n- Urethrotomy interna according to Sachse\n\n- Calculated intravenous antibiotic therapy with Meropenem starting on\n 03/14/2020\n\n- Extension of therapy to include antifungal treatment with\n Fluconazole on 03/15/2020\n\n**Medical History:** The patient presents with a recurrence of\nsymptomatic urethral stricture at the anastomosis site following\nprostatectomy. The main symptoms are frequent urination, dysuria, and\nresidual urine formation up to 175 ml. In January 2019, urethrotomy\ninterna was already performed. Since the last hospitalization due to a\nurinary tract infection, the patient has had a continuous\ncatheterization.\n\n**Physical Examination:** Patient in a reduced general condition and\nobese nutritional status. The abdomen is soft, without signs of\nresistance or pain. Kidney beds on both sides are indolent.\n\n**Urine Diagnostics**: Urine dipstick: Leukocytes 500, Nitrite negative,\nErythrocytes 50\n\n**Microbiology**: Candida in urine, collected by the general\npractitioner on 03/11/2020.\n\n**Chest X-ray in two planes on 02/19/2020:**\n\n[Clinical Information, Question, Justification for the\nExamination]{.underline}: Deterioration of general condition. History of\nrecurrent sepsis. History of lung transplantation. Infiltrates?\n\n**Findings**: The heart is shifted to the left and has a mitral\nconfiguration. No signs of acute congestion. The mediastinum shows no\nsigns of emphysema, is centrally located, and of normal width. No active\npneumonia in the ventilated lung regions. Progressive costophrenic angle\neffusion on the left. No pleural effusion on the right, as far as can be\nassessed. No pneumothorax. Degenerative changes in the spine.\nHyperkyphosis of the thoracic spine.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complication. Scar tissue at the level of the bladder sphincter\nwas incised. The postoperative course was uneventful. The transurethral\nindwelling catheter was removed on the 19th postoperative day. At the\ntime of discharge, the patient could urinate without residual urine with\na good urinary stream. We discharged the patient on 03/19/2020 for\nfurther outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------------- ------------------- ------------------\n Magnesium Oxide 400 mg 1-0-0-0\n Atorvastatin (Lipitor) 43.3 mg 0-0-1-0\n Candesartan Cilexetil (Atacand) 16 mg 1-1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol, oily) 20,000 IU 1x every 2 weeks\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 385 mg 1-0-1-0\n Pantoprazole (Protonix) 22.6 mg 1-0-0-0\n Piperacillin/Tazobactam (Zosyn) 4.17 g and 0.54 g 1-1-1-0\n Cyclosporine, microemulsified (Neoral) 10 mg 1-0-1-0\n Cyclosporine, microemulsified (Neoral) 50 mg 1-0-1-0\n Torsemide (Demadex) 10 mg 2-1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------------ ---------------------\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 3.02 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 19 mL/min/1.73m² \\-\n Total Bilirubin 0.73 mg/dL \\< 1.20 mg/dL\n Direct Bilirubin 0.41 mg/dL \\< 0.30 mg/dL\n C-reactive Protein 78.3 mg/dL \\< 5.0 mg/dL\n Alanine Aminotransferase 35 U/L \\< 41 U/L\n Aspartate Aminotransferase 33 U/L \\< 50 U/L\n Alkaline Phosphatase 273 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 184 U/L 8-61 U/L\n Lipase 102 U/L 13-60 U/L\n Hemoglobin 12.3 g/dL 12.5-17.2 g/dL\n Hematocrit 39.0% 37.0-49.0%\n Red Blood Cells 4.2 M/uL 4.0-5.6 M/uL\n White Blood Cells 10.41 K/uL 3.90-10.50 K/uL\n Platelets 488 K/uL 150-370 K/uL\n Mean Corpuscular Volume 92.4 fL 80.0-101.0 fL\n Mean Corpuscular Hemoglobin 29.1 pg 27.0-34.0 pg\n Mean Corpuscular Hemoglobin Concentration 31.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.3 fL 7.0-12.0 fL\n Red Cell Distribution Width 13.5% 11.5-15.0%\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_3\n**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n\nHere is the query:\nWhat treatment was Mr. Davies given for bronchopneumonia in 2009?\n\nChoose the correct answer from the following options:\nA. Amoxicillin\nB. Cefuroxime and Sodium Chloride 0.9% inhalation\nC. Prednisone\nD. Oxygen supplementation\nE. Intravenous fluids only\n\n\nYour response:\n", "role": "user" }, { "content": "Cefuroxime and Sodium Chloride 0.9% inhalation", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n\n\n### text_5\n**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n\n\n\n\nHere is the query:\nWhat was the total bilirubin level in Mr. Wells' lab results upon discharge?\n\nChoose the correct answer from the following options:\nA. 0.5 mg/dL\nB. 1.5 mg/dL\nC. 1.9 mg/dL\nD. 2.5 mg/dL\nE. 5.0 mg/dL\n\n\nYour response:\n", "role": "user" }, { "content": "0.5 mg/dL", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nPatient: Miller, John, born 04/07/1961\n\nWe report to you about our common patient, Mr. John Miller, who is in\nour inpatient treatment since 07/30/2019.\n\n**Diagnoses:**\n\n\\- Suspected right cerebral glioblastoma (first diagnosis)\n\n\\- Symptoms: Aphasia, passive confusion\n\n**Patient history: **\n\nMr. Miller was admitted as an emergency. He was on the phone with a\nfriend when he suddenly began to exhibit speech difficulties and\nstruggled to find the right words. Consequently, his friend called 911.\n\nUpon the ambulance\\'s arrival, Mr. Miller was disoriented and exhibited\naggressive behavior. There was evidence of a torn door. He had blood on\nhis right forearm and around his mouth, but there were no indications of\na tongue bite or urinary incontinence.\n\nUpon admission, Mr. Miller was coherent and showed no speech issues. He\nattributed a mild weakness in his right arm to pre-existing pain in the\nupper arm. An immediate CT scan revealed a mass suggestive of a\nglioblastoma in the right cerebral hemisphere, leading to a\nneurosurgical consultation.\n\nGiven the possibility of an epileptic seizure, Mr. Miller was\nhospitalized and started on Levetiracetam. He is currently unaware of\nhis regular medications but takes antihypertensives and diabetes\nmedications, among others. His friend and brother have been notified and\nare ensuring that a detailed medication list is provided.\n\nAfter a brief stay in ward ABC, Mr. Miller was transferred to the\nneurosurgery team for further evaluation and treatment. We appreciate\nthe prompt transfer and are available for any further inquiries.\n\nPlanned Procedures:\n\n-Schedule EEG\n\n-Clarify routine medications\n\n**Surgery Report**\n\n**Diagnosis:** Suspected HGG (high-grade glioma) of the right hemisphere\n\n**Procedure:** Microsurgical navigation-guided resection of the tumor\nwith intraoperative neuromonitoring (stable MEPs) and intraoperative MRI\nusing 5-ALA. Pathology samples taken (Preliminary: HGG; Final to be\nconfirmed). Resection was followed by duragen placement, watertight\ndural closure, and multilayer wound closure, with skin sutures.\n\n**Time:**\n\n-Start: 11:12 am\n\n-Finish: 3:54 pm\n\n-Duration: 4 hours 42 minutes\n\n**Assessment:**\n\nMr. Miller presented with a seizure characterized by speech disturbance\nand disorientation. Imaging revealed a significant right hemispheral\nmass, likely representing a high-grade brain tumor. The need for\nsurgical resection was determined following discussions at our\ninterdisciplinary tumor board. After being informed about the procedure,\nalternative treatments, the operation\\'s urgency, benefits, and\npotential risks, Mr. Miller provided written consent following ample\ntime for consideration and the opportunity to ask further questions.\n\n**Procedure Details:**\n\nThe patient was positioned supine with his head secured in a Nova clamp.\nNavigation data were read, followed by skin preparation, and the\nsurgical field was sterilized and draped. An arch-shaped incision was\nmade, followed by hemostasis, deep tissue dissection, placement of a\nburr hole, and the creation of a large bone flap over the lesion. The\nbone flap was then elevated. Multiple washings were performed, followed\nby dural opening under microscopic visualization. A corticotomy was\ncarried out with bipolar forceps, CUSA, and suction to progressively\nreduce the tumor, utilizing 5-ALA fluorescence and continuous\nneurophysiological monitoring. An intraoperative MRI showed residual\ntumor, prompting further resection. Hemostasis was achieved, and the\nwound was closed using tabotamp, followed by duragen placement and dural\nsuturing. The bone flap was refixed using Dogbone plates. The wound area\nwas irrigated extensively once more, followed by subcutaneous and skin\nsutures.\n\n**Date:** 10/01/2019\n\n**Clinical Indication:**Suspected recurrence of GBM in the right\nhemisphere\n\n**Requested Imaging:**cMRI with or without contrast + DTI.\n\n**Findings:***Imaging Modality (GE 3.0T):* 3D FLAIR, DTI, SWI, T2\\*\nperfusion, 3D T1 with and without contrast, 3D T2,\nsubtraction.Following resection of a right hemispheric glioblastoma in\n08/19, and compared to the last two scans (external: 07/19, internal:\n08/19), there is a notable expansion of the prior detected flair\nhyperintense regions. These now span from the right parietal-subcortical\narea across the right basal ganglia to the right temporo-occipital/right\ntemporal pole. Specifically, at the dorsocranial edge of the resection\ncavity, the hyperintense regions appear to have grown since 08/19. These\ncoincide with hyperperfused regions in the T2\\* perfusion. Linear SWI\nsignal changes are suggestive of mild post-surgical bleeding. No\nsignificant postoperative hemorrhage or territorial ischemia is\ndetected. A normal venous sinus drainage is observed. Right temporal\nhorn appears congested, possibly due to CSF trapping.\n\n**Assessment:**\n\nFollowing the resection of the right hemispheric glioblastoma in 08/19:\n\n-Markedly progressive flair edema and evolving barrier disturbance.\nRegions especially towards the dorsal side of the resection cavity show\nthis alongside associated hyperperfusion. With the recent PET imaging\nfrom 10/19, there is an indication of progressive disease as per RANO\ncriteria.\n\n-Long-term progressive congestion of the right temporal horn, likely CSF\ntrapping.\n\n**Surgery Report****Diagnosis:**Tumor recurrence after resection of a\nglioblastoma (IDH wild type, WHO CNS grade 4) of the right hemisphere in\n08/2019. The patient underwent combined radiochemotherapy at the local\nclinical center.\n\n**Procedure:**Navigated, microsurgical resection supported by 5-ALA,\nwith stable MEPs through the previous right temporal access. iMRI\nconducted between 11:10 and 11:50. Used Duragen/TachoSil, dog bones for\nclosure, followed by layered wound closure and skin sutures.\n\n**Timing:**\n\n-Incision: 09:23 am on 10/12/19\n\n-Suture: 12:32 pm on 10/12/19\n\n**Assessment:**The patient had previously undergone surgery for a\nglioblastoma and a recurrence was detected on imaging. The tumor board\nhad already deliberated on the surgery. The patient was informed about\nthe surgical procedure, particularly about conducting an extensive\nresection caudally without impacting function post-mapping. The patient\nconsented, understanding the potential for longer progression-free\nsurvival.\n\n**Procedure Details:**The patient was placed in a supine position with\nthe head turned to the side and fixed using the Noras clamp. The right\nshoulder was padded. The surgical area was prepared by trimming hair\naround the previous scar, followed by sterilization and draping. After a\nteam time-out, prophylactic antibiotics were administered. The previous\nscar was reopened and old plates were removed. The microscope was then\nswung into position and the dura was opened. Navigation proceeded\nbeneath the labbé vein, with tumor resection as guided by ALA\nfluorescence. Post-tumor removal, extensive hemostasis was achieved\nusing absorbent cotton and TABOTAMP. Intraoperative MRI confirmed a\ncomplete resection of the tumor. The dura was sealed using DuraGen,\nensuring a watertight closure. The bone flap was reinserted, followed by\nsubcutaneous suturing, skin suturing, and sterile dressing of the wound.\n\n\n\n\n### text_1\n**Dear colleague, **\n\nWe write to update you regarding our shared patient, Mr. John Miller,\nborn on 07/04/1961, who visited us on 12/02/2019.\n\n**Diagnosis:**Glioblastoma recurrence, IDH 1 wild type.\n\n**Tumor Location:**Right hemisphere including temporal regions.\n\n**Clinical History & Treatment:**\n\n-07/2019: Mr. Miller experienced speech disturbances and confusion.\n\n-08/01/2019: Brain PET-MRI revealed a suspected malignancy in the right\nhemisphere, including temporal areas.\n\n-08/11/2019: Glioblastoma was resected at our facility.\n\n-08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy\nwith a boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local\nclinical center.\n\n-10/01/2019: cMRI with suspected recurrence.\n\n-10/12/2019: A recurrent resection was performed at our facility.\n\n-11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n**Recent Evaluation (12/01/2019):**Mr. Miller visited our facility with\nhis brother. Our assessment, based on CTCAE criteria, indicated that he\nis in a fair but stable general and nutritional health (KPS 70-80%,\nweight undisclosed, height 175 cm). Neurological and general evaluations\nrevealed a degree of aphasia, mainly with word-finding difficulty, and\nshort-term memory impairment. However, he remains fully oriented and\nindependent in daily life.\n\n**Additional Observations:**\n\nHis surgical wound has healed well.\n\n**Pre-existing Conditions:** Arterial hypertension, Diabetes Mellitus\nType II\n\n**Allergies:** None\n\n**Current Medications:** Antihypertensive drugs and insulin.\n\nPostoperatively, Mr. Miller remains in good health. A recent brain MRI\nnoted that the suspected recurring GBM lesion near the superior border\nof the surgical site was entirely resected. Furthermore, CT scans at the\nanterior medial and lateral edges suggest that a complete resection was\nmost likely achieved.\n\nGiven the presumed complete resection of the glioblastoma recurrence, we\nhave recommended Mr. Miller for a neuro-oncology review and a follow-up\nwith PET-MRI in three months.\n\n**Next Steps:**\n\n-He has a scheduled appointment in neuro-oncology on 01/23/2020 at 10:00\nAM.\n\n-A follow-up PET-MRI is set for 01/29/2020 at 12:45 PM. We have advised\nMr. Miller to fast for 4 hours prior and to bring a referral from his\nprimary care physician, along with a recent creatinine test result.\n\n-A review of these findings will be held in our outpatient department on\n01/30/2020 at 2:00 PM.\n\nThank you for your continued care and collaboration. Please do not\nhesitate to reach out for any additional information.\n\nWarm regards,\n\n\n\n### text_2\n**Dear colleague, **\n\nRegarding our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nGlioblastoma recurrence, IDH 1 wild type\n\n**Tumor Location**:\n\nRight hemisphere/temporal.\n\n**Medical History**:\n\n07/2019: Onset of speech arrest and confusion.\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\nMr. Miller came in on 12/01/2019 with his brother. Clinical examination\nfindings are as follows:\n\n-General health: Stable with reduced vitality.\n\n-Nutritional status: Stable (KPS 70-80%, weight in kg, height 169 cm).\n\n-No evident motor, sensory, visual, or cranial nerve deficits.\n\n-Neurocognitive deficits: Short-term memory issues.\n\n-Aphasia: Grade II (mainly word-finding disorders). The patient is fully\noriented and independent in daily life.\n\n-No evidence of recurrence in PET-MRI. Next imaging scheduled in\n03/2020.\n\n**Past Medical Conditions**:\n\n-Hypertension\n\n-Type II Diabetes Mellitus\n\n**Allergies**: None.\n\n**Medications**:\n\n-Antihypertensive medications\n\n-Insulin\n\nBest Regards,\n\n\n\n\n### text_3\n**Dear colleague, **\n\nUpdating you on our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nRecurrent Glioblastoma, IDH 1 wild type (ICD-10: 71.8).\n\n**Molecular Pathology**:\n\nNo p.R132H mutation in IDH.\n\nNo combined 1p/19q loss.\n\nSuspected CDKN2A/B deletion.\n\n**Medical History**:\n\nNo pain or B symptoms.\n\nIntermittent dizziness and headaches since the last check-up.\n\n**Neurological Findings**:\n\nPatient is alert and oriented.\n\nWeight: 80 kg (total loss: 15 kg), Height: 175 cm.\n\nKarnofsky Performance Score: 80%.\n\nMotor function and sensory assessments were unremarkable.\n\n**Allergies**: None.\n\n**Medications**:\n\nLisinopril 10mg once daily in the morning\n\nBisoprolol 2.5mg once daily at bedtime\n\nJanuvia 50mg twice daily\n\nAllopurinol 100mg once daily in the morning\n\nEzetimibe 10mg once daily at bedtime\n\nLevetiracetam 1000mg once daily in the morning Insulin as per regimen\n\n**Secondary Diagnoses**:\n\nHypertension\n\nType II Diabetes Mellitus\n\n**Medical Course**:\n\nDetails from 07/2019 through 03/2020 provided, including surgeries,\nradiochemotherapies, and diagnostics.\n\nIn summary, Mr. Miller\\'s glioblastoma diagnosis in 07/2019 led to\nvarious treatments, including radiochemotherapy and surgeries. His\nrecent PET/MRI on 01/2020 indicates potential recurrent areas.\n\nBest regards,\n\n**Patient:** John Miller\n\n**DOB:** 04/07/1961\n\n**Admission Date:** 04/11/2020\n\n**Discharge Date:** 04/18/2020\n\n**Admission Diagnosis:**\n\nRecurrent tumor in the hippocampal region and along the prior resection\ncavity.\n\nHistory of glioblastoma (IDH wild type, WHO CNS grade 4) in the right\nhemisphere, resected on 08/2019.\n\nHistory of combined radiochemotherapy with Temodar (Temozolomide) from\nAugust to September 2019 at the local clinical center.\n\nSubsequent first re-resection in 10/2019.\n\n**Presenting Complaint:**\n\nMr. Miller presented to the neurosurgical outpatient department\naccompanied by his wife. Recent imaging indicated a potential recurrence\nof the glioblastoma. The neuro-oncological board on 04/12/2020\nrecommended a re-resection.\n\n**Physical eon Admission:**\n\nAlert, oriented x4, cooperative.\n\nNon-fluent aphasia.\n\nCranial nerves intact.\n\nNo sensory or motor deficits in the extremities.\n\nSurgical scar clean and dry.\n\nNo signs of neurogenic bladder or rectal dysfunction.\n\nKPSS 70%.\n\n**Medications on Admission:**\n\n-Lisinopril 10mg daily\n\n-Bisoprolol 2.5mg nightly\n\n-Januvia 50mg twice daily\n\n-Allopurinol 100mg daily\n\n-Atorvastatin 40mg nightly\n\n-Ezetimibe 10mg nightly\n\n-Levetiracetam 1000mg twice daily\n\n-Actraphane insulin as prescribed\n\n**Surgical Intervention (04/12/2020):**\n\nNavigated microsurgical resection of tumor spots assisted with 5-ALA.\nStable MEPs were maintained. An intraoperative MRI (iMRI) was utilized.\nPost-resection, the surgical area was managed using Tabotamp, Duragen,\nTachoSil, and dog-bone plates, concluding with layered wound closure.\n\n**Postoperative Course:**\n\nUncomplicated recovery.\n\nPost-op MRI showed no residual tumor.\n\nSurgical site remained clean, dry, and showed no signs of infection or\nirritation.\n\n**Discharge Diagnosis:**\n\nRecurrence of known glioblastoma, WHO CNS grade 4.\n\n**Interdisciplinary Neuro-oncological Tumor Board Recommendation\n(04/20/2020):**\n\nMolecular tumor board review.\n\nOffer reinitiation of Temozolomide chemotherapy.\n\n**Physical Examination on Discharge:**\n\nSimilar to admission, with suture in place and wound site in good\ncondition.\n\nKPSS 70%.\n\n**Medications on Discharge:**\n\n-Allopurinol 100mg daily (morning)\n\n-Atorvastatin 40mg nightly (evening)\n\n-Bisoprolol 2.5mg nightly (evening)\n\n-Ezetimibe 10mg nightly (evening)\n\n-Sitagliptin (Januvia) 50mg twice daily (morning and evening)\n\n-Levetiracetam (Keppra) 1000mg twice daily (morning and evening)\n\n-Lisinopril 10mg daily (morning)\n\n-Acetaminophen 500mg as needed for pain or fever\n\n-Actraphane insulin as prescribed\n\n**Surgery Report **\n\n**Diagnosis**:\n\nTumor recurrence in the right hippocampal region and along the resection\ncavity post glioblastoma resection on 8/11/2019.\n\nPrevious treatments include radiochemotherapy at our clinic. Local\ntherapy center (from August to September 2019) and re-resection on\n10/12/2019.\n\n**Surgery Type**:\n\nRe-opening of the temporal region with navigation, microsurgery using\n5-ALA assistance, iMRI, and re-resection, among other procedures.\n\n**Procedure Details**:\n\nStart: 11:50 pm on 04/12/2020\n\nEnd: 4:00 pm on 04/12/2020\n\nDuration: 4 hours 10 minutes.\n\n**Assessment**:\n\nEvidence of recurrent glioblastoma areas warranted another biopsy and\nresection. After informing Mr. Miller about the procedure\\'s risks and\nbenefits, he provided written consent.\n\n**Operation**:\n\nDetails on the positioning, pre-operative preparations, resection, and\npost-operative procedures are provided.\n\nBest regards,\n\nMEDICAL HISTORY:\n\nMr. Miller underwent surgery because of tumor recurrence in the right\nhemisphere last November to treat a right temporal glioblastoma. He\npresented to our private outpatient clinic due to a wound complication,\nspecifically a wound dehiscence measuring about 1 cm. On closer\nexamination, pus was noted. Despite being symptom-free otherwise, a\nconsultation with Dr. Doe was scheduled. After discussion, it was\ndecided to clean the wound, trim the deteriorated wound edges, and clean\nthe bone flap with an antibiotic solution before reinserting it. The\npatient was thoroughly educated about the nature and risks of the\nprocedure and gave consent.\n\nOPERATION:\n\nThe patient was placed in a supine position. The hair surrounding the\nsurgical site was trimmed, followed by skin disinfection and sterile\ndraping. The bicoronal skin incision was reopened. Deteriorated wound\nedges were excised and the wound was extensively cleaned with\nirrigation. The bone flap was removed and immersed in a Refobacin\nsolution. The epidural pannus tissue was removed. The dura was\ncompletely sutured. Multiple samples were collected both subgaleally and\nepidurally. A sponge was applied, followed by the reinsertion of the\nbone flap using a dog bone miniplate fixation and local application of\nvancomycin powder. A subgaleal drain was placed, and the skin was closed\nusing Donati continuous sutures. A sterile staple dressing was applied,\nand the patient was transferred to recovery.\n\nCLINICAL NOTES:\n\nEpidural pannus suggestive of infection. Past surgical history includes\nglioblastoma removal in 8/11/2019 and subsequent surgeries because of\nrecurrence, the last of these in 04/12/2020. Nature and type of growth?\n\nMACROSCOPIC EXAMINATION:\n\nFixed tissue samples measuring 1.2 x 1.0 x 0.4 cm were entirely\nembedded.\n\nSTAINING: 1 block, Hematoxylin & Eosin (HE), Periodic Acid Schiff (PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology shows entirely necrotic tissue and some bony fragments. No\nmicroorganisms were detected in the PAS stain.\n\nFINDINGS:\n\nFully necrotic tissue. No signs of inflammation or malignancy in the\navailable samples.\n\nOPERATIVE REPORT:\n\nDiagnosis: Wound healing disruption high on the forehead, following a\nresection of recurrent gioblastoma in the right hemisphere in\n04/12/2020.\n\nProcedure: Wound revision, thorough wound cleaning, reinsertion of the\nautologous bone flap.\n\nTime of incision: 3:30 PM, 06/01/2020\n\nTime of suture completion: 4:35, 06/01/2020\n\nDuration: 65 minutes\n\nPATIENT HISTORY:\n\nThe patient had two prior surgeries with our team. The most recent was a\nrevision due to a wound healing complication. The patient was informed\nabout the procedure\\'s nature, extent, risks, and potential outcomes,\nand was given ample opportunity to ask questions. After thoughtful\nconsideration, written consent was obtained.\n\nOPERATION:\n\nThe patient was positioned supine with the head in a neutral position.\nThe surgical area was sterilized and draped. Antibiotic prophylaxis was\nadministered, and a timeout procedure was conducted. The old wound was\nreopened and slightly extended by about 1 cm in both directions. The\nbone flap was removed, inspected, and cleaned. It was then reinserted\nafter refreshing the bone edges. The wound edges were refreshed, and the\nwound was irrigated again before closure.\n\nSUMMARY:\n\nSuccessful wound revision without complications for a wound healing\ncomplication post-glioblastoma surgery.\n\nCLINICAL NOTES:\n\nComplication in wound healing after glioblastoma removal and radiation\ntherapy. Possible inflammation? Evaluate for pus. Nature and type of\ngrowth?\n\nMACROSCOPIC EXAMINATION:\n\nSubcutaneous tissue samples, 1.2 x 1.0 x 0.4 cm, were completely\nembedded after being cut into two.\n\nEpidural tissue samples, 5.6 x 5.3 x 1.0 cm, were partially embedded.\n\nSTAINING: 2 blocks, Hematoxylin & Eosin (HE), Periodic Acid Schiff\n(PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology displays connective tissue surrounded by a pronounced\ninflammatory infiltrate, comprised of neutrophils, lymphocytes, and\nnumerous eosinophils. Additionally, budding capillaries were seen. No\nspecific findings in the PAS stain.\n\nHistologically, connective tissue infiltrated by predominantly\nlymphocytic inflammation was observed. Eosinophils and abundant necrotic\ntissue were also seen. Additionally, polarizable material was noted,\noccasionally engulfed by multinucleated giant cells. Hemorrhagic signs\nwere indicated by hemosiderin deposits. No specific findings in the PAS\nstain.\n\nFINDINGS:\n\n1 & 2. Soft tissue displays acute phlegmonous inflammation and chronic\ngranulating inflammation.\n\n**Brief report (07/15/2020): **\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 06/01/2020.\n\nWound healing disorder right parietal at the site of previous right-side\nglioblastoma, last revision 04/12/2020.\n\n-Single right body focal seizure 04/20/2020, single generalized seizure\n05/12/2020\n\n-Previous resection on 10/12/2019\n\n-Wound healing disorder with subsequent wound revision (06/2020)\n\n-Last cMRI on 05/03/2020: no recurrence observed.\n\nSecondary diagnoses:\n\nHypothyroidism\n\nSurgery type: injection of Ropivacaine, smear for microbiology,\nreadaptation of three small wound dehiscence, tobacco bag suture,\noverlay polyhexanide gel, plaster application\n\nInstructions: Return next Tuesday for wound check. Sutures to remain in\nplace for 10 days. Check microbiology results on Thursday. Clinically,\nno signs of infection observed.\n\nSurgical report:\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 04/20/2020.\n\nASSESSMENT:\n\nThe patient was presented at the emergency unit after observing a small\nwound dehiscence after the aforementioned surgery for a wound healing\ndisorder. The treating surgeon recommended a second local wound revision\nattempting to readapt the wound with a minor surgery. The patient\nprovided written consent for the procedure. The intervention was\nconducted with standard coagulation parameters.\n\nSURGERY:\n\nSterile preparation and draping of the surgical area. Initial injection\nof Ropivacaine. This was followed by swab collection for microbiology.\nThe wound edges were excised and the wound dehiscence was readapted\nusing a tobacco bag suture. Afterward, polyhexanide gel was applied,\nfollowed by a sterile plaster dressing.\n\nSurgery report:\n\nDiagnosis: significant scalp wound healing disorder in the prior\nsurgical access area post-resection and irradiation of a glioblastoma\nmultiforme.\n\nOperating time: 49 minutes\n\n\n\n### text_4\n**Dear colleague, **\n\nwe report on Mr. Miller, John, born 04/07/1961, who was in our inpatient\ntreatment from 09/12/2020 to 10/07/2020.\n\nDischarge diagnosis: Recurrence of the pre-described glioblastoma right\ninsular, WHO CNS grade 4 (IDH wild type, MGMT methylated).\n\nPhysical examination on admission:\n\nPatient awake, fully oriented, cooperative. Non-fluent aphasia. Speech\nclear and fluent. Latent left hemisymptomatic with strength grades 4+/5,\nstance and gait unsteady. Cranial nerve status regular. Scar conditions\nnon-irritant except for frontal superficial erosion at frontal wound\npole of pterional approach. Karnofsky 70%.\n\nMedication on Admission:\n\nLevothyroxine sodium 50 μg/1 pc (Synthroid® 50 micrograms, tablets)\n1-0-0-0\n\nLorazepam 0.5 mg/1 pc (Ativan® 0.5 mg, tablets) 1-1-1-1\n\nLacosamide 100 mg/1 pc (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\n**Imaging: **\n\ncMRI +/- contrast agent dated 09/15/2020: There is a contrast enhancing\nformation on the right temporo-mesial with approach to the insular\ncistern with suspected tumor recurrence.\n\nPET dated 09/10/2020 (external): Significant tracer multinodulation with\nactive areas in the islet region is seen.\n\n**Surgery of 09/18/2020: **\n\nReopening of existing skin incision and extension of craniotomy\ncranially, microsurgical navigated tumor resection right insular (IONM:\nMEP waste lower extremity with incomplete recovery) CUSA; extensive\nhemostasis, intraoperative MRI, sutures, reimplantation of bone flap\nwith multilayer wound closure. Skin suture.\n\nHistopathological report:\n\nRecurrence of pre-described glioblastoma, WHO CNS grade 4 (IDH wild\ntype, MGMT methylated).\n\nCourse:\n\nThe patient initially presented postoperatively with left hemiplegia in\nthe sense of SMA. This regressed significantly during the inpatient\nstay. Postoperative imaging revealed a regular resection finding. In\ncase of a possible adjustment disorder, the patient was treated with\nsertraline and lorazepam. The wound was dry and non-irritant during the\ninpatient stay. The patient received regular physiotherapeutic exercise.\nThe patient\\'s case was discussed in our neuro-oncological tumor board\non 09/29/2020, where the decision was made for adjuvant definitive\nradiochemotherapy. An inpatient transfer was offered by the colleagues\nof radiotherapy.\n\nProcedure:\n\nWe transfer Mr. Miller today in good clinical general condition to your\nfurther treatment and thank you for the kind takeover. We ask for\nregular wound controls as well as regular ECG controls to exclude a\nQTc-time prolongation under sertraline. Furthermore, the medication with\nlorazepam should be further phased out in the course of time. In case of\nacute neurological deterioration, a re-presentation in our neurosurgical\noutpatient clinic or surgical emergency room is possible at any time.\n\nClinical examination findings at discharge:\n\nPatient awake, fully oriented, cooperative. Speech clear and fluent.\nCranial nerve status without pathological findings. Hemiparesis\nleft-sided strength grade 4/5, right-sided no sensorimotor deficit.\nStance and gait unsteady. Non-fluent aphasia. Wound dry, without\nirritation. Karnofsky 70%.\n\n**Medication at Discharge:**\n\nLevothyroxine sodium 50 μg (Synthroid® 50 micrograms, tablets) 1-0-0-0\n\nLorazepam 0.5 mg (Ativan® 0.5 mg, tablets) as needed\n\nLacosamide 100 mg (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\nAcetaminophen 500 mg (Tylenol® 500 mg tablets) 1-1-1-1\n\nSertraline 50 mg (Zoloft® 50 mg film-coated tablets) by regimen\n\n**Magnetic Resonance Imaging (MRI) Report**\n\nDate of Examination: 02/02/2021\n\nClinical Indication: Multifocal glioblastoma WHO grade IV, IDH wild\ntype, MGMT methylated.\n\nClinical Query: Hemiparesis on the right side. Is there a structural\ncorrelate? Tumor progression?\n\n**Previous Imaging**: Multiple prior studies. The most recent contrasted\nMRI was on 09/15/2020.\n\n**Findings**:\n\n**Imaging Device**: GE 3T; Protocol: 3D FLAIR, 3D T1 Mprage with and\nwithout contrast, SWI, DWI, 3D T2, axial T2\\*, perfusion, DTI.\n\n1. **Report: **\n\n Known multimodal pretreated GBM since 2019, recently post-surgical\n resection for tumor progression in the frontotemporal region on\n 09/18/2020. Also noted is a post-surgical resection of additional\n foci in the right insular region. The resection cavity in the right\n frontal, insular, and temporal regions appears unchanged in size and\n configuration. Residual blood products are noted within.\n\n There are increased areas of contrast enhancement compared to the\n immediate post-operative images. There is a minor growth in a\n nodular enhancement posterior to the right middle cerebral artery.\n Adjacent to this, there\\'s a new nodular enhancement, which could be\n a postoperative reactive change or a new tumor lesion.\n\n Ongoing diffusion abnormalities are observed in the right caput\n nuclei caudatus, putamen, and globus pallidus, especially pronounced\n in posterior sections.\n\n Persistent FLAIR-hyperintense peritumoral edema in the right\n hemisphere remains unchanged. The midline shift is approximately 9mm\n to the left, which remains unchanged.\n\n Post-operative swelling and fluid accumulation are noted at the\n surgical entry point. The bone flap is in place. The width of both\n the internal and external CSF spaces remains constant, with no\n evidence of obstruction.\n\n The orbital contents are symmetrical. Paranasal sinuses and mastoid\n air cells are aerated appropriately.\n\n**Impression**:\n\nResidual tumor segments along the right middle cerebral artery showing\ngrowth. Adjacent to it, a new nodular area of contrast enhancement\nsuggests either a postoperative change or a new tumor lesion.\n\nPreviously identified ischemic changes in the right caput nuclei\ncaudatus, putamen, and globus pallidus. Persistent brain edema with a\nleftward midline shift of approximately 9mm remains unchanged.\n\n\n\n### text_5\n**Dear colleague, **\n\nHerewith we report on our common patient Mr. John Miller, born\n04/07/1961, who was at our clinic between 02/04/2021 to 04/22/2021.\n\n-Recurrent manifestation of a glioblastoma\n\n-Stage: WHO CNS grade 4\n\n**Histology:**\n\nRecurrence of the pre-described glioblastoma, WHO CNS grade 4.\n\nMolecular pathological findings:\n\nIDH status: no p.R132H mutation (immunohistochemical).\n\nATRX: preservation of nuclear expression (immunohistochemical).\n\np53: technically not evaluable (immunohistochemical).\n\n1p/19q status: no combined loss (850k methylation analysis).\n\nCDKN2A/B: Deleted (850k methylation analysis).\n\nMGMT promoter: Methylated (850k methylation analysis).\n\nTumor localization: Islet/frontal right\n\nSecondary diagnoses:\n\nSymptomatic epilepsy\n\nHypothyroidism\n\nNausea\n\nLeukopenia I° (CTCAE)\n\nAnemia II° (CTCAE)\n\nPrevious course / therapies:\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n03/2020: Suspected recurrence\n\n04/2020: Revision surgery\n\n06-07/2020 Wound revisions and flap plasty for atrophic wound healing\ndisorder\n\n02/2021: Suspected recurrence with new FLAIR-positive tumor\nmanifestation insular on the right side. Stereotactic biopsy with\nevidence of glioblastoma.\n\nPathology: Renewed manifestation of a glioblastoma.\n\nRecommended radiochemotherapy.\n\nAccording to the interdisciplinary neuro-oncology board of 01/26/2021,\nwe gave the indication for adjuvant radiochemotherapy for the recurrence\nof glioblastoma.\n\n**Radiochemotherapy: **\n\nTechnique:\n\n1\\) Percutaneous intensity-modulated radiotherapy was administered to the\nformer recurrence tumor region in the frontal/insular right after CT-\nand MRI-guided radiation planning with 6 MV-photons in helical\ntomotherapy technique with a single dose of 2 Gy up to a total dose of\n60 Gy with 5 fractions per week. Daily position controls by CT.\n\n2\\) Subsequently, local dose saturation of the macroscopic tumor remnant\nwas performed.\n\nInsular right stereotactic ablative radiosurgery at the gamma knee to\nsaturate the macroscopic GammaKnife (Cobalt-60: 1.17 MeV and 1.33 MeV\nphotons) in mask fixation after CT- and MRI-guided radiotherapy planning\nunder image-guided setting (ConeBeam-CT) with a dose of 6 Gy in 2 Gy\nsingle dose to the 68% isodose up to a total cumulative dose of 66 Gy.\n\nChemotherapy:\n\nConcurrent chemotherapy with 75mg/m²KOF temozolomide daily (120 mg\ndaily).\n\nAbsolute dose: 5000 mg.\n\nTreatment Period:\n\nRadiotherapy 03/09/2021 -- 04/21/2021\n\nChemotherapy 03/09/2021 -- 04/21/2021\n\n**Course under therapy:**\n\nWe took over Mr. Miller on 03/06/2021 in reduced general and slightly\nreduced nutritional condition (Kanofsky index: 70 %, BMI: 18.5 kg/m²)\nfrom the Clinic for Neurosurgery for adjuvant re-radiochemotherapy on\nour radiooncology ward. At the time of admission, the patient had arm\n\nright hemiparesis (strength grades arm: 2/5, leg: 3/5). The patient was\nambulatory with assistance. Cranial nerve status was unremarkable.\nHeadache, nausea or dizziness were denied.\n\nOn 09/03/2021, combined re-radiochemotherapy was initiated.\n\nDuring the course of therapy with temozolomide, mild nausea occurred,\nwhich was treated with ondansetron 4mg as needed and dimenhydrinate\nSustained-release tablets 150 mg as needed. Under this treatment the\nsymptoms clearly regressed. Mild constipation was treated. Laboratory\ntests revealed mild leukopenia I° and anemia II° (CTCAE).\n\nOtherwise, the re-radiochemotherapy was very well tolerated overall.\n\nMr. Miller received physiotherapeutic exercise and psychotherapy during\nthe entire physiotherapeutic training and psycho-oncological support.\nUnder the physiotherapeutic treatment, his motor skills improved\nsignificantly. At the end of the therapy, the patient was also mobile\noutside the\n\nhouse without any aids.\n\nOn 04/22/2021 we discharged Mr. Miller to the outpatient care by his\nfamily doctor.\n\n04/11/2021: MR brain post contrast\n\nAfter renewed radiochemotherapy for a glioblastoma recurrence, a\nresidual suspicious barrier disturbance adjacent to the adjacent to the\nright cerebral artery. Stable nodular contrast enhancement\n\nPostoperative/reactive changes as described above. MR perfusion\nsequences show residual, contrast-absorbing tumor portions along the\nright A. cerebri media. Lateral to this, new nodular contrast-absorbing\nlesion, possibly postoperative reactive change. Previously known\nischemia at the right caput nuclei caudatii, putamen, and globus\npallidus. Unchanged medullary edema with midline shift to the left by\napproximately 9mm.\n\nLast lab:\n\nMCHC 29.4 g/dL (32 - 36) 04/20/2021\n\nMCH 25 pg (27 - 32) 04/20/2021\n\nLeukocytes 3.32 G/l (4.0 - 9.0) 04/20/2021\n\nHematocrit 31.6 % (37 - 43) 04/20/2021\n\nHemoglobin 9.3 g/dL (12 - 16) 04/20/2021\n\nErythrocytes 3.7 T/l (4.1 - 5.4) 04/20/2021\n\nUric acid 2.2 mg/dl (2.5 - 5.5) 04/20/2021\n\n**Further Procedure:**\n\nFurther skin care and behavior regarding side effects were explained to\nthe patient in detail.\n\nA first radiooncological control appointment was scheduled for\n06/05/2021 at 12:00 AM in our outpatient clinic. Prior to this, on\n06/02/2021 at 10:30 AM, an imaging exam (brain MRI) is scheduled.\n\nA further neuro-oncological connection is planned close to home via the\ntreating oncologist.\n\nAfter radiation therapy, we recommend annual ophthalmological check-ups\nand annual endocrinologic.\n\nwith testing of the hypothalamic-pituitary hormone axes.\n\n\n\n### text_6\n**Dear colleague, **\n\nThis is a report on our mutual patient, Mr. John Miller, born\n04/07/1961:\n\nDiagnosis:\n\nRecurrent manifestation of glioblastoma\n\nWHO CNS grade 4\n\nTumor localization: Right isle/frontal\n\nSecondary diagnoses: Symptomatic epilepsy\n\nHypothyroidism Previous\n\nTreatments / Therapies\n\nResection and revisions\n\nAdjuvant radiochemotherapy\n\nTwo wound revisions and flap plasty for atrophic wound healing disorder\n\nNew FLAIR-positive tumor manifestation insular on the right side\n(02/2021)\n\nStereotactic biopsy with histopathology with evidence of glioblastoma\n\nTumor Board: Recommended new radiochemotherapy up to a total dose of 60\nGy à 2 Gy single dose. Subsequent local dose saturation of the\nmacroscopic tumor remnant as radiosurgery on GammaKnife with a dose of 6\nGy à 2 Gy single dose (\\@68% isodose).\n\n03-4/2021 Repeat stereotactic RTx in the area of the basal ganglia and\nthe resection cavity right frontal on the Gamma Knife with 46 Gy à 2 Gy;\n3 doses of Bevacizumab 7.5 mg/kg i.v.\n\n**Summary:**\n\nOn 07/03/2023, we conducted an initial telephone follow-up with the\npatient, Mr. Miller, for a radio-oncology consultation. Presently, Mr.\nMiller is undergoing rehabilitation, from which he feels he is deriving\nsubstantial benefits. His recent radiotherapy was well-received without\nany complications. Since the onset of his symptoms, there have been no\nnew developments. Symptoms related to intracranial pressure or new\nneurological deficits were denied. Fortunately, while on anticonvulsant\ntherapy with Lacosamide, Mr. Miller experienced no epileptic seizures.\nHis skin condition is normal. However, Mr. Miller did mention some\ncognitive challenges that minimally impact his daily activities,\nalongside feelings of fatigue and grade I CTCAE symptoms. The cMRI scan\nfrom 06/02/2021 revealed a notable reduction in the barrier disturbance\nof the right-sided basal ganglia. This was accompanied by small, mildly\nhyperperfused residual findings near the third ventricle. Moreover, the\npinpoint contrast enhancement in the left parietal lobe appeared\nunchanged, suggesting it is a scarring reaction. In collaboration with\nthe neurooncology team, Mr. Miller has discussed starting chemotherapy.\nThe next imaging assessment is scheduled for mid-September. We have also\nscheduled another radio-oncologic follow-up with Mr. Miller for\nSeptember 28th, per his preference, via telephone. For patient safety,\nMr. Miller is prohibited from operating private or commercial vehicles\nfor 3 months post-intracerebral radiotherapy. This duration may extend\nif there are existing or progressing brain conditions. Following\nradiotherapy, we are mandated by the Radiation Protection Act to\nfacilitate regular checks. Hence, we encourage enrollment in the\naftercare calendar, prompt reporting of any significant findings, and\nattendance of scheduled follow-ups. Alongside these, regular oncological\ncheck-ups by specialist practitioners are mandatory. Mr. Miller has been\nduly informed of all these requirements.\n\n\n\n\nHere is the query:\nWhen was the recurrence of Mr. Miller's glioblastoma resected?\n\nChoose the correct answer from the following options:\nA. 08/15/19\nB. 08/01/19\nC. 08/11/19\nD. 10/12/19\nE. 12/01/19\n\n\nYour response:\n", "role": "user" }, { "content": "10/12/19", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nPatient: Miller, John, born 04/07/1961\n\nWe report to you about our common patient, Mr. John Miller, who is in\nour inpatient treatment since 07/30/2019.\n\n**Diagnoses:**\n\n\\- Suspected right cerebral glioblastoma (first diagnosis)\n\n\\- Symptoms: Aphasia, passive confusion\n\n**Patient history: **\n\nMr. Miller was admitted as an emergency. He was on the phone with a\nfriend when he suddenly began to exhibit speech difficulties and\nstruggled to find the right words. Consequently, his friend called 911.\n\nUpon the ambulance\\'s arrival, Mr. Miller was disoriented and exhibited\naggressive behavior. There was evidence of a torn door. He had blood on\nhis right forearm and around his mouth, but there were no indications of\na tongue bite or urinary incontinence.\n\nUpon admission, Mr. Miller was coherent and showed no speech issues. He\nattributed a mild weakness in his right arm to pre-existing pain in the\nupper arm. An immediate CT scan revealed a mass suggestive of a\nglioblastoma in the right cerebral hemisphere, leading to a\nneurosurgical consultation.\n\nGiven the possibility of an epileptic seizure, Mr. Miller was\nhospitalized and started on Levetiracetam. He is currently unaware of\nhis regular medications but takes antihypertensives and diabetes\nmedications, among others. His friend and brother have been notified and\nare ensuring that a detailed medication list is provided.\n\nAfter a brief stay in ward ABC, Mr. Miller was transferred to the\nneurosurgery team for further evaluation and treatment. We appreciate\nthe prompt transfer and are available for any further inquiries.\n\nPlanned Procedures:\n\n-Schedule EEG\n\n-Clarify routine medications\n\n**Surgery Report**\n\n**Diagnosis:** Suspected HGG (high-grade glioma) of the right hemisphere\n\n**Procedure:** Microsurgical navigation-guided resection of the tumor\nwith intraoperative neuromonitoring (stable MEPs) and intraoperative MRI\nusing 5-ALA. Pathology samples taken (Preliminary: HGG; Final to be\nconfirmed). Resection was followed by duragen placement, watertight\ndural closure, and multilayer wound closure, with skin sutures.\n\n**Time:**\n\n-Start: 11:12 am\n\n-Finish: 3:54 pm\n\n-Duration: 4 hours 42 minutes\n\n**Assessment:**\n\nMr. Miller presented with a seizure characterized by speech disturbance\nand disorientation. Imaging revealed a significant right hemispheral\nmass, likely representing a high-grade brain tumor. The need for\nsurgical resection was determined following discussions at our\ninterdisciplinary tumor board. After being informed about the procedure,\nalternative treatments, the operation\\'s urgency, benefits, and\npotential risks, Mr. Miller provided written consent following ample\ntime for consideration and the opportunity to ask further questions.\n\n**Procedure Details:**\n\nThe patient was positioned supine with his head secured in a Nova clamp.\nNavigation data were read, followed by skin preparation, and the\nsurgical field was sterilized and draped. An arch-shaped incision was\nmade, followed by hemostasis, deep tissue dissection, placement of a\nburr hole, and the creation of a large bone flap over the lesion. The\nbone flap was then elevated. Multiple washings were performed, followed\nby dural opening under microscopic visualization. A corticotomy was\ncarried out with bipolar forceps, CUSA, and suction to progressively\nreduce the tumor, utilizing 5-ALA fluorescence and continuous\nneurophysiological monitoring. An intraoperative MRI showed residual\ntumor, prompting further resection. Hemostasis was achieved, and the\nwound was closed using tabotamp, followed by duragen placement and dural\nsuturing. The bone flap was refixed using Dogbone plates. The wound area\nwas irrigated extensively once more, followed by subcutaneous and skin\nsutures.\n\n**Date:** 10/01/2019\n\n**Clinical Indication:**Suspected recurrence of GBM in the right\nhemisphere\n\n**Requested Imaging:**cMRI with or without contrast + DTI.\n\n**Findings:***Imaging Modality (GE 3.0T):* 3D FLAIR, DTI, SWI, T2\\*\nperfusion, 3D T1 with and without contrast, 3D T2,\nsubtraction.Following resection of a right hemispheric glioblastoma in\n08/19, and compared to the last two scans (external: 07/19, internal:\n08/19), there is a notable expansion of the prior detected flair\nhyperintense regions. These now span from the right parietal-subcortical\narea across the right basal ganglia to the right temporo-occipital/right\ntemporal pole. Specifically, at the dorsocranial edge of the resection\ncavity, the hyperintense regions appear to have grown since 08/19. These\ncoincide with hyperperfused regions in the T2\\* perfusion. Linear SWI\nsignal changes are suggestive of mild post-surgical bleeding. No\nsignificant postoperative hemorrhage or territorial ischemia is\ndetected. A normal venous sinus drainage is observed. Right temporal\nhorn appears congested, possibly due to CSF trapping.\n\n**Assessment:**\n\nFollowing the resection of the right hemispheric glioblastoma in 08/19:\n\n-Markedly progressive flair edema and evolving barrier disturbance.\nRegions especially towards the dorsal side of the resection cavity show\nthis alongside associated hyperperfusion. With the recent PET imaging\nfrom 10/19, there is an indication of progressive disease as per RANO\ncriteria.\n\n-Long-term progressive congestion of the right temporal horn, likely CSF\ntrapping.\n\n**Surgery Report****Diagnosis:**Tumor recurrence after resection of a\nglioblastoma (IDH wild type, WHO CNS grade 4) of the right hemisphere in\n08/2019. The patient underwent combined radiochemotherapy at the local\nclinical center.\n\n**Procedure:**Navigated, microsurgical resection supported by 5-ALA,\nwith stable MEPs through the previous right temporal access. iMRI\nconducted between 11:10 and 11:50. Used Duragen/TachoSil, dog bones for\nclosure, followed by layered wound closure and skin sutures.\n\n**Timing:**\n\n-Incision: 09:23 am on 10/12/19\n\n-Suture: 12:32 pm on 10/12/19\n\n**Assessment:**The patient had previously undergone surgery for a\nglioblastoma and a recurrence was detected on imaging. The tumor board\nhad already deliberated on the surgery. The patient was informed about\nthe surgical procedure, particularly about conducting an extensive\nresection caudally without impacting function post-mapping. The patient\nconsented, understanding the potential for longer progression-free\nsurvival.\n\n**Procedure Details:**The patient was placed in a supine position with\nthe head turned to the side and fixed using the Noras clamp. The right\nshoulder was padded. The surgical area was prepared by trimming hair\naround the previous scar, followed by sterilization and draping. After a\nteam time-out, prophylactic antibiotics were administered. The previous\nscar was reopened and old plates were removed. The microscope was then\nswung into position and the dura was opened. Navigation proceeded\nbeneath the labbé vein, with tumor resection as guided by ALA\nfluorescence. Post-tumor removal, extensive hemostasis was achieved\nusing absorbent cotton and TABOTAMP. Intraoperative MRI confirmed a\ncomplete resection of the tumor. The dura was sealed using DuraGen,\nensuring a watertight closure. The bone flap was reinserted, followed by\nsubcutaneous suturing, skin suturing, and sterile dressing of the wound.\n\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe write to update you regarding our shared patient, Mr. John Miller,\nborn on 07/04/1961, who visited us on 12/02/2019.\n\n**Diagnosis:**Glioblastoma recurrence, IDH 1 wild type.\n\n**Tumor Location:**Right hemisphere including temporal regions.\n\n**Clinical History & Treatment:**\n\n-07/2019: Mr. Miller experienced speech disturbances and confusion.\n\n-08/01/2019: Brain PET-MRI revealed a suspected malignancy in the right\nhemisphere, including temporal areas.\n\n-08/11/2019: Glioblastoma was resected at our facility.\n\n-08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy\nwith a boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local\nclinical center.\n\n-10/01/2019: cMRI with suspected recurrence.\n\n-10/12/2019: A recurrent resection was performed at our facility.\n\n-11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n**Recent Evaluation (12/01/2019):**Mr. Miller visited our facility with\nhis brother. Our assessment, based on CTCAE criteria, indicated that he\nis in a fair but stable general and nutritional health (KPS 70-80%,\nweight undisclosed, height 175 cm). Neurological and general evaluations\nrevealed a degree of aphasia, mainly with word-finding difficulty, and\nshort-term memory impairment. However, he remains fully oriented and\nindependent in daily life.\n\n**Additional Observations:**\n\nHis surgical wound has healed well.\n\n**Pre-existing Conditions:** Arterial hypertension, Diabetes Mellitus\nType II\n\n**Allergies:** None\n\n**Current Medications:** Antihypertensive drugs and insulin.\n\nPostoperatively, Mr. Miller remains in good health. A recent brain MRI\nnoted that the suspected recurring GBM lesion near the superior border\nof the surgical site was entirely resected. Furthermore, CT scans at the\nanterior medial and lateral edges suggest that a complete resection was\nmost likely achieved.\n\nGiven the presumed complete resection of the glioblastoma recurrence, we\nhave recommended Mr. Miller for a neuro-oncology review and a follow-up\nwith PET-MRI in three months.\n\n**Next Steps:**\n\n-He has a scheduled appointment in neuro-oncology on 01/23/2020 at 10:00\nAM.\n\n-A follow-up PET-MRI is set for 01/29/2020 at 12:45 PM. We have advised\nMr. Miller to fast for 4 hours prior and to bring a referral from his\nprimary care physician, along with a recent creatinine test result.\n\n-A review of these findings will be held in our outpatient department on\n01/30/2020 at 2:00 PM.\n\nThank you for your continued care and collaboration. Please do not\nhesitate to reach out for any additional information.\n\nWarm regards,\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nRegarding our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nGlioblastoma recurrence, IDH 1 wild type\n\n**Tumor Location**:\n\nRight hemisphere/temporal.\n\n**Medical History**:\n\n07/2019: Onset of speech arrest and confusion.\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\nMr. Miller came in on 12/01/2019 with his brother. Clinical examination\nfindings are as follows:\n\n-General health: Stable with reduced vitality.\n\n-Nutritional status: Stable (KPS 70-80%, weight in kg, height 169 cm).\n\n-No evident motor, sensory, visual, or cranial nerve deficits.\n\n-Neurocognitive deficits: Short-term memory issues.\n\n-Aphasia: Grade II (mainly word-finding disorders). The patient is fully\noriented and independent in daily life.\n\n-No evidence of recurrence in PET-MRI. Next imaging scheduled in\n03/2020.\n\n**Past Medical Conditions**:\n\n-Hypertension\n\n-Type II Diabetes Mellitus\n\n**Allergies**: None.\n\n**Medications**:\n\n-Antihypertensive medications\n\n-Insulin\n\nBest Regards,\n\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nUpdating you on our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nRecurrent Glioblastoma, IDH 1 wild type (ICD-10: 71.8).\n\n**Molecular Pathology**:\n\nNo p.R132H mutation in IDH.\n\nNo combined 1p/19q loss.\n\nSuspected CDKN2A/B deletion.\n\n**Medical History**:\n\nNo pain or B symptoms.\n\nIntermittent dizziness and headaches since the last check-up.\n\n**Neurological Findings**:\n\nPatient is alert and oriented.\n\nWeight: 80 kg (total loss: 15 kg), Height: 175 cm.\n\nKarnofsky Performance Score: 80%.\n\nMotor function and sensory assessments were unremarkable.\n\n**Allergies**: None.\n\n**Medications**:\n\nLisinopril 10mg once daily in the morning\n\nBisoprolol 2.5mg once daily at bedtime\n\nJanuvia 50mg twice daily\n\nAllopurinol 100mg once daily in the morning\n\nEzetimibe 10mg once daily at bedtime\n\nLevetiracetam 1000mg once daily in the morning Insulin as per regimen\n\n**Secondary Diagnoses**:\n\nHypertension\n\nType II Diabetes Mellitus\n\n**Medical Course**:\n\nDetails from 07/2019 through 03/2020 provided, including surgeries,\nradiochemotherapies, and diagnostics.\n\nIn summary, Mr. Miller\\'s glioblastoma diagnosis in 07/2019 led to\nvarious treatments, including radiochemotherapy and surgeries. His\nrecent PET/MRI on 01/2020 indicates potential recurrent areas.\n\nBest regards,\n\n**Patient:** John Miller\n\n**DOB:** 04/07/1961\n\n**Admission Date:** 04/11/2020\n\n**Discharge Date:** 04/18/2020\n\n**Admission Diagnosis:**\n\nRecurrent tumor in the hippocampal region and along the prior resection\ncavity.\n\nHistory of glioblastoma (IDH wild type, WHO CNS grade 4) in the right\nhemisphere, resected on 08/2019.\n\nHistory of combined radiochemotherapy with Temodar (Temozolomide) from\nAugust to September 2019 at the local clinical center.\n\nSubsequent first re-resection in 10/2019.\n\n**Presenting Complaint:**\n\nMr. Miller presented to the neurosurgical outpatient department\naccompanied by his wife. Recent imaging indicated a potential recurrence\nof the glioblastoma. The neuro-oncological board on 04/12/2020\nrecommended a re-resection.\n\n**Physical eon Admission:**\n\nAlert, oriented x4, cooperative.\n\nNon-fluent aphasia.\n\nCranial nerves intact.\n\nNo sensory or motor deficits in the extremities.\n\nSurgical scar clean and dry.\n\nNo signs of neurogenic bladder or rectal dysfunction.\n\nKPSS 70%.\n\n**Medications on Admission:**\n\n-Lisinopril 10mg daily\n\n-Bisoprolol 2.5mg nightly\n\n-Januvia 50mg twice daily\n\n-Allopurinol 100mg daily\n\n-Atorvastatin 40mg nightly\n\n-Ezetimibe 10mg nightly\n\n-Levetiracetam 1000mg twice daily\n\n-Actraphane insulin as prescribed\n\n**Surgical Intervention (04/12/2020):**\n\nNavigated microsurgical resection of tumor spots assisted with 5-ALA.\nStable MEPs were maintained. An intraoperative MRI (iMRI) was utilized.\nPost-resection, the surgical area was managed using Tabotamp, Duragen,\nTachoSil, and dog-bone plates, concluding with layered wound closure.\n\n**Postoperative Course:**\n\nUncomplicated recovery.\n\nPost-op MRI showed no residual tumor.\n\nSurgical site remained clean, dry, and showed no signs of infection or\nirritation.\n\n**Discharge Diagnosis:**\n\nRecurrence of known glioblastoma, WHO CNS grade 4.\n\n**Interdisciplinary Neuro-oncological Tumor Board Recommendation\n(04/20/2020):**\n\nMolecular tumor board review.\n\nOffer reinitiation of Temozolomide chemotherapy.\n\n**Physical Examination on Discharge:**\n\nSimilar to admission, with suture in place and wound site in good\ncondition.\n\nKPSS 70%.\n\n**Medications on Discharge:**\n\n-Allopurinol 100mg daily (morning)\n\n-Atorvastatin 40mg nightly (evening)\n\n-Bisoprolol 2.5mg nightly (evening)\n\n-Ezetimibe 10mg nightly (evening)\n\n-Sitagliptin (Januvia) 50mg twice daily (morning and evening)\n\n-Levetiracetam (Keppra) 1000mg twice daily (morning and evening)\n\n-Lisinopril 10mg daily (morning)\n\n-Acetaminophen 500mg as needed for pain or fever\n\n-Actraphane insulin as prescribed\n\n**Surgery Report **\n\n**Diagnosis**:\n\nTumor recurrence in the right hippocampal region and along the resection\ncavity post glioblastoma resection on 8/11/2019.\n\nPrevious treatments include radiochemotherapy at our clinic. Local\ntherapy center (from August to September 2019) and re-resection on\n10/12/2019.\n\n**Surgery Type**:\n\nRe-opening of the temporal region with navigation, microsurgery using\n5-ALA assistance, iMRI, and re-resection, among other procedures.\n\n**Procedure Details**:\n\nStart: 11:50 pm on 04/12/2020\n\nEnd: 4:00 pm on 04/12/2020\n\nDuration: 4 hours 10 minutes.\n\n**Assessment**:\n\nEvidence of recurrent glioblastoma areas warranted another biopsy and\nresection. After informing Mr. Miller about the procedure\\'s risks and\nbenefits, he provided written consent.\n\n**Operation**:\n\nDetails on the positioning, pre-operative preparations, resection, and\npost-operative procedures are provided.\n\nBest regards,\n\nMEDICAL HISTORY:\n\nMr. Miller underwent surgery because of tumor recurrence in the right\nhemisphere last November to treat a right temporal glioblastoma. He\npresented to our private outpatient clinic due to a wound complication,\nspecifically a wound dehiscence measuring about 1 cm. On closer\nexamination, pus was noted. Despite being symptom-free otherwise, a\nconsultation with Dr. Doe was scheduled. After discussion, it was\ndecided to clean the wound, trim the deteriorated wound edges, and clean\nthe bone flap with an antibiotic solution before reinserting it. The\npatient was thoroughly educated about the nature and risks of the\nprocedure and gave consent.\n\nOPERATION:\n\nThe patient was placed in a supine position. The hair surrounding the\nsurgical site was trimmed, followed by skin disinfection and sterile\ndraping. The bicoronal skin incision was reopened. Deteriorated wound\nedges were excised and the wound was extensively cleaned with\nirrigation. The bone flap was removed and immersed in a Refobacin\nsolution. The epidural pannus tissue was removed. The dura was\ncompletely sutured. Multiple samples were collected both subgaleally and\nepidurally. A sponge was applied, followed by the reinsertion of the\nbone flap using a dog bone miniplate fixation and local application of\nvancomycin powder. A subgaleal drain was placed, and the skin was closed\nusing Donati continuous sutures. A sterile staple dressing was applied,\nand the patient was transferred to recovery.\n\nCLINICAL NOTES:\n\nEpidural pannus suggestive of infection. Past surgical history includes\nglioblastoma removal in 8/11/2019 and subsequent surgeries because of\nrecurrence, the last of these in 04/12/2020. Nature and type of growth?\n\nMACROSCOPIC EXAMINATION:\n\nFixed tissue samples measuring 1.2 x 1.0 x 0.4 cm were entirely\nembedded.\n\nSTAINING: 1 block, Hematoxylin & Eosin (HE), Periodic Acid Schiff (PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology shows entirely necrotic tissue and some bony fragments. No\nmicroorganisms were detected in the PAS stain.\n\nFINDINGS:\n\nFully necrotic tissue. No signs of inflammation or malignancy in the\navailable samples.\n\nOPERATIVE REPORT:\n\nDiagnosis: Wound healing disruption high on the forehead, following a\nresection of recurrent gioblastoma in the right hemisphere in\n04/12/2020.\n\nProcedure: Wound revision, thorough wound cleaning, reinsertion of the\nautologous bone flap.\n\nTime of incision: 3:30 PM, 06/01/2020\n\nTime of suture completion: 4:35, 06/01/2020\n\nDuration: 65 minutes\n\nPATIENT HISTORY:\n\nThe patient had two prior surgeries with our team. The most recent was a\nrevision due to a wound healing complication. The patient was informed\nabout the procedure\\'s nature, extent, risks, and potential outcomes,\nand was given ample opportunity to ask questions. After thoughtful\nconsideration, written consent was obtained.\n\nOPERATION:\n\nThe patient was positioned supine with the head in a neutral position.\nThe surgical area was sterilized and draped. Antibiotic prophylaxis was\nadministered, and a timeout procedure was conducted. The old wound was\nreopened and slightly extended by about 1 cm in both directions. The\nbone flap was removed, inspected, and cleaned. It was then reinserted\nafter refreshing the bone edges. The wound edges were refreshed, and the\nwound was irrigated again before closure.\n\nSUMMARY:\n\nSuccessful wound revision without complications for a wound healing\ncomplication post-glioblastoma surgery.\n\nCLINICAL NOTES:\n\nComplication in wound healing after glioblastoma removal and radiation\ntherapy. Possible inflammation? Evaluate for pus. Nature and type of\ngrowth?\n\nMACROSCOPIC EXAMINATION:\n\nSubcutaneous tissue samples, 1.2 x 1.0 x 0.4 cm, were completely\nembedded after being cut into two.\n\nEpidural tissue samples, 5.6 x 5.3 x 1.0 cm, were partially embedded.\n\nSTAINING: 2 blocks, Hematoxylin & Eosin (HE), Periodic Acid Schiff\n(PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology displays connective tissue surrounded by a pronounced\ninflammatory infiltrate, comprised of neutrophils, lymphocytes, and\nnumerous eosinophils. Additionally, budding capillaries were seen. No\nspecific findings in the PAS stain.\n\nHistologically, connective tissue infiltrated by predominantly\nlymphocytic inflammation was observed. Eosinophils and abundant necrotic\ntissue were also seen. Additionally, polarizable material was noted,\noccasionally engulfed by multinucleated giant cells. Hemorrhagic signs\nwere indicated by hemosiderin deposits. No specific findings in the PAS\nstain.\n\nFINDINGS:\n\n1 & 2. Soft tissue displays acute phlegmonous inflammation and chronic\ngranulating inflammation.\n\n**Brief report (07/15/2020): **\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 06/01/2020.\n\nWound healing disorder right parietal at the site of previous right-side\nglioblastoma, last revision 04/12/2020.\n\n-Single right body focal seizure 04/20/2020, single generalized seizure\n05/12/2020\n\n-Previous resection on 10/12/2019\n\n-Wound healing disorder with subsequent wound revision (06/2020)\n\n-Last cMRI on 05/03/2020: no recurrence observed.\n\nSecondary diagnoses:\n\nHypothyroidism\n\nSurgery type: injection of Ropivacaine, smear for microbiology,\nreadaptation of three small wound dehiscence, tobacco bag suture,\noverlay polyhexanide gel, plaster application\n\nInstructions: Return next Tuesday for wound check. Sutures to remain in\nplace for 10 days. Check microbiology results on Thursday. Clinically,\nno signs of infection observed.\n\nSurgical report:\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 04/20/2020.\n\nASSESSMENT:\n\nThe patient was presented at the emergency unit after observing a small\nwound dehiscence after the aforementioned surgery for a wound healing\ndisorder. The treating surgeon recommended a second local wound revision\nattempting to readapt the wound with a minor surgery. The patient\nprovided written consent for the procedure. The intervention was\nconducted with standard coagulation parameters.\n\nSURGERY:\n\nSterile preparation and draping of the surgical area. Initial injection\nof Ropivacaine. This was followed by swab collection for microbiology.\nThe wound edges were excised and the wound dehiscence was readapted\nusing a tobacco bag suture. Afterward, polyhexanide gel was applied,\nfollowed by a sterile plaster dressing.\n\nSurgery report:\n\nDiagnosis: significant scalp wound healing disorder in the prior\nsurgical access area post-resection and irradiation of a glioblastoma\nmultiforme.\n\nOperating time: 49 minutes\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nwe report on Mr. Miller, John, born 04/07/1961, who was in our inpatient\ntreatment from 09/12/2020 to 10/07/2020.\n\nDischarge diagnosis: Recurrence of the pre-described glioblastoma right\ninsular, WHO CNS grade 4 (IDH wild type, MGMT methylated).\n\nPhysical examination on admission:\n\nPatient awake, fully oriented, cooperative. Non-fluent aphasia. Speech\nclear and fluent. Latent left hemisymptomatic with strength grades 4+/5,\nstance and gait unsteady. Cranial nerve status regular. Scar conditions\nnon-irritant except for frontal superficial erosion at frontal wound\npole of pterional approach. Karnofsky 70%.\n\nMedication on Admission:\n\nLevothyroxine sodium 50 μg/1 pc (Synthroid® 50 micrograms, tablets)\n1-0-0-0\n\nLorazepam 0.5 mg/1 pc (Ativan® 0.5 mg, tablets) 1-1-1-1\n\nLacosamide 100 mg/1 pc (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\n**Imaging: **\n\ncMRI +/- contrast agent dated 09/15/2020: There is a contrast enhancing\nformation on the right temporo-mesial with approach to the insular\ncistern with suspected tumor recurrence.\n\nPET dated 09/10/2020 (external): Significant tracer multinodulation with\nactive areas in the islet region is seen.\n\n**Surgery of 09/18/2020: **\n\nReopening of existing skin incision and extension of craniotomy\ncranially, microsurgical navigated tumor resection right insular (IONM:\nMEP waste lower extremity with incomplete recovery) CUSA; extensive\nhemostasis, intraoperative MRI, sutures, reimplantation of bone flap\nwith multilayer wound closure. Skin suture.\n\nHistopathological report:\n\nRecurrence of pre-described glioblastoma, WHO CNS grade 4 (IDH wild\ntype, MGMT methylated).\n\nCourse:\n\nThe patient initially presented postoperatively with left hemiplegia in\nthe sense of SMA. This regressed significantly during the inpatient\nstay. Postoperative imaging revealed a regular resection finding. In\ncase of a possible adjustment disorder, the patient was treated with\nsertraline and lorazepam. The wound was dry and non-irritant during the\ninpatient stay. The patient received regular physiotherapeutic exercise.\nThe patient\\'s case was discussed in our neuro-oncological tumor board\non 09/29/2020, where the decision was made for adjuvant definitive\nradiochemotherapy. An inpatient transfer was offered by the colleagues\nof radiotherapy.\n\nProcedure:\n\nWe transfer Mr. Miller today in good clinical general condition to your\nfurther treatment and thank you for the kind takeover. We ask for\nregular wound controls as well as regular ECG controls to exclude a\nQTc-time prolongation under sertraline. Furthermore, the medication with\nlorazepam should be further phased out in the course of time. In case of\nacute neurological deterioration, a re-presentation in our neurosurgical\noutpatient clinic or surgical emergency room is possible at any time.\n\nClinical examination findings at discharge:\n\nPatient awake, fully oriented, cooperative. Speech clear and fluent.\nCranial nerve status without pathological findings. Hemiparesis\nleft-sided strength grade 4/5, right-sided no sensorimotor deficit.\nStance and gait unsteady. Non-fluent aphasia. Wound dry, without\nirritation. Karnofsky 70%.\n\n**Medication at Discharge:**\n\nLevothyroxine sodium 50 μg (Synthroid® 50 micrograms, tablets) 1-0-0-0\n\nLorazepam 0.5 mg (Ativan® 0.5 mg, tablets) as needed\n\nLacosamide 100 mg (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\nAcetaminophen 500 mg (Tylenol® 500 mg tablets) 1-1-1-1\n\nSertraline 50 mg (Zoloft® 50 mg film-coated tablets) by regimen\n\n**Magnetic Resonance Imaging (MRI) Report**\n\nDate of Examination: 02/02/2021\n\nClinical Indication: Multifocal glioblastoma WHO grade IV, IDH wild\ntype, MGMT methylated.\n\nClinical Query: Hemiparesis on the right side. Is there a structural\ncorrelate? Tumor progression?\n\n**Previous Imaging**: Multiple prior studies. The most recent contrasted\nMRI was on 09/15/2020.\n\n**Findings**:\n\n**Imaging Device**: GE 3T; Protocol: 3D FLAIR, 3D T1 Mprage with and\nwithout contrast, SWI, DWI, 3D T2, axial T2\\*, perfusion, DTI.\n\n1. **Report: **\n\n Known multimodal pretreated GBM since 2019, recently post-surgical\n resection for tumor progression in the frontotemporal region on\n 09/18/2020. Also noted is a post-surgical resection of additional\n foci in the right insular region. The resection cavity in the right\n frontal, insular, and temporal regions appears unchanged in size and\n configuration. Residual blood products are noted within.\n\n There are increased areas of contrast enhancement compared to the\n immediate post-operative images. There is a minor growth in a\n nodular enhancement posterior to the right middle cerebral artery.\n Adjacent to this, there\\'s a new nodular enhancement, which could be\n a postoperative reactive change or a new tumor lesion.\n\n Ongoing diffusion abnormalities are observed in the right caput\n nuclei caudatus, putamen, and globus pallidus, especially pronounced\n in posterior sections.\n\n Persistent FLAIR-hyperintense peritumoral edema in the right\n hemisphere remains unchanged. The midline shift is approximately 9mm\n to the left, which remains unchanged.\n\n Post-operative swelling and fluid accumulation are noted at the\n surgical entry point. The bone flap is in place. The width of both\n the internal and external CSF spaces remains constant, with no\n evidence of obstruction.\n\n The orbital contents are symmetrical. Paranasal sinuses and mastoid\n air cells are aerated appropriately.\n\n**Impression**:\n\nResidual tumor segments along the right middle cerebral artery showing\ngrowth. Adjacent to it, a new nodular area of contrast enhancement\nsuggests either a postoperative change or a new tumor lesion.\n\nPreviously identified ischemic changes in the right caput nuclei\ncaudatus, putamen, and globus pallidus. Persistent brain edema with a\nleftward midline shift of approximately 9mm remains unchanged.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nHerewith we report on our common patient Mr. John Miller, born\n04/07/1961, who was at our clinic between 02/04/2021 to 04/22/2021.\n\n-Recurrent manifestation of a glioblastoma\n\n-Stage: WHO CNS grade 4\n\n**Histology:**\n\nRecurrence of the pre-described glioblastoma, WHO CNS grade 4.\n\nMolecular pathological findings:\n\nIDH status: no p.R132H mutation (immunohistochemical).\n\nATRX: preservation of nuclear expression (immunohistochemical).\n\np53: technically not evaluable (immunohistochemical).\n\n1p/19q status: no combined loss (850k methylation analysis).\n\nCDKN2A/B: Deleted (850k methylation analysis).\n\nMGMT promoter: Methylated (850k methylation analysis).\n\nTumor localization: Islet/frontal right\n\nSecondary diagnoses:\n\nSymptomatic epilepsy\n\nHypothyroidism\n\nNausea\n\nLeukopenia I° (CTCAE)\n\nAnemia II° (CTCAE)\n\nPrevious course / therapies:\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n03/2020: Suspected recurrence\n\n04/2020: Revision surgery\n\n06-07/2020 Wound revisions and flap plasty for atrophic wound healing\ndisorder\n\n02/2021: Suspected recurrence with new FLAIR-positive tumor\nmanifestation insular on the right side. Stereotactic biopsy with\nevidence of glioblastoma.\n\nPathology: Renewed manifestation of a glioblastoma.\n\nRecommended radiochemotherapy.\n\nAccording to the interdisciplinary neuro-oncology board of 01/26/2021,\nwe gave the indication for adjuvant radiochemotherapy for the recurrence\nof glioblastoma.\n\n**Radiochemotherapy: **\n\nTechnique:\n\n1\\) Percutaneous intensity-modulated radiotherapy was administered to the\nformer recurrence tumor region in the frontal/insular right after CT-\nand MRI-guided radiation planning with 6 MV-photons in helical\ntomotherapy technique with a single dose of 2 Gy up to a total dose of\n60 Gy with 5 fractions per week. Daily position controls by CT.\n\n2\\) Subsequently, local dose saturation of the macroscopic tumor remnant\nwas performed.\n\nInsular right stereotactic ablative radiosurgery at the gamma knee to\nsaturate the macroscopic GammaKnife (Cobalt-60: 1.17 MeV and 1.33 MeV\nphotons) in mask fixation after CT- and MRI-guided radiotherapy planning\nunder image-guided setting (ConeBeam-CT) with a dose of 6 Gy in 2 Gy\nsingle dose to the 68% isodose up to a total cumulative dose of 66 Gy.\n\nChemotherapy:\n\nConcurrent chemotherapy with 75mg/m²KOF temozolomide daily (120 mg\ndaily).\n\nAbsolute dose: 5000 mg.\n\nTreatment Period:\n\nRadiotherapy 03/09/2021 -- 04/21/2021\n\nChemotherapy 03/09/2021 -- 04/21/2021\n\n**Course under therapy:**\n\nWe took over Mr. Miller on 03/06/2021 in reduced general and slightly\nreduced nutritional condition (Kanofsky index: 70 %, BMI: 18.5 kg/m²)\nfrom the Clinic for Neurosurgery for adjuvant re-radiochemotherapy on\nour radiooncology ward. At the time of admission, the patient had arm\n\nright hemiparesis (strength grades arm: 2/5, leg: 3/5). The patient was\nambulatory with assistance. Cranial nerve status was unremarkable.\nHeadache, nausea or dizziness were denied.\n\nOn 09/03/2021, combined re-radiochemotherapy was initiated.\n\nDuring the course of therapy with temozolomide, mild nausea occurred,\nwhich was treated with ondansetron 4mg as needed and dimenhydrinate\nSustained-release tablets 150 mg as needed. Under this treatment the\nsymptoms clearly regressed. Mild constipation was treated. Laboratory\ntests revealed mild leukopenia I° and anemia II° (CTCAE).\n\nOtherwise, the re-radiochemotherapy was very well tolerated overall.\n\nMr. Miller received physiotherapeutic exercise and psychotherapy during\nthe entire physiotherapeutic training and psycho-oncological support.\nUnder the physiotherapeutic treatment, his motor skills improved\nsignificantly. At the end of the therapy, the patient was also mobile\noutside the\n\nhouse without any aids.\n\nOn 04/22/2021 we discharged Mr. Miller to the outpatient care by his\nfamily doctor.\n\n04/11/2021: MR brain post contrast\n\nAfter renewed radiochemotherapy for a glioblastoma recurrence, a\nresidual suspicious barrier disturbance adjacent to the adjacent to the\nright cerebral artery. Stable nodular contrast enhancement\n\nPostoperative/reactive changes as described above. MR perfusion\nsequences show residual, contrast-absorbing tumor portions along the\nright A. cerebri media. Lateral to this, new nodular contrast-absorbing\nlesion, possibly postoperative reactive change. Previously known\nischemia at the right caput nuclei caudatii, putamen, and globus\npallidus. Unchanged medullary edema with midline shift to the left by\napproximately 9mm.\n\nLast lab:\n\nMCHC 29.4 g/dL (32 - 36) 04/20/2021\n\nMCH 25 pg (27 - 32) 04/20/2021\n\nLeukocytes 3.32 G/l (4.0 - 9.0) 04/20/2021\n\nHematocrit 31.6 % (37 - 43) 04/20/2021\n\nHemoglobin 9.3 g/dL (12 - 16) 04/20/2021\n\nErythrocytes 3.7 T/l (4.1 - 5.4) 04/20/2021\n\nUric acid 2.2 mg/dl (2.5 - 5.5) 04/20/2021\n\n**Further Procedure:**\n\nFurther skin care and behavior regarding side effects were explained to\nthe patient in detail.\n\nA first radiooncological control appointment was scheduled for\n06/05/2021 at 12:00 AM in our outpatient clinic. Prior to this, on\n06/02/2021 at 10:30 AM, an imaging exam (brain MRI) is scheduled.\n\nA further neuro-oncological connection is planned close to home via the\ntreating oncologist.\n\nAfter radiation therapy, we recommend annual ophthalmological check-ups\nand annual endocrinologic.\n\nwith testing of the hypothalamic-pituitary hormone axes.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nThis is a report on our mutual patient, Mr. John Miller, born\n04/07/1961:\n\nDiagnosis:\n\nRecurrent manifestation of glioblastoma\n\nWHO CNS grade 4\n\nTumor localization: Right isle/frontal\n\nSecondary diagnoses: Symptomatic epilepsy\n\nHypothyroidism Previous\n\nTreatments / Therapies\n\nResection and revisions\n\nAdjuvant radiochemotherapy\n\nTwo wound revisions and flap plasty for atrophic wound healing disorder\n\nNew FLAIR-positive tumor manifestation insular on the right side\n(02/2021)\n\nStereotactic biopsy with histopathology with evidence of glioblastoma\n\nTumor Board: Recommended new radiochemotherapy up to a total dose of 60\nGy à 2 Gy single dose. Subsequent local dose saturation of the\nmacroscopic tumor remnant as radiosurgery on GammaKnife with a dose of 6\nGy à 2 Gy single dose (\\@68% isodose).\n\n03-4/2021 Repeat stereotactic RTx in the area of the basal ganglia and\nthe resection cavity right frontal on the Gamma Knife with 46 Gy à 2 Gy;\n3 doses of Bevacizumab 7.5 mg/kg i.v.\n\n**Summary:**\n\nOn 07/03/2023, we conducted an initial telephone follow-up with the\npatient, Mr. Miller, for a radio-oncology consultation. Presently, Mr.\nMiller is undergoing rehabilitation, from which he feels he is deriving\nsubstantial benefits. His recent radiotherapy was well-received without\nany complications. Since the onset of his symptoms, there have been no\nnew developments. Symptoms related to intracranial pressure or new\nneurological deficits were denied. Fortunately, while on anticonvulsant\ntherapy with Lacosamide, Mr. Miller experienced no epileptic seizures.\nHis skin condition is normal. However, Mr. Miller did mention some\ncognitive challenges that minimally impact his daily activities,\nalongside feelings of fatigue and grade I CTCAE symptoms. The cMRI scan\nfrom 06/02/2021 revealed a notable reduction in the barrier disturbance\nof the right-sided basal ganglia. This was accompanied by small, mildly\nhyperperfused residual findings near the third ventricle. Moreover, the\npinpoint contrast enhancement in the left parietal lobe appeared\nunchanged, suggesting it is a scarring reaction. In collaboration with\nthe neurooncology team, Mr. Miller has discussed starting chemotherapy.\nThe next imaging assessment is scheduled for mid-September. We have also\nscheduled another radio-oncologic follow-up with Mr. Miller for\nSeptember 28th, per his preference, via telephone. For patient safety,\nMr. Miller is prohibited from operating private or commercial vehicles\nfor 3 months post-intracerebral radiotherapy. This duration may extend\nif there are existing or progressing brain conditions. Following\nradiotherapy, we are mandated by the Radiation Protection Act to\nfacilitate regular checks. Hence, we encourage enrollment in the\naftercare calendar, prompt reporting of any significant findings, and\nattendance of scheduled follow-ups. Alongside these, regular oncological\ncheck-ups by specialist practitioners are mandatory. Mr. Miller has been\nduly informed of all these requirements.\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. Brian Carter, born on\n04/24/1956, who was under our inpatient care from 09/28/2021 to\n09/30/2021.\n\n**Diagnosis**: ARDS in the context of a COVID-19 infection\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Mr. Carter presented to our facility on foot\non 09/28/2021 with a five-day history of slowly progressive dyspnea, dry\ncough, and non-apoplectic, holocentral headache. His initial room air\nsaturation was 78%, which improved to 86% with 10 liters of oxygen.\nArterial blood gas analysis revealed an oxygenation disorder with a paO2\nof 50 mmHg, prompting the initiation of NIV therapy, under which Mr.\nCarter remained hemodynamically stable. CT imaging showed bilateral\ninterstitial pneumonia with COVID-typical infiltrates. Both a rapid test\nin the initial care unit and one from his primary care physician were\nnegative for COVID-19. Therefore, we admitted Mr. Carter to our\nintensive care unit for further evaluation.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Alert and cooperative\n\n[Cardiovascular/Abdominal Examination]{.underline}: Severely impaired\noxygenation improved with NIV; Sinus rhythm at 80 beats per minute\n\n[Abdomen]{.underline}: Surgical abdomen\n\n[Renal System:]{.underline} Urination initially scant, then polyuria\nOthers.\n\n**Therapy and Progression:** Upon admission, Mr. Carter was alert,\ncooperative, and hemodynamically stable despite significant oxygenation\nimpairment. Temporary improvement was achieved with differentiated NIV\nmask ventilation. On 09/30, there was a further deterioration in\noxygenation with an increase in respiratory rate and escalation of\nventilator settings, leading to the decision to intubate. A tolerable\nventilation situation was achieved with an oxygenation index of 125. Due\nto radiological suspicion of atypical pneumonia, we initiated empirical\nanti-infective therapy with Piperacillin/Tazobactam, Clarithromycin, and\nCotrimoxazole. Microbiological test results were pending at the time of\ntransfer. We also initiated mucolytic therapy with Ambroxol. The\npre-existing immunosuppressive therapy with Prednisolone was\ndiscontinued and switched to Dexamethasone 10 mg. At the time of\ntransfer, Mr. Carter was hemodynamically stable with low catecholamine\ndoses (0.07 µg/kg/min). A central venous catheter was placed, and\nenteral or parenteral nutrition had not yet been initiated. Diuresis was\nsufficient after a single dose of 20 mg furosemide, with retention\nparameters within the normal range. Prophylactic anticoagulation with\nheparin 500 U/h was initiated.\n\n**Status at Transfer**:\n\n[Neurology]{.underline}: RASS -5 under Propofol and Sufentanil sedation\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline (NA)\n0.07; Hemoglobin 12.8 g/dL\n\n[Lungs]{.underline}: Adequate decarboxylation with borderline\noxygenation: paO2 87.6 under FiO2 0.7; PEEP 16; PEAK 27\n\n[Abdomen]{.underline}: Soft abdomen, no nutrition initiated\n\n[Renal System]{.underline}: Normal urine output without stimulation.\nRetention values within normal range. Clear urine.\n\n[Access]{.underline}: CVC placed on 09/30, left radial artery catheter\nplaced on 09/30.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under our inpatient care from 09/30/2021 to 10/13/2021.\n\n**Diagnosis:** ARDS due to COVID-19 pneumonia with superinfection by\nAspergillus fumigatus\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The patient was admitted from the emergency\ndepartment, presenting with dyspnea and confirmed SARS-CoV-2 infection.\nAfter initial management in the intensive care unit, a non-invasive\nventilation (NIV) trial was attempted, followed by successful\nintubation. The patient was then transferred to the Intensive Care Unit.\n\n**Therapy and Progression:** Upon admission, the patient was sedated,\nintubated, and controlled on mechanical ventilation with mild\ncatecholamine support. Due to oxygenation impairment despite\nlung-protective ventilation and inhaled supportive NO therapy,\nconservative ARDS therapy was initiated, including positioning therapy\n(a total of 9 prone positions). After stabilization of gas exchange with\npositioning therapy, sedation and ventilation weaning were performed.\nGas exchange and oxygenation are currently stable under BIPAP\nventilation (PiP 25 mbar, PEEP 13 mbar, breathing rate 18/min). The\npatient, under reduced analgosedation with Sufentanil and Clonidine,\nexhibits a sufficient awakening response, is adequately responsive, and\nfollows commands with reduced muscle strength.\n\nThe home medication of Methotrexate and Prednisolone for uveitis was\ndiscontinued upon admission. The patient received Dexamethasone for 10\ndays initially and, starting from 11/10, prednisolone with prophylactic\nCotrimoxazole therapy.\n\nUpon detection of Aspergillus in tracheobronchial secretions, antifungal\ntherapy with Voriconazole and Caspofungin (until target Voriconazole\nlevels were achieved) was initiated. The initially started antimicrobial\ntherapy with Piperacillin + Tazobactam was escalated to Meropenem on\n10/05/2021 due to worsening infection parameters and progression of\ninfiltrates on X-ray. Infection parameters have been fluctuating, and\nfever is not currently observed. Diuresis is qualitatively and\nquantitatively within normal limits, and retention parameters are within\nthe normal range.\n\nAnticoagulation was administered in therapeutic doses using\nlow-molecular-weight heparin.\n\nEnteral nutrition is provided through a nasogastric tube, and the\npatient has regular bowel movements.\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Analgosedated, GCS 10, pupils equal and\nreactive, limb movement prompt, follows commands with reduced strength\n\n[Lungs]{.underline}: Intubated with BIPAP 25/13, FiO2 0.4\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline 0.05\n\n[Abdomen]{.underline}: Obese, no tenderness, abdomen soft, oral intake\nvia a nasogastric tube, regular bowel movements\n\n[Diuresis]{.underline}: Normal urine output, retention parameters within\nnormal limits\n\nSkin/Wounds: Some pressure sores from positioning (see nursing handover\nsheet)\n\n[Mobilization]{.underline}: Not conducted\n\n**Imaging:**\n\n**Bedside Chest X-ray from 10/11/2021:**\n\n[Clinical information, question, justifying indication:]{.underline}\nCOVID pneumonia, insertion of a central venous catheter (CVC)\n\n**Assessment**: Comparison with 10/05/21: Endotracheal tube identical,\ngastric tube seen extending well into the abdomen, left CVC currently\npositioned in the brachiocephalic vein region, right CVC via internal\njugular vein with tip in superior vena cava. No pneumothorax, no\neffusions, increasing consolidation of infiltrates in the right lower\nlobe and retrocardially on the left without significant cavitation as\nfar as can be assessed. Left heart without significant central\ncongestion.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under intensive care treatment from 09/28/2021 to 10/12/2021 and\nin our intensive care unit from 10/13/2021 to 10/21/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The initial hospital admission of the patient was\nthrough our emergency department due to severe respiratory insufficiency\nin the context of COVID-19 pneumonia.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Skin/Mucous Membranes]{.underline}: Warm, Skin Perfusion: Good\nperfusion, Edema: Lower legs\n\n[Head]{.underline}: Mobility: Active and passive free movement, Tongue:\nMoist\n\n[Thorax]{.underline}: Auscultation: Clear bilaterally\n\n[Abdomen]{.underline}: Soft, no guarding, Bowel Sounds: Sparse\nperistalsis, Tenderness: None\n\n[Neurology]{.underline}: Pupil Shape: Round, Pupil Size: Moderate, Light\nReaction: Both sides +++\n\nAlertness: Awake\n\n**ECG on admission:** Tachycardic sinus rhythm with 107/min, Left type,\nP-wave normally configured, normal PQ interval, no pathological Q as in\nPardee-Q, narrow QRS, regular R progression, R/S transition in V3/4, no\nS persistence, no ST segment changes, no discordant T-negatives.\n\n**Therapy and Progression:** Despite intensified oxygen therapy with\nnasal high-flow and mask CPAP, adequate oxygenation could not be\nachieved, and the patient was intubated on 09/29/21. Leading oxygenation\nimpairment led to lung-protective ventilation with inhaled supportive NO\ntherapy and conservative ARDS therapy, including positioning therapy (a\ntotal of 9 prone positions, 16 hours each, from 09/29/21 to 10/8/21).\n\nDue to elevated procalcitonin, the patient received empirical antibiotic\ntreatment with Piperacillin/Tazobactam starting from 10/2/21, which was\nescalated to Meropenem on 10/5/21 and continued until 10/14/21.\n\nAfter the detection of Aspergillus in tracheobronchial secretions and\nBAL, the patient received Voriconazole since 10/7/2021 (treatment\nduration formally 4-6 weeks). Most recently, the level was\nsubtherapeutic, so the dose was adjusted to 2 x 400 mg daily.\n\nThe immunosuppressive therapy with Methotrexate and Prednisolone for\nrheumatoid arthritis was switched to Dexamethasone (09/29 to 10/8) and,\nsince 10/09, Prednisolone monotherapy. After controlling the fungal\ninfection, a rheumatology re-consultation was planned. Furthermore,\nsubtherapeutic anticoagulation with Fraxiparine was initiated for the\nprevention of thrombotic complications in the context of COVID-19.\n\nUnder this treatment regimen, gas exchange continuously improved, and on\n10/12/21, the patient was transferred with low catecholamine\nrequirements for ventilation and sedation weaning. Mr. Carter was\nextubated on 12/13/21 and now maintains good oxygenation with less than\n3L oxygen via nasal cannula. Delirium symptoms after extubation\ncompletely regressed within a few days.\n\nSevere dysphagia was observed after invasive ventilation, leading to a\nspeech therapy consultation. Oral feeding is currently not possible, so\nMr. Carter is receiving parenteral nutrition. As a result, there was a\nparavasate in the upper right extremity with painful erythema. Adequate\npain control was achieved with local cooling and Piritramide as needed.\nDue to continued dietary restrictions, a central venous catheter was\nplaced on 10/20/2021 for parenteral nutrition.\n\nWe request continued speech therapy treatment.\n\nOn 10/21/21, Staphylococcus aureus was detected in blood culture, so we\ninitiated the administration of Flucloxacillin. The MRSA rapid test was\nnegative.\n\nWe are transferring Mr. Carter on 10/21/21 in stable condition, awake,\nand appropriately responsive for further treatment. We appreciate the\ntransfer of our patient and are available for any further questions.\n\n**Current Recommendations:**\n\n- Continuation of antifungal therapy for a total of at least 4-6 weeks\n\n- Voriconazole level measurement\n\n- Speech therapy consultation\n\n- Rheumatology re-consultation\n\n- Follow-up blood cultures upon detection of Staph. aureus\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Mr. Brian Carter, born on 04/24/1956, who was under\nour inpatient care from 10/21/2021 to 11/08/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Transfer for continuation of antimicrobial\ntherapy for MSSA bacteremia. Transesophageal echocardiogram planned for\ntomorrow. Cleared for full diet by speech therapy today. Patient\nmobilized to standing position for the first time today. Overall,\nmobility is significantly limited, but the patient can mobilize to the\nedge of the bed independently. No pain, no fever, mild cough without\nsputum. No shortness of breath. Mood is significantly depressed, but\nthis is a known issue. Before COVID-19, he was heavily affected by\nrheumatoid arthritis.\n\n**Medical History:** The patient was transferred to our COVID ward after\na positive SARS-CoV-2 RNA PCR test in the naso-oropharyngeal swab and\nrespiratory failure. On physical examination, he had a reduced general\ncondition. Respiratory rate was 24/min, and oxygen saturation was 97% on\n4 L/min of O2 via nasal cannula. Oxygen supply of 4 L via nasal cannula\ncould not be reduced during the course. A chest X-ray performed on 11/21\nshowed increasingly loosened infiltrates in the left basal region and a\nminimal effusion at the base.\n\nA SARS-CoV-2 RNA PCR test from 11/10/2020 was negative, so Mr. Carter\nwas no longer in isolation.\n\nDue to the detection of Aspergillus fumigatus in bronchoalveolar lavage,\nintravenous Voriconazole therapy initiated on 10/07/2021 was continued\nand was planned to be adjusted according to drug level monitoring.\nAdditionally, Staph. aureus was identified in a blood culture, and\nStaph. epidermidis. Antibiotic therapy with Cefazolin was started on\n10/22 and was to be continued for a total of 14 days after the first\nnegative blood culture. The central venous catheter, likely the source\nof infection, was removed on 10/22, and microbiological examination of\nthe catheter tip indicated suspicion of Staphylococci. To rule out\nendocarditis, a transesophageal echocardiogram was scheduled for 10/24.\nMr. Carter has already been informed about this intervention, and\nFraxiparine was to be paused on the evening of 10/24 and the morning of\n10/27, with the patient kept fasting.\n\nThere is also a known history of rheumatoid arthritis, which was treated\non an outpatient basis with Methotrexate and Prednisolone. Due to the\ncurrent infection, Methotrexate was paused, and after consultation with\nthe rheumatologists, it was decided to continue with prednisolone 5mg.\nAfter complete pulmonary recovery, a rheumatology re-consultation was\nplanned, and the resumption of methotrexate was considered.\n\nUpon admission, the patient had significant dysphagia, which improved\nduring the course. A flexible endoscopic swallowing examination\nperformed on 10/24/2021 by speech therapists and phoniatrics revealed a\nnormal swallow reflex. Mr. Carter can now resume a regular diet.\n\n**Physical Examination:** Weight: 83 kg, Height: 182 cm. Temperature:\n36.5°C, Heart rate: 80/min, Respiratory rate: 25/min, Blood pressure:\n130/80 mmHg, Oxygen saturation: 98% with 2 L/min O2\n\n[Skin/mucous membranes:]{.underline} No edema, no skin abnormalities.\nCentral venous catheter exit site on the neck is unremarkable.\n\n[Head/neck:]{.underline} Own teeth, intact mucous membranes\n\n[Heart]{.underline}: Rhythmic, tachycardic up to 100/min, clear heart\nsounds, no murmurs\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no adventitious\nsounds\n\n[Abdomen]{.underline}: Soft, active bowel sounds, no tenderness, no\nresistance\n\n[Lymph nodes:]{.underline} Cervical, axillary nodes not palpable\n\n[Vessels]{.underline}: Foot pulses palpable\n\n[Musculoskeletal:]{.underline} Muscle strength reduced due to CIP/CIM.\nCan mobilize to the bedside independently\n\n[Basic neurological examination:]{.underline} Alert, oriented, friendly\n\n[Psychological state]{.underline}: Depressed mood\n\n**Therapy and Progression:** The emergency presentation of Mr. Carter\nwas on 09/28/2021 due to severe dyspnea and respiratory insufficiency.\nAfter direct transfer to Intensive Care Unit, despite intensified oxygen\ntherapy with nasal high flow and mask CPAP, adequate oxygenation could\nnot be achieved, leading to intubation on 10/29/21.\n\nLung-protective ventilation was initiated due to leading oxygenation\nimpairment, with inhalational supportive NO therapy and conservative\nARDS therapy, including positional changes (a total of 9 sessions of 16\nhours each from 09/29/21 to 10/08/21). Due to elevated PCT levels, the\npatient received empiric antibiotic therapy with\nPiperacillin/Tazobactam, escalated to Meropenem. Voriconazole was\ninitiated on 10/07/2021 after the detection of Aspergillus in\ntracheobronchial secretions and BAL (intended treatment duration 4-6\nweeks).\n\nSubtherapeutic anticoagulation with Fraxiparine was administered for the\nprevention of thrombotic complications in the context of COVID-19. Under\nthis treatment regimen, gas exchange steadily improved, and on 10/12/21,\nthe patient was transferred with low catecholamine requirements for\nweaning from mechanical ventilation and sedation. There, he was\nextubated on 10/13/21.\n\nAfter extubation, severe dysphagia was observed, and speech therapy was\nconsulted. Oral diet is currently not possible, so Mr. Carter is on\nparenteral nutrition. This led to a paravasate in the right upper\nextremity with painful erythema. Adequate pain control was achieved with\nlocal cooling and subcutaneous Piritramide, as needed.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- ------------ ---------------------\n Absolute Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.3 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.61 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\>90 \\>90\n BUN 23 mg/dL 17-48 mg/dL\n Total Bilirubin 0.18 mg/dL \\< 1.20 mg/dL\n C-Reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 6.1 ng/L \\< 14 ng/L\n ALT 50 U/L \\< 41 U/L\n AST 40 U/L \\< 50 U/L\n Alkaline Phosphatase 111 U/L 40-130 U/L\n Gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cells 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.56 K/µL 3.90-10.50 K/µL\n Platelets 280 K/µL 150-370 K/µL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Prothrombin Time 89% 78-123%\n INR 1.09 0.90-1.25\n Activated Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n**Imaging:**\n\n**Chest X-ray bedside on 09/29/2021:** CT scan of the chest from\n9/28/2021 is available for comparison. Tracheal tube tip supracarinal.\nCentral venous catheter (CVC) via right internal jugular vein, tip in\nthe confluence of veins. Gastric tube tip infradiaphragmatic. Patchy\nconfluent bilateral lung infiltrates, mainly perihilar, left and right\nupper and lower fields. No significant changes compared to the previous\nday. Small bilateral pleural effusions. No pneumothorax in the lying\nposition. Left-sided heart prominence with mild stasis/capillary leak.\n\n**Chest X-ray bedside on 10/3/2021:**\n\n[Findings]{.underline}: Compared to 09/29/2021. Tracheal tube with tip\napproximately 4 cm above the carina. Gastric tube slightly retracted,\ntip located just below the diaphragm. Central venous catheter via the\nright internal jugular vein, currently with the tip in the superior vena\ncava. Regression and loosening of infiltrates (mainly in the lower\nfields on both sides). No significant effusion or pneumothorax. No\nsubstantial volume overload.\n\n**Chest X-ray bedside on 10/6/2021:**\n\n[Findings]{.underline}: Compared to the previous examination on\n11/4/2020. New central venous catheter (CVC) from the left internal\njugular vein with tip in the confluence. No pneumothorax in the lying\nposition, no large pleural effusions. Progressive infiltrates in the\nright lower field, perihilar regions on both sides. No significant\ncentral stasis. Heart not enlarged, mediastinum slim.\n\n**Chest X-ray bedside on 10/11/2021:**\n\n[Findings]{.underline}: Compared to 10/5/2021. Tracheal tube and gastric\ntube as before. Left CVC with the tip currently in the region of the\nbrachiocephalic vein, right CVC via the internal jugular vein with the\ntip in the superior vena cava. No pneumothorax, no effusions, increasing\nconsolidation of infiltrates in the right lower field and retrocardial\nleft with no significant cavitation. Left-biased heart without\nsignificant central congestion.\n\n**Chest X-ray bedside on 10/16/2021:**\n\n[Findings]{.underline}: Compared to previous examinations on 10/11/2021.\nHeart borderline enlarged. Mediastinum, as far as can be assessed from\nslightly rotated images, appears central and slim. Increasing\nconsolidation in the right lower lobe and left lower lobe, which is well\ncompatible with pneumonic infiltrates. At most, a small pleural effusion\non the left. No pneumothorax in the lying position. No signs of\nsignificant congestion. Right jugular catheter projecting into the\nsuperior vena cava. Tracheal tube and left jugular catheter have been\nremoved since the last examination.\n\n**Chest X-ray bedside on 10/20/2021:**\n\n[Findings]{.underline}: Compared to the examination on 10/16/2021. In\nthe course of known COVID pneumonia, there is an increasingly loosened\nappearance of infiltrates in the left basal region. A small effusion\ncontinues to drain basally. Otherwise, no significant changes in the\nshort-term follow-up. Right jugular catheter projecting into the\nsuperior vena cava, as before.\n\n**EKG on 10/27/2021:** Normal sinus rhythm, 86/min. Indeterminate axis.\nPQ interval: 108ms QRS duration: 108ms. QTc interval: 484ms. Peripheral\nlow voltage. Delayed R progression up to and including V3. RS transition\nin V4. No significant ST-T wave changes.\n\n**Ultrasound Abdomen on 11/01/2021:**\n\n[Reason for referral:]{.underline} History of COVID, Aspergillosis\n\n[Liver]{.underline}: Vertical diameter in the midclavicular line on the\nright is 120 mm.\n\n[Biliary tract]{.underline}: Well visualized. No abnormalities in the\nintrahepatic and extrahepatic bile ducts. Maximum width of the common\nbile duct is 3 mm.\n\n[Gallbladder]{.underline}: Well visualized. Normal findings.\n\n[Pancreas]{.underline}: Maximum diameters - Head: 17 mm, Body: 12 mm,\nTail: 15 mm. Well visualized. Normal findings.\n\n[Spleen]{.underline}: Normal size, normal homogeneous internal echo\npattern, no focal changes, hilum is free. Organ size: 120 mm x 38 mm.\n\n[Right kidney:]{.underline} Partially assessable, as far as\nrecognizable, parenchymal edge is age-appropriate, smooth organ contour,\nno urinary obstruction, no stones. Size: 120 mm x 45 mm, parenchymal\nthickness 21 mm.\n\n[Left kidney:]{.underline} Partially assessable, as far as recognizable,\nparenchymal edge is age-appropriate, smooth organ contour, no urinary\nobstruction, no stones. Size: 115 mm x 61 mm, parenchymal thickness 19\nmm.\n\n[Bladder:]{.underline} Well visualized, orthotopically located, normal\nwall proportions, no pathological echo structures in the lumen, normal\norgan size.\n\n[Abdominal vessels:]{.underline} Normal findings.\n\n[Abdominal lymph nodes:]{.underline} No evidence of enlarged lymph nodes\nin the subphrenic region.\n\n[Peritoneum]{.underline}: No free fluid.\n\n[Color duplex sonography of the portal vein:]{.underline} Orthograde\nflow, no evidence of thrombosis.\n\n[Assessment]{.underline}: In the right lower lobe cranial-lateral\n(segment VII), there is an entirely echo-free cystic structure with a\nslightly lobulated contour. There is no \\\"double wall,\\\" and there are\nno features suggestive of Echinococcus. This is most likely a congenital\ncyst. The overall structure, architecture, and texture of the liver are\nnormal, with no other focal abnormalities. In the rest of the abdomen,\nthere are no other pathological findings.\n\n**Cardiology Consultation on 10/29/2021:**\n\n**Medical History:** The patient reports thoracic complaints following\nthe intensive care unit stay post-COVID. These pains have been noticed\nwith mild exertion and are described as retrosternal with radiation to\nthe left chest. This last occurred on Sunday afternoon, lasting for\napproximately 1 hour and then spontaneously resolving at rest. This pain\ncannot be induced by a change in position, coughing, or deep\ninspiration. Dyspnea is continuously present, and the patient still\nrequires oxygen. Dyspnea worsens when lying down.\n\n**Cardiovascular risk factors**: Mildly elevated blood pressure\n(hypertension) since May of this year, managed with half a tablet\naccording to self-measurements (averaging 120/80 mmHg, rarely in the\n130s). Lipid profile checked by the general practitioner earlier this\nyear, presumably with good results. No known diabetes. Former smoker\nuntil 2007, but it is difficult to estimate the pack-years, as smoking\noccurred on occasions and during stressful times, less than 15\npack-years. No family history of cardiovascular diseases.\nUveitis/scleritis/episcleritis managed with 10mg MTX per week and 5 mg p\n\nPrednisolone orally daily, well-controlled without recurrence.\n\n**Physical Examination**: Lungs with moist rales bilaterally. Cardiac\nexamination with faint heart sounds. Regular heart rate of 80/min. No\npericardial rub. Pale-gray skin color. Respiratory rate of 15/min while\nsitting. Radial pulses palpable bilaterally. Groin pulses not examined.\nAllen\\'s test operable on the right, borderline on the left.\n\n**ECG**: tachycardic sinus rhythm with a heart rate of 109/min, left\naxis deviation, regular R-wave progression in chest leads, mild\nS-persistence in V6, no significant ST-T wave changes.\n\n**Transthoracic and transesophageal echocardiography on 11/27/2020**:\n\n[Kinetics]{.underline}: Hypokinesia of the lateral and anterior walls,\notherwise normokinetic and synergistic. Systolic function (right\nventricle): TAPSE 18 mm (\\> 16 mm), RV-S\\' 17.6 cm/s (\\> 10 cm/s).\n\n[Valves]{.underline}: Mitral valve - Delicate leaflets, good opening\nmotion, no significant insufficiency. Lambl\\'s excrescences on the\natrial side. Small fluttering structure at the subvalvular apparatus,\ncompatible with chordae tendineae. Aortic valve - Tricuspid, delicate\nvalve. Functionally intact (AV Vmax 1.0 m/s). Tricuspid valve -\nMorphologically normal. Mild insufficiency. TR Vmax 1.9 m/s, sPAP 15\nmmHg + CVP. Pulmonic valve - Morphologically and functionally normal.\n\n[Other Findings:]{.underline} No pericardial effusion. Small Persistent\nForamen Ovale. Left atrial appendage free of intracavitary thrombi at\n60°/90°/150°. Thoracic aorta with smooth-walled plaques, no dissections\nor thrombi.\n\n[Assessment]{.underline}: No structures suggestive of endocarditis. No\nrelevant valvular abnormalities. Incidentally, there is a moderately\nreduced LVEF with wall motion abnormalities in the RIVA (right\nventricular anterior) region. We request a cardiology consultation and\nfurther diagnostics.\n\n**Phoniatric Consultation on 10/24/2021:**\n\n[Medical History:]{.underline} Patient with a history of COVID\npneumonia, twice tested negative. Currently, the patient has Aspergillus\nand pneumonia. Previously, the patient was in the ICU and intubated for\ntwo weeks due to COVID. Following speech therapy for dysphagia, a\nflexible endoscopic evaluation of swallowing (FEES) is requested.\n\n[Findings]{.underline}: FEES reveals a normal configuration of the\nlarynx with good mobility of the tongue and lips. Normal gross mobility\nof the vocal cords during phonation and respiration transitions. Full\nglottic closure appears complete. Flexible transnasal swallow evaluation\n(FEES) with blue dye: Sufficient oral bolus control for liquids, purees,\nand solids. No drooling or leakage. Swallow reflex present. Voluntary\ninitiation of the swallow act is possible. Side-by-side swallowing of\ntest substances over the valleculae without evidence of\npre-/intra-/post-deglutitive penetration or aspiration for all test\nconsistencies. Rosenbeck\\'s Penetration-Aspiration Scale score: 1\n(Minimal retention in the valleculae with puree, which can be completely\ncleared by swallowing). Normal sensitivity, strong cough reflex. No\nnasal regurgitation.\n\n[Assessment]{.underline}: Normal swallowing function.\n\n[Current Recommendations:]{.underline} Able to consume regular diet and\nthin liquids, as well as medications with water.\n\n**Therapy and Progression:** The patient was admitted for further\ntreatment. Upon admission, the patient was in a reduced general\ncondition with significant mobility limitations.\n\nStaphylococcus aureus was detected in a blood culture, leading to a\ntransesophageal echocardiogram (TEE) on 11/26/2020. No vegetations were\nfound, but a moderate hypokinesia of the left ventricle in the RIVA area\nwas observed. Cardiac enzymes were within normal limits. This was\ninterpreted as post-COVID myocarditis, differential diagnosis myocardial\ninjury in severe ARDS, coronary artery disease, or mixed picture.\n\nIn consultation with the cardiology colleagues, a cautious heart failure\nmedication regimen with beta-blockers and ACE inhibitors was initiated.\nWe recommend an elective coronary angiography in the future. Currently,\nthe patient was symptom-free with low cardiac markers and a normal ECG,\nso acute diagnostic procedures were not indicated.\n\nThe antibiotic therapy with Cefazolin was continued until 11/05/2021\n(last sterile blood cultures from 10/24/2021). Staphylococcus\nepidermidis detected in the blood culture on 10/20/21 and at the tip of\nthe central venous catheter on 10/22/21 were considered\ncatheter-associated. The catheter was immediately removed. The patient\ndid not develop a fever during the hospital stay. Inflammatory markers\nimproved over time.\n\nAn abdominal ultrasound was performed due to an unclear liver lesion,\nwhich was found to be a congenital cyst. Echinococcus serology was\nnegative.\n\nIn consultation with the psychiatric colleagues, Quetiapine medication\nwas cautiously resumed for known depression, but it had to be\ndiscontinued later due to significant QTc prolongation. Long-term oxygen\ntherapy of 2 liters was indicated.\n\nOur ophthalmology colleagues recommended the resumption of MTX therapy\ngiven the patient\\'s stable vision. We request this therapy be initiated\nand an outpatient follow-up appointment in ophthalmology arranged after\nthe patient completes rehabilitation.\n\nWith physiotherapy, the patient achieved mobilization up to walking.\nSwallowing and articulation difficulties also significantly improved.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency** **Route**\n ---------------------------------- --------------- ------------------------------ ------------\n Metoprolol Succinate (Toprol XL) 23.8 mg 1-0-1-0 Oral\n Dicloxacillin Sodium (Dynapen) 2176 mg 1-1-1-0 Oral\n Voriconazole (Vfend) 200 mg 2-0-2-0 Oral\n Acetaminophen (Tylenol) 500 mg As needed Oral\n Ipratropium Bromide (Atrovent) 0.26 mg/2 ml 6-0-0-0 Inhalation\n Albuterol Sulfate (ProAir) 1.5 mg/2.5 ml 6-0-0-0 Inhalation\n Amitriptyline (Elavil) 28.3 mg 0-0-1-0 Oral\n Citalopram (Celexa) 50 mg 1-0-0-0 Oral\n Melatonin 2 mg 0-0-2-0 Oral\n Montelukast (Singulair) 10 mg 1-0-0-0 Oral\n Pantoprazole (Protonix) 45 mg 0-0-1-0 Oral\n Eplerenone (Inspra) 25 mg 1-0-0-0 Oral\n Ramipril (Altace) 2.5 mg 0-0-1-0 Oral\n Folic Acid 5 mg 0-0-1-0 48h after MTX intake Oral\n Methotrexate (Trexall) 15 mg 1-0-0-0 Once a Week Oral\n\n\n\n### text_4\n**Dear colleague, **\n\nWe thank you for referring your patient, Mr. Brian Carter, born on\n04/24/1956 to our outpatient care on 02/03/2022.\n\n**Diagnoses**: Suspected Post-Intensive-Care Syndrome with:\n\n- Dysphagia\n\n- ICU-acquired weakness\n\n- Depressive mood, anxiety\n\n**Other Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n<!-- -->\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** Mr. Carter was treated in the intensive care unit\nfor a total of 24 days in September and October 2021 due to COVID-19.\nFollowing intensive care treatment, he underwent neurological\nrehabilitation from 11/08/2021 to 01/18/2022, with the following\nrehabilitation results: \\\"Mr. I. benefited well from the therapies.\nParticularly, physiotherapy helped regain confidence in walking. During\ntreatment, breathing difficulties improved, and oxygen supplementation\nwas no longer necessary.\\\" An antidepressant therapy with Mirtazapine\nwas initiated for sleep disorders and mood swings, resulting in a\nreduction in sleep disturbances.\n\n**Assessment**: Since the illness, Mr. Carter reports general fatigue,\nquick fatigue, and weakness, especially in the lower extremities. He is\ncurrently not undergoing physiotherapy or any other treatments.\nRegarding psychopharmacological therapy, the patient has been seeing a\npsychiatrist once a month based on anamnesis. After a short exertion, he\nexperiences dyspnea and regularly needs to take breaks. Room air\nsaturation was at 94%. Physical examination revealed significant\nexpiratory wheezing and prolonged expiration bilaterally. Furthermore,\nthe patient reports cognitive impairments with marked forgetfulness and\ndifficulty concentrating. This is evident in the reduced results of the\nMiniCog (2/3 words, normal clock, 4 points) and animal naming tests\n(correct single naming of 10 animals, 3 points). Additionally, the\npatient reports an exacerbation of symptoms of depression known since\n2011, including sadness, fatigue, sleep disturbances, and anxiety. These\nworsened during the ICU stay. The current medication includes Citalopram\n40 mg and Mirtazapine 7.5 mg, which have somewhat improved previously\nworsened sleep disturbances. Psychotherapy is not currently taking place\nbut is strongly recommended.\n\nDysphagia diagnosed during the intensive care unit stay has slightly\nimproved, allowing Mr. Carter to consume regular food again. However, he\nstill experiences dysphagia and coughing during each meal. An\nappointment at the swallowing clinic has been scheduled by us (see\nbelow).\n\n**Current Recommendations:**\n\nAs swallowing difficulties persist, an appointment has been scheduled at\nour local swallowing clinic. We also recommend a pulmonary evaluation.\nContact has already been made, and the colleagues from Pulmonology will\nget in touch with Mr. Carter. Furthermore, due to a previously existing\ndepressive mood with currently exacerbated symptoms, we recommend\nconnecting the patient with an outpatient psychotherapist. Some\ntherapists have already been suggested by the patient\\'s general\npractitioner, and we strongly recommend further contact. A prescription\nfor physiotherapy has been issued for pronounced muscle weakness and\nsuspected ICU-acquired weakness. Further physiotherapeutic engagement\nwith the general practitioner\\'s assistance is urgently required.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------- ------------- ---------------------\n Neutrophils 49.0 % 42.0-77.0 %\n Lymphocytes 31.9 % 20.0-44.0 %\n Monocytes 7.2 % 2.0-9.5 %\n Basophils 0.7 % 0.0-1.8 %\n Eosinophils 10.8 % 0.5-5.5 %\n Immature Granulocytes 0.4 % 0.0-1.0 %\n Sodium 139 mEq/L 136-145 mEq/L\n Potassium 3.5 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.99 mg/dL 0.70-1.20 mg/dL\n BUN 25 mg/dL 17-48 mg/dL\n Total Bilirubin 0.45 mg/dL \\< 1.20 mg/dL\n CRP 3.9 mg/dL \\< 5.0 mg/dL\n ALT 21 U/L \\< 41 U/L\n AST 20 U/L \\< 50 U/L\n Alkaline Phosphatase 65 U/L 40-130 U/L\n Gamma-GT 38 U/L 8-61 U/L\n LDH 160 U/L 135-250 U/L\n Lipase 20 U/L 13-60 U/L\n Procalcitonin 0.03 µg/L \\< 0.50 µg/L\n Hemoglobin 13.2 g/dL 13.5-17.0 g/dL\n Hematocrit 44.2 % 39.5-50.5 %\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 7.62 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n\n\n\n\nHere is the query:\nMr. Carter's transesophageal echocardiogram on 11/26/2020 revealed hypokinesia of which cardiac region?\n\nChoose the correct answer from the following options:\nA. Left ventricle\nB. Right ventricle\nC. Anterior wall\nD. RIVA area\nE. Lateral wall\n\n\nYour response:\n", "role": "user" }, { "content": "RIVA area", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. Brian Carter, born on\n04/24/1956, who was under our inpatient care from 09/28/2021 to\n09/30/2021.\n\n**Diagnosis**: ARDS in the context of a COVID-19 infection\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Mr. Carter presented to our facility on foot\non 09/28/2021 with a five-day history of slowly progressive dyspnea, dry\ncough, and non-apoplectic, holocentral headache. His initial room air\nsaturation was 78%, which improved to 86% with 10 liters of oxygen.\nArterial blood gas analysis revealed an oxygenation disorder with a paO2\nof 50 mmHg, prompting the initiation of NIV therapy, under which Mr.\nCarter remained hemodynamically stable. CT imaging showed bilateral\ninterstitial pneumonia with COVID-typical infiltrates. Both a rapid test\nin the initial care unit and one from his primary care physician were\nnegative for COVID-19. Therefore, we admitted Mr. Carter to our\nintensive care unit for further evaluation.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Alert and cooperative\n\n[Cardiovascular/Abdominal Examination]{.underline}: Severely impaired\noxygenation improved with NIV; Sinus rhythm at 80 beats per minute\n\n[Abdomen]{.underline}: Surgical abdomen\n\n[Renal System:]{.underline} Urination initially scant, then polyuria\nOthers.\n\n**Therapy and Progression:** Upon admission, Mr. Carter was alert,\ncooperative, and hemodynamically stable despite significant oxygenation\nimpairment. Temporary improvement was achieved with differentiated NIV\nmask ventilation. On 09/30, there was a further deterioration in\noxygenation with an increase in respiratory rate and escalation of\nventilator settings, leading to the decision to intubate. A tolerable\nventilation situation was achieved with an oxygenation index of 125. Due\nto radiological suspicion of atypical pneumonia, we initiated empirical\nanti-infective therapy with Piperacillin/Tazobactam, Clarithromycin, and\nCotrimoxazole. Microbiological test results were pending at the time of\ntransfer. We also initiated mucolytic therapy with Ambroxol. The\npre-existing immunosuppressive therapy with Prednisolone was\ndiscontinued and switched to Dexamethasone 10 mg. At the time of\ntransfer, Mr. Carter was hemodynamically stable with low catecholamine\ndoses (0.07 µg/kg/min). A central venous catheter was placed, and\nenteral or parenteral nutrition had not yet been initiated. Diuresis was\nsufficient after a single dose of 20 mg furosemide, with retention\nparameters within the normal range. Prophylactic anticoagulation with\nheparin 500 U/h was initiated.\n\n**Status at Transfer**:\n\n[Neurology]{.underline}: RASS -5 under Propofol and Sufentanil sedation\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline (NA)\n0.07; Hemoglobin 12.8 g/dL\n\n[Lungs]{.underline}: Adequate decarboxylation with borderline\noxygenation: paO2 87.6 under FiO2 0.7; PEEP 16; PEAK 27\n\n[Abdomen]{.underline}: Soft abdomen, no nutrition initiated\n\n[Renal System]{.underline}: Normal urine output without stimulation.\nRetention values within normal range. Clear urine.\n\n[Access]{.underline}: CVC placed on 09/30, left radial artery catheter\nplaced on 09/30.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under our inpatient care from 09/30/2021 to 10/13/2021.\n\n**Diagnosis:** ARDS due to COVID-19 pneumonia with superinfection by\nAspergillus fumigatus\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The patient was admitted from the emergency\ndepartment, presenting with dyspnea and confirmed SARS-CoV-2 infection.\nAfter initial management in the intensive care unit, a non-invasive\nventilation (NIV) trial was attempted, followed by successful\nintubation. The patient was then transferred to the Intensive Care Unit.\n\n**Therapy and Progression:** Upon admission, the patient was sedated,\nintubated, and controlled on mechanical ventilation with mild\ncatecholamine support. Due to oxygenation impairment despite\nlung-protective ventilation and inhaled supportive NO therapy,\nconservative ARDS therapy was initiated, including positioning therapy\n(a total of 9 prone positions). After stabilization of gas exchange with\npositioning therapy, sedation and ventilation weaning were performed.\nGas exchange and oxygenation are currently stable under BIPAP\nventilation (PiP 25 mbar, PEEP 13 mbar, breathing rate 18/min). The\npatient, under reduced analgosedation with Sufentanil and Clonidine,\nexhibits a sufficient awakening response, is adequately responsive, and\nfollows commands with reduced muscle strength.\n\nThe home medication of Methotrexate and Prednisolone for uveitis was\ndiscontinued upon admission. The patient received Dexamethasone for 10\ndays initially and, starting from 11/10, prednisolone with prophylactic\nCotrimoxazole therapy.\n\nUpon detection of Aspergillus in tracheobronchial secretions, antifungal\ntherapy with Voriconazole and Caspofungin (until target Voriconazole\nlevels were achieved) was initiated. The initially started antimicrobial\ntherapy with Piperacillin + Tazobactam was escalated to Meropenem on\n10/05/2021 due to worsening infection parameters and progression of\ninfiltrates on X-ray. Infection parameters have been fluctuating, and\nfever is not currently observed. Diuresis is qualitatively and\nquantitatively within normal limits, and retention parameters are within\nthe normal range.\n\nAnticoagulation was administered in therapeutic doses using\nlow-molecular-weight heparin.\n\nEnteral nutrition is provided through a nasogastric tube, and the\npatient has regular bowel movements.\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Analgosedated, GCS 10, pupils equal and\nreactive, limb movement prompt, follows commands with reduced strength\n\n[Lungs]{.underline}: Intubated with BIPAP 25/13, FiO2 0.4\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline 0.05\n\n[Abdomen]{.underline}: Obese, no tenderness, abdomen soft, oral intake\nvia a nasogastric tube, regular bowel movements\n\n[Diuresis]{.underline}: Normal urine output, retention parameters within\nnormal limits\n\nSkin/Wounds: Some pressure sores from positioning (see nursing handover\nsheet)\n\n[Mobilization]{.underline}: Not conducted\n\n**Imaging:**\n\n**Bedside Chest X-ray from 10/11/2021:**\n\n[Clinical information, question, justifying indication:]{.underline}\nCOVID pneumonia, insertion of a central venous catheter (CVC)\n\n**Assessment**: Comparison with 10/05/21: Endotracheal tube identical,\ngastric tube seen extending well into the abdomen, left CVC currently\npositioned in the brachiocephalic vein region, right CVC via internal\njugular vein with tip in superior vena cava. No pneumothorax, no\neffusions, increasing consolidation of infiltrates in the right lower\nlobe and retrocardially on the left without significant cavitation as\nfar as can be assessed. Left heart without significant central\ncongestion.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under intensive care treatment from 09/28/2021 to 10/12/2021 and\nin our intensive care unit from 10/13/2021 to 10/21/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The initial hospital admission of the patient was\nthrough our emergency department due to severe respiratory insufficiency\nin the context of COVID-19 pneumonia.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Skin/Mucous Membranes]{.underline}: Warm, Skin Perfusion: Good\nperfusion, Edema: Lower legs\n\n[Head]{.underline}: Mobility: Active and passive free movement, Tongue:\nMoist\n\n[Thorax]{.underline}: Auscultation: Clear bilaterally\n\n[Abdomen]{.underline}: Soft, no guarding, Bowel Sounds: Sparse\nperistalsis, Tenderness: None\n\n[Neurology]{.underline}: Pupil Shape: Round, Pupil Size: Moderate, Light\nReaction: Both sides +++\n\nAlertness: Awake\n\n**ECG on admission:** Tachycardic sinus rhythm with 107/min, Left type,\nP-wave normally configured, normal PQ interval, no pathological Q as in\nPardee-Q, narrow QRS, regular R progression, R/S transition in V3/4, no\nS persistence, no ST segment changes, no discordant T-negatives.\n\n**Therapy and Progression:** Despite intensified oxygen therapy with\nnasal high-flow and mask CPAP, adequate oxygenation could not be\nachieved, and the patient was intubated on 09/29/21. Leading oxygenation\nimpairment led to lung-protective ventilation with inhaled supportive NO\ntherapy and conservative ARDS therapy, including positioning therapy (a\ntotal of 9 prone positions, 16 hours each, from 09/29/21 to 10/8/21).\n\nDue to elevated procalcitonin, the patient received empirical antibiotic\ntreatment with Piperacillin/Tazobactam starting from 10/2/21, which was\nescalated to Meropenem on 10/5/21 and continued until 10/14/21.\n\nAfter the detection of Aspergillus in tracheobronchial secretions and\nBAL, the patient received Voriconazole since 10/7/2021 (treatment\nduration formally 4-6 weeks). Most recently, the level was\nsubtherapeutic, so the dose was adjusted to 2 x 400 mg daily.\n\nThe immunosuppressive therapy with Methotrexate and Prednisolone for\nrheumatoid arthritis was switched to Dexamethasone (09/29 to 10/8) and,\nsince 10/09, Prednisolone monotherapy. After controlling the fungal\ninfection, a rheumatology re-consultation was planned. Furthermore,\nsubtherapeutic anticoagulation with Fraxiparine was initiated for the\nprevention of thrombotic complications in the context of COVID-19.\n\nUnder this treatment regimen, gas exchange continuously improved, and on\n10/12/21, the patient was transferred with low catecholamine\nrequirements for ventilation and sedation weaning. Mr. Carter was\nextubated on 12/13/21 and now maintains good oxygenation with less than\n3L oxygen via nasal cannula. Delirium symptoms after extubation\ncompletely regressed within a few days.\n\nSevere dysphagia was observed after invasive ventilation, leading to a\nspeech therapy consultation. Oral feeding is currently not possible, so\nMr. Carter is receiving parenteral nutrition. As a result, there was a\nparavasate in the upper right extremity with painful erythema. Adequate\npain control was achieved with local cooling and Piritramide as needed.\nDue to continued dietary restrictions, a central venous catheter was\nplaced on 10/20/2021 for parenteral nutrition.\n\nWe request continued speech therapy treatment.\n\nOn 10/21/21, Staphylococcus aureus was detected in blood culture, so we\ninitiated the administration of Flucloxacillin. The MRSA rapid test was\nnegative.\n\nWe are transferring Mr. Carter on 10/21/21 in stable condition, awake,\nand appropriately responsive for further treatment. We appreciate the\ntransfer of our patient and are available for any further questions.\n\n**Current Recommendations:**\n\n- Continuation of antifungal therapy for a total of at least 4-6 weeks\n\n- Voriconazole level measurement\n\n- Speech therapy consultation\n\n- Rheumatology re-consultation\n\n- Follow-up blood cultures upon detection of Staph. aureus\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Brian Carter, born on 04/24/1956, who was under\nour inpatient care from 10/21/2021 to 11/08/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Transfer for continuation of antimicrobial\ntherapy for MSSA bacteremia. Transesophageal echocardiogram planned for\ntomorrow. Cleared for full diet by speech therapy today. Patient\nmobilized to standing position for the first time today. Overall,\nmobility is significantly limited, but the patient can mobilize to the\nedge of the bed independently. No pain, no fever, mild cough without\nsputum. No shortness of breath. Mood is significantly depressed, but\nthis is a known issue. Before COVID-19, he was heavily affected by\nrheumatoid arthritis.\n\n**Medical History:** The patient was transferred to our COVID ward after\na positive SARS-CoV-2 RNA PCR test in the naso-oropharyngeal swab and\nrespiratory failure. On physical examination, he had a reduced general\ncondition. Respiratory rate was 24/min, and oxygen saturation was 97% on\n4 L/min of O2 via nasal cannula. Oxygen supply of 4 L via nasal cannula\ncould not be reduced during the course. A chest X-ray performed on 11/21\nshowed increasingly loosened infiltrates in the left basal region and a\nminimal effusion at the base.\n\nA SARS-CoV-2 RNA PCR test from 11/10/2020 was negative, so Mr. Carter\nwas no longer in isolation.\n\nDue to the detection of Aspergillus fumigatus in bronchoalveolar lavage,\nintravenous Voriconazole therapy initiated on 10/07/2021 was continued\nand was planned to be adjusted according to drug level monitoring.\nAdditionally, Staph. aureus was identified in a blood culture, and\nStaph. epidermidis. Antibiotic therapy with Cefazolin was started on\n10/22 and was to be continued for a total of 14 days after the first\nnegative blood culture. The central venous catheter, likely the source\nof infection, was removed on 10/22, and microbiological examination of\nthe catheter tip indicated suspicion of Staphylococci. To rule out\nendocarditis, a transesophageal echocardiogram was scheduled for 10/24.\nMr. Carter has already been informed about this intervention, and\nFraxiparine was to be paused on the evening of 10/24 and the morning of\n10/27, with the patient kept fasting.\n\nThere is also a known history of rheumatoid arthritis, which was treated\non an outpatient basis with Methotrexate and Prednisolone. Due to the\ncurrent infection, Methotrexate was paused, and after consultation with\nthe rheumatologists, it was decided to continue with prednisolone 5mg.\nAfter complete pulmonary recovery, a rheumatology re-consultation was\nplanned, and the resumption of methotrexate was considered.\n\nUpon admission, the patient had significant dysphagia, which improved\nduring the course. A flexible endoscopic swallowing examination\nperformed on 10/24/2021 by speech therapists and phoniatrics revealed a\nnormal swallow reflex. Mr. Carter can now resume a regular diet.\n\n**Physical Examination:** Weight: 83 kg, Height: 182 cm. Temperature:\n36.5°C, Heart rate: 80/min, Respiratory rate: 25/min, Blood pressure:\n130/80 mmHg, Oxygen saturation: 98% with 2 L/min O2\n\n[Skin/mucous membranes:]{.underline} No edema, no skin abnormalities.\nCentral venous catheter exit site on the neck is unremarkable.\n\n[Head/neck:]{.underline} Own teeth, intact mucous membranes\n\n[Heart]{.underline}: Rhythmic, tachycardic up to 100/min, clear heart\nsounds, no murmurs\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no adventitious\nsounds\n\n[Abdomen]{.underline}: Soft, active bowel sounds, no tenderness, no\nresistance\n\n[Lymph nodes:]{.underline} Cervical, axillary nodes not palpable\n\n[Vessels]{.underline}: Foot pulses palpable\n\n[Musculoskeletal:]{.underline} Muscle strength reduced due to CIP/CIM.\nCan mobilize to the bedside independently\n\n[Basic neurological examination:]{.underline} Alert, oriented, friendly\n\n[Psychological state]{.underline}: Depressed mood\n\n**Therapy and Progression:** The emergency presentation of Mr. Carter\nwas on 09/28/2021 due to severe dyspnea and respiratory insufficiency.\nAfter direct transfer to Intensive Care Unit, despite intensified oxygen\ntherapy with nasal high flow and mask CPAP, adequate oxygenation could\nnot be achieved, leading to intubation on 10/29/21.\n\nLung-protective ventilation was initiated due to leading oxygenation\nimpairment, with inhalational supportive NO therapy and conservative\nARDS therapy, including positional changes (a total of 9 sessions of 16\nhours each from 09/29/21 to 10/08/21). Due to elevated PCT levels, the\npatient received empiric antibiotic therapy with\nPiperacillin/Tazobactam, escalated to Meropenem. Voriconazole was\ninitiated on 10/07/2021 after the detection of Aspergillus in\ntracheobronchial secretions and BAL (intended treatment duration 4-6\nweeks).\n\nSubtherapeutic anticoagulation with Fraxiparine was administered for the\nprevention of thrombotic complications in the context of COVID-19. Under\nthis treatment regimen, gas exchange steadily improved, and on 10/12/21,\nthe patient was transferred with low catecholamine requirements for\nweaning from mechanical ventilation and sedation. There, he was\nextubated on 10/13/21.\n\nAfter extubation, severe dysphagia was observed, and speech therapy was\nconsulted. Oral diet is currently not possible, so Mr. Carter is on\nparenteral nutrition. This led to a paravasate in the right upper\nextremity with painful erythema. Adequate pain control was achieved with\nlocal cooling and subcutaneous Piritramide, as needed.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- ------------ ---------------------\n Absolute Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.3 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.61 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\>90 \\>90\n BUN 23 mg/dL 17-48 mg/dL\n Total Bilirubin 0.18 mg/dL \\< 1.20 mg/dL\n C-Reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 6.1 ng/L \\< 14 ng/L\n ALT 50 U/L \\< 41 U/L\n AST 40 U/L \\< 50 U/L\n Alkaline Phosphatase 111 U/L 40-130 U/L\n Gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cells 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.56 K/µL 3.90-10.50 K/µL\n Platelets 280 K/µL 150-370 K/µL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Prothrombin Time 89% 78-123%\n INR 1.09 0.90-1.25\n Activated Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n**Imaging:**\n\n**Chest X-ray bedside on 09/29/2021:** CT scan of the chest from\n9/28/2021 is available for comparison. Tracheal tube tip supracarinal.\nCentral venous catheter (CVC) via right internal jugular vein, tip in\nthe confluence of veins. Gastric tube tip infradiaphragmatic. Patchy\nconfluent bilateral lung infiltrates, mainly perihilar, left and right\nupper and lower fields. No significant changes compared to the previous\nday. Small bilateral pleural effusions. No pneumothorax in the lying\nposition. Left-sided heart prominence with mild stasis/capillary leak.\n\n**Chest X-ray bedside on 10/3/2021:**\n\n[Findings]{.underline}: Compared to 09/29/2021. Tracheal tube with tip\napproximately 4 cm above the carina. Gastric tube slightly retracted,\ntip located just below the diaphragm. Central venous catheter via the\nright internal jugular vein, currently with the tip in the superior vena\ncava. Regression and loosening of infiltrates (mainly in the lower\nfields on both sides). No significant effusion or pneumothorax. No\nsubstantial volume overload.\n\n**Chest X-ray bedside on 10/6/2021:**\n\n[Findings]{.underline}: Compared to the previous examination on\n11/4/2020. New central venous catheter (CVC) from the left internal\njugular vein with tip in the confluence. No pneumothorax in the lying\nposition, no large pleural effusions. Progressive infiltrates in the\nright lower field, perihilar regions on both sides. No significant\ncentral stasis. Heart not enlarged, mediastinum slim.\n\n**Chest X-ray bedside on 10/11/2021:**\n\n[Findings]{.underline}: Compared to 10/5/2021. Tracheal tube and gastric\ntube as before. Left CVC with the tip currently in the region of the\nbrachiocephalic vein, right CVC via the internal jugular vein with the\ntip in the superior vena cava. No pneumothorax, no effusions, increasing\nconsolidation of infiltrates in the right lower field and retrocardial\nleft with no significant cavitation. Left-biased heart without\nsignificant central congestion.\n\n**Chest X-ray bedside on 10/16/2021:**\n\n[Findings]{.underline}: Compared to previous examinations on 10/11/2021.\nHeart borderline enlarged. Mediastinum, as far as can be assessed from\nslightly rotated images, appears central and slim. Increasing\nconsolidation in the right lower lobe and left lower lobe, which is well\ncompatible with pneumonic infiltrates. At most, a small pleural effusion\non the left. No pneumothorax in the lying position. No signs of\nsignificant congestion. Right jugular catheter projecting into the\nsuperior vena cava. Tracheal tube and left jugular catheter have been\nremoved since the last examination.\n\n**Chest X-ray bedside on 10/20/2021:**\n\n[Findings]{.underline}: Compared to the examination on 10/16/2021. In\nthe course of known COVID pneumonia, there is an increasingly loosened\nappearance of infiltrates in the left basal region. A small effusion\ncontinues to drain basally. Otherwise, no significant changes in the\nshort-term follow-up. Right jugular catheter projecting into the\nsuperior vena cava, as before.\n\n**EKG on 10/27/2021:** Normal sinus rhythm, 86/min. Indeterminate axis.\nPQ interval: 108ms QRS duration: 108ms. QTc interval: 484ms. Peripheral\nlow voltage. Delayed R progression up to and including V3. RS transition\nin V4. No significant ST-T wave changes.\n\n**Ultrasound Abdomen on 11/01/2021:**\n\n[Reason for referral:]{.underline} History of COVID, Aspergillosis\n\n[Liver]{.underline}: Vertical diameter in the midclavicular line on the\nright is 120 mm.\n\n[Biliary tract]{.underline}: Well visualized. No abnormalities in the\nintrahepatic and extrahepatic bile ducts. Maximum width of the common\nbile duct is 3 mm.\n\n[Gallbladder]{.underline}: Well visualized. Normal findings.\n\n[Pancreas]{.underline}: Maximum diameters - Head: 17 mm, Body: 12 mm,\nTail: 15 mm. Well visualized. Normal findings.\n\n[Spleen]{.underline}: Normal size, normal homogeneous internal echo\npattern, no focal changes, hilum is free. Organ size: 120 mm x 38 mm.\n\n[Right kidney:]{.underline} Partially assessable, as far as\nrecognizable, parenchymal edge is age-appropriate, smooth organ contour,\nno urinary obstruction, no stones. Size: 120 mm x 45 mm, parenchymal\nthickness 21 mm.\n\n[Left kidney:]{.underline} Partially assessable, as far as recognizable,\nparenchymal edge is age-appropriate, smooth organ contour, no urinary\nobstruction, no stones. Size: 115 mm x 61 mm, parenchymal thickness 19\nmm.\n\n[Bladder:]{.underline} Well visualized, orthotopically located, normal\nwall proportions, no pathological echo structures in the lumen, normal\norgan size.\n\n[Abdominal vessels:]{.underline} Normal findings.\n\n[Abdominal lymph nodes:]{.underline} No evidence of enlarged lymph nodes\nin the subphrenic region.\n\n[Peritoneum]{.underline}: No free fluid.\n\n[Color duplex sonography of the portal vein:]{.underline} Orthograde\nflow, no evidence of thrombosis.\n\n[Assessment]{.underline}: In the right lower lobe cranial-lateral\n(segment VII), there is an entirely echo-free cystic structure with a\nslightly lobulated contour. There is no \\\"double wall,\\\" and there are\nno features suggestive of Echinococcus. This is most likely a congenital\ncyst. The overall structure, architecture, and texture of the liver are\nnormal, with no other focal abnormalities. In the rest of the abdomen,\nthere are no other pathological findings.\n\n**Cardiology Consultation on 10/29/2021:**\n\n**Medical History:** The patient reports thoracic complaints following\nthe intensive care unit stay post-COVID. These pains have been noticed\nwith mild exertion and are described as retrosternal with radiation to\nthe left chest. This last occurred on Sunday afternoon, lasting for\napproximately 1 hour and then spontaneously resolving at rest. This pain\ncannot be induced by a change in position, coughing, or deep\ninspiration. Dyspnea is continuously present, and the patient still\nrequires oxygen. Dyspnea worsens when lying down.\n\n**Cardiovascular risk factors**: Mildly elevated blood pressure\n(hypertension) since May of this year, managed with half a tablet\naccording to self-measurements (averaging 120/80 mmHg, rarely in the\n130s). Lipid profile checked by the general practitioner earlier this\nyear, presumably with good results. No known diabetes. Former smoker\nuntil 2007, but it is difficult to estimate the pack-years, as smoking\noccurred on occasions and during stressful times, less than 15\npack-years. No family history of cardiovascular diseases.\nUveitis/scleritis/episcleritis managed with 10mg MTX per week and 5 mg p\n\nPrednisolone orally daily, well-controlled without recurrence.\n\n**Physical Examination**: Lungs with moist rales bilaterally. Cardiac\nexamination with faint heart sounds. Regular heart rate of 80/min. No\npericardial rub. Pale-gray skin color. Respiratory rate of 15/min while\nsitting. Radial pulses palpable bilaterally. Groin pulses not examined.\nAllen\\'s test operable on the right, borderline on the left.\n\n**ECG**: tachycardic sinus rhythm with a heart rate of 109/min, left\naxis deviation, regular R-wave progression in chest leads, mild\nS-persistence in V6, no significant ST-T wave changes.\n\n**Transthoracic and transesophageal echocardiography on 11/27/2020**:\n\n[Kinetics]{.underline}: Hypokinesia of the lateral and anterior walls,\notherwise normokinetic and synergistic. Systolic function (right\nventricle): TAPSE 18 mm (\\> 16 mm), RV-S\\' 17.6 cm/s (\\> 10 cm/s).\n\n[Valves]{.underline}: Mitral valve - Delicate leaflets, good opening\nmotion, no significant insufficiency. Lambl\\'s excrescences on the\natrial side. Small fluttering structure at the subvalvular apparatus,\ncompatible with chordae tendineae. Aortic valve - Tricuspid, delicate\nvalve. Functionally intact (AV Vmax 1.0 m/s). Tricuspid valve -\nMorphologically normal. Mild insufficiency. TR Vmax 1.9 m/s, sPAP 15\nmmHg + CVP. Pulmonic valve - Morphologically and functionally normal.\n\n[Other Findings:]{.underline} No pericardial effusion. Small Persistent\nForamen Ovale. Left atrial appendage free of intracavitary thrombi at\n60°/90°/150°. Thoracic aorta with smooth-walled plaques, no dissections\nor thrombi.\n\n[Assessment]{.underline}: No structures suggestive of endocarditis. No\nrelevant valvular abnormalities. Incidentally, there is a moderately\nreduced LVEF with wall motion abnormalities in the RIVA (right\nventricular anterior) region. We request a cardiology consultation and\nfurther diagnostics.\n\n**Phoniatric Consultation on 10/24/2021:**\n\n[Medical History:]{.underline} Patient with a history of COVID\npneumonia, twice tested negative. Currently, the patient has Aspergillus\nand pneumonia. Previously, the patient was in the ICU and intubated for\ntwo weeks due to COVID. Following speech therapy for dysphagia, a\nflexible endoscopic evaluation of swallowing (FEES) is requested.\n\n[Findings]{.underline}: FEES reveals a normal configuration of the\nlarynx with good mobility of the tongue and lips. Normal gross mobility\nof the vocal cords during phonation and respiration transitions. Full\nglottic closure appears complete. Flexible transnasal swallow evaluation\n(FEES) with blue dye: Sufficient oral bolus control for liquids, purees,\nand solids. No drooling or leakage. Swallow reflex present. Voluntary\ninitiation of the swallow act is possible. Side-by-side swallowing of\ntest substances over the valleculae without evidence of\npre-/intra-/post-deglutitive penetration or aspiration for all test\nconsistencies. Rosenbeck\\'s Penetration-Aspiration Scale score: 1\n(Minimal retention in the valleculae with puree, which can be completely\ncleared by swallowing). Normal sensitivity, strong cough reflex. No\nnasal regurgitation.\n\n[Assessment]{.underline}: Normal swallowing function.\n\n[Current Recommendations:]{.underline} Able to consume regular diet and\nthin liquids, as well as medications with water.\n\n**Therapy and Progression:** The patient was admitted for further\ntreatment. Upon admission, the patient was in a reduced general\ncondition with significant mobility limitations.\n\nStaphylococcus aureus was detected in a blood culture, leading to a\ntransesophageal echocardiogram (TEE) on 11/26/2020. No vegetations were\nfound, but a moderate hypokinesia of the left ventricle in the RIVA area\nwas observed. Cardiac enzymes were within normal limits. This was\ninterpreted as post-COVID myocarditis, differential diagnosis myocardial\ninjury in severe ARDS, coronary artery disease, or mixed picture.\n\nIn consultation with the cardiology colleagues, a cautious heart failure\nmedication regimen with beta-blockers and ACE inhibitors was initiated.\nWe recommend an elective coronary angiography in the future. Currently,\nthe patient was symptom-free with low cardiac markers and a normal ECG,\nso acute diagnostic procedures were not indicated.\n\nThe antibiotic therapy with Cefazolin was continued until 11/05/2021\n(last sterile blood cultures from 10/24/2021). Staphylococcus\nepidermidis detected in the blood culture on 10/20/21 and at the tip of\nthe central venous catheter on 10/22/21 were considered\ncatheter-associated. The catheter was immediately removed. The patient\ndid not develop a fever during the hospital stay. Inflammatory markers\nimproved over time.\n\nAn abdominal ultrasound was performed due to an unclear liver lesion,\nwhich was found to be a congenital cyst. Echinococcus serology was\nnegative.\n\nIn consultation with the psychiatric colleagues, Quetiapine medication\nwas cautiously resumed for known depression, but it had to be\ndiscontinued later due to significant QTc prolongation. Long-term oxygen\ntherapy of 2 liters was indicated.\n\nOur ophthalmology colleagues recommended the resumption of MTX therapy\ngiven the patient\\'s stable vision. We request this therapy be initiated\nand an outpatient follow-up appointment in ophthalmology arranged after\nthe patient completes rehabilitation.\n\nWith physiotherapy, the patient achieved mobilization up to walking.\nSwallowing and articulation difficulties also significantly improved.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency** **Route**\n ---------------------------------- --------------- ------------------------------ ------------\n Metoprolol Succinate (Toprol XL) 23.8 mg 1-0-1-0 Oral\n Dicloxacillin Sodium (Dynapen) 2176 mg 1-1-1-0 Oral\n Voriconazole (Vfend) 200 mg 2-0-2-0 Oral\n Acetaminophen (Tylenol) 500 mg As needed Oral\n Ipratropium Bromide (Atrovent) 0.26 mg/2 ml 6-0-0-0 Inhalation\n Albuterol Sulfate (ProAir) 1.5 mg/2.5 ml 6-0-0-0 Inhalation\n Amitriptyline (Elavil) 28.3 mg 0-0-1-0 Oral\n Citalopram (Celexa) 50 mg 1-0-0-0 Oral\n Melatonin 2 mg 0-0-2-0 Oral\n Montelukast (Singulair) 10 mg 1-0-0-0 Oral\n Pantoprazole (Protonix) 45 mg 0-0-1-0 Oral\n Eplerenone (Inspra) 25 mg 1-0-0-0 Oral\n Ramipril (Altace) 2.5 mg 0-0-1-0 Oral\n Folic Acid 5 mg 0-0-1-0 48h after MTX intake Oral\n Methotrexate (Trexall) 15 mg 1-0-0-0 Once a Week Oral\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient, Mr. Brian Carter, born on\n04/24/1956 to our outpatient care on 02/03/2022.\n\n**Diagnoses**: Suspected Post-Intensive-Care Syndrome with:\n\n- Dysphagia\n\n- ICU-acquired weakness\n\n- Depressive mood, anxiety\n\n**Other Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n<!-- -->\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** Mr. Carter was treated in the intensive care unit\nfor a total of 24 days in September and October 2021 due to COVID-19.\nFollowing intensive care treatment, he underwent neurological\nrehabilitation from 11/08/2021 to 01/18/2022, with the following\nrehabilitation results: \\\"Mr. I. benefited well from the therapies.\nParticularly, physiotherapy helped regain confidence in walking. During\ntreatment, breathing difficulties improved, and oxygen supplementation\nwas no longer necessary.\\\" An antidepressant therapy with Mirtazapine\nwas initiated for sleep disorders and mood swings, resulting in a\nreduction in sleep disturbances.\n\n**Assessment**: Since the illness, Mr. Carter reports general fatigue,\nquick fatigue, and weakness, especially in the lower extremities. He is\ncurrently not undergoing physiotherapy or any other treatments.\nRegarding psychopharmacological therapy, the patient has been seeing a\npsychiatrist once a month based on anamnesis. After a short exertion, he\nexperiences dyspnea and regularly needs to take breaks. Room air\nsaturation was at 94%. Physical examination revealed significant\nexpiratory wheezing and prolonged expiration bilaterally. Furthermore,\nthe patient reports cognitive impairments with marked forgetfulness and\ndifficulty concentrating. This is evident in the reduced results of the\nMiniCog (2/3 words, normal clock, 4 points) and animal naming tests\n(correct single naming of 10 animals, 3 points). Additionally, the\npatient reports an exacerbation of symptoms of depression known since\n2011, including sadness, fatigue, sleep disturbances, and anxiety. These\nworsened during the ICU stay. The current medication includes Citalopram\n40 mg and Mirtazapine 7.5 mg, which have somewhat improved previously\nworsened sleep disturbances. Psychotherapy is not currently taking place\nbut is strongly recommended.\n\nDysphagia diagnosed during the intensive care unit stay has slightly\nimproved, allowing Mr. Carter to consume regular food again. However, he\nstill experiences dysphagia and coughing during each meal. An\nappointment at the swallowing clinic has been scheduled by us (see\nbelow).\n\n**Current Recommendations:**\n\nAs swallowing difficulties persist, an appointment has been scheduled at\nour local swallowing clinic. We also recommend a pulmonary evaluation.\nContact has already been made, and the colleagues from Pulmonology will\nget in touch with Mr. Carter. Furthermore, due to a previously existing\ndepressive mood with currently exacerbated symptoms, we recommend\nconnecting the patient with an outpatient psychotherapist. Some\ntherapists have already been suggested by the patient\\'s general\npractitioner, and we strongly recommend further contact. A prescription\nfor physiotherapy has been issued for pronounced muscle weakness and\nsuspected ICU-acquired weakness. Further physiotherapeutic engagement\nwith the general practitioner\\'s assistance is urgently required.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------- ------------- ---------------------\n Neutrophils 49.0 % 42.0-77.0 %\n Lymphocytes 31.9 % 20.0-44.0 %\n Monocytes 7.2 % 2.0-9.5 %\n Basophils 0.7 % 0.0-1.8 %\n Eosinophils 10.8 % 0.5-5.5 %\n Immature Granulocytes 0.4 % 0.0-1.0 %\n Sodium 139 mEq/L 136-145 mEq/L\n Potassium 3.5 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.99 mg/dL 0.70-1.20 mg/dL\n BUN 25 mg/dL 17-48 mg/dL\n Total Bilirubin 0.45 mg/dL \\< 1.20 mg/dL\n CRP 3.9 mg/dL \\< 5.0 mg/dL\n ALT 21 U/L \\< 41 U/L\n AST 20 U/L \\< 50 U/L\n Alkaline Phosphatase 65 U/L 40-130 U/L\n Gamma-GT 38 U/L 8-61 U/L\n LDH 160 U/L 135-250 U/L\n Lipase 20 U/L 13-60 U/L\n Procalcitonin 0.03 µg/L \\< 0.50 µg/L\n Hemoglobin 13.2 g/dL 13.5-17.0 g/dL\n Hematocrit 44.2 % 39.5-50.5 %\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 7.62 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/18/2018 to\n03/01/2018.\n\n**Diagnoses: **\n\n- Malignant melanoma of the left scapula, TD 16 mm, exophytic\n ulcerating, invasion stage - III, R0\n\n- **Mutation analysis:** BRAF status: mutated. PD-L1 status: PD-L1\n tumor proportion score (TPS): \\<1%. Immune cell infiltrate (IC): 2%\n of tumor area. PD-L1 combined-positive score (CPS): 2.\n\n- **History:** Ms. Done was admitted to the hospital with high grade\n suspicion of malignant melanoma of the back. The patient reported a\n skin lesion that had been present for approximately 4 weeks. The\n lesion had grown rapidly during this time and appeared to be oozing\n and bleeding. She presented to our outpatient clinic, where she was\n advised to undergo surgical excision in case of suspected\n malignancy.\n\n- Questions about B-symptoms, AP complaints, stool or urine\n abnormalities were negated.\n\n- System Therapy (Adjuvant Treatment for Stage III Melanoma): 1\n\n02/22/18: 1st dose pembrolizumab 200mg\n\n03/15/18: 2nd dose Pembrolizumab 200mg\n\n04/05/18: 3rd dose Pembrolizumab 200mg\n\n04/26/18: 4th dose Pembrolizumab 200mg\n\n05/17/18: 5th dose Pembrolizumab 200mg\n\n06/07/18: 6th dose Pembrolizumab 200mg\n\n06/28/18: 7th dose Pembrolizumab 200mg\n\n07/19/18: 8th dose Pembrolizumab 200mg\n\n08/09/18: 9th dose Pembrolizumab 200mg i.v.\n\n**Physical examination findings:** 52-year-old female patient in normal\ngeneral condition, nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement normal. Pupils are equal and\nreactive to light and accommodation. Regular, normocardial heart rate\nduring recording. Cor and pulmo auscultatory and percutaneously\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall, liver\nand spleen not enlarged, no pain to palpation, no resistance to\npalpation, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged cervical, submandibular, supra- and infraclavicular, axillary\nand inguinal lymph nodes palpable. inguinal lymph nodes palpable.\nFurther internal and orienting neurological examination neurological\nexamination remained without pathological findings.\n\n**Skin findings:** In the area of the left scapula, a table tennis-ball\nsized area with a slightly fissured, oozing, pink-black pigmented\nsurface. On the cranial side an irregularly black-brown pigmented macula\nof about 3.2x1.2 cm is visible.\n\n**PET/CT with 203 MBq (F-18)-Fluorodeoxyglucose from 02/18/2018: **\n\nWeight: 66 kg, blood glucose: 118 mg/dL. 20 mg furosemide; acquisition\nstart 91 min after tracer injection; 821 mm scan length á () mm/s in\nflow technique (neck to proximal thigh); oral and i.v. contrast (1.5\nmL/kg, i.v., max. 120 mL). Quantitative analysis of\nattenuation-corrected image data using SUV calculation.\n\n**Findings:**\n\nCT: In case of known contrast agent allergy, premedication was performed\nwith one ampoule each of H1 and H2 antihistamine. The contrast-enhanced\nexamination proceeded without complications during the course.\n\nNeck: Symmetrical visualization of the soft tissues of the neck. No\nevidence of pathologically enlarged cervical lymph nodes. Struma nodosa\nwith several hypodense nodes on the right side up to max. approx. 1 cm.\n\nThorax: Cutaneous/subcutaneous irregular-shaped lesion caudal to the\nright scapula. Limited assessability in the lung window with motion\nartifacts and shallow inspiration depth. As far as assessable, no\nevidence of larger suspicious intrapulmonary pulmonary round foci. No\ninfiltrate. No pleural effusion. No evidence of pathologically enlarged\nlymph nodes mediastinal, hilar and axillary bilaterally.\n\nAbdomen/pelvis: Normal contrast of liver parenchyma without evidence of\nsuspicious focal liver lesions. Portal vein and hepatic veins perfused\nregularly. Gallbladder without irritation. Spleen with accessory spleen,\npancreas and adrenal glands bds. regular. Kidneys perfused at the same\nside. No urinary retention. Nephrolithiasis on the right side.\nVisualization of the parenchymatous upper abdominal organs. No evidence\nof pathologically enlarged coeliacal, mesenteric, retroperitoneal,\niliac, and inguinal lymph nodes. Inhomogeneously contrasted enlarged\nprostate. Urinary bladder wall, as far as assessable with low filling\ncircumferentially wall thickened.\n\nSkeleton: no evidence of suspicious osteodestructive lesions. Osteopenia\nwith degenerative skeletal changes.\n\nPET:\n\nIncreased tracer enhancement of the suspicious lesion caudal to left\nscapula, indicative of a melanoma (SUVmax 67). Focal intense tracer\nenhancement in the right thyroid lobe (SUVmax approximately 7.9).\nElongated intense tracer enhancement in the lower abdomen ventrally\nmedian without clear correlate, most consistent with contamination.\nOtherwise, unremarkable activity distribution in the study area.\n\nAssessment:\n\nNo evidence of metabolically active metastases in the study area.\n\n**Operation report from** **02/22/2018**:\n\nProcedure: Excision of malignant melanoma on the left upper back.\n\nPreoperative Diagnosis: Malignant melanoma, left upper back.\n\nPostoperative Diagnosis: Malignant melanoma, left upper back.\n\nAnesthesia: Local anesthesia using 70 mL tumescent solution comprising\n0.21% Lidocaine/Ropivacaine with epinephrine.\n\nProcedure Details: The surgical area was prepped using Betadine. The\narea was draped in a sterile fashion. Excision of the exophytic tumor\nwas performed, measuring 51 x 20 x 15 mm. A safety margin of 10 mm was\nmaintained in depth, with the excision extending slightly into the\nsubcutaneous tissue but not beyond the fascia. This resulted in a total\ndefect size of 75 x 45 mm. The defect could not be closed with a simple\nprimary suture. Perforator vessels were coagulated, and the defect was\nbridged using skin flaps. Additional resection of Burow triangles was\ndone according to aesthetic units. The wound was closed using an\nintracutaneous suture technique. A continuous overhand blocked suture\nwas used with 3-0 Vicryl. The patient was advised that the visible\nsuture material could be removed between postoperative days 14 and 16. A\ndressing was applied, followed by a pressure dressing to minimize\nswelling and promote healing. Comments: The patient tolerated the\nprocedure well and was provided postoperative care instructions.\n\nPlan: Follow up in clinic for suture removal and wound assessment\nbetween postoperative days 14 and 16.\n\n**Histology Dermatohistology:** **02/23/2018.**\n\n**Gross Examination:** A roughly oval excision specimen measuring 48 x\n36 x 14 mm. The specimen is serially sectioned into lamellar stages A\nthrough H (8 cassettes).\n\n**Microscopic Examination:**\n\nStage A: Displays a benign epidermis and dermis without evidence of\nmelanocytic tumor cells.\n\nStage B: Features an irregularly thickened epidermis. At the center of\nthe section, melanocytic tumor cells are observed at the dermoepidermal\njunction (positive for MelanA stain). Additionally, abundant\nmelanophages and pigment deposits are noted. The lateral safety margin\nmeasures at least 8 mm.\n\nStage C: Resembles stage B. Atypical melanocytic tumor cells are present\nat the dermoepidermal junction. Upper dermis displays fibrosis,\ninflammation, and numerous melanophages (confirmed by positive MelanA\nstaining). The lateral safety margin is at least 6 mm.\n\nStage D: Central region shows melanocytic tumor cells in both the\nepidermis and upper dermis. There is significant inflammation,\nmelanophages, and pigment deposition (confirmed by MelanA staining).\n\nThe maximum lateral safety margin here is approximately 8 mm. A small\nlymph node in the subcutaneous fat tissue is also seen, infiltrated by\nmelanocytic tumor cells.\n\nThe tumor shows stages E, F, G and H: Exophytic, bovist-like growing\nulcerated hemorrhagic tumor consisting of completely pleomorphic tumor\ncells. These cells vary in morphology, appearing both nested and\nspindle-shaped, with clear cytoplasm and conspicuous nucleoli. Notable\npigment production is observed, as are numerous atypical mitoses.\nControl staining in stage F with MelanA is completely positive. The\nsections are entirely excised.\n\n**Diagnosis:** Exophytic, ulcerated malignant melanoma with a tumor\nthickness of at least 15 mm. The tumor invasion is categorized as stage\nIII.\n\n**Medication upon discharge: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ----------------------------------------- --------------- -------------- ------------------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Oral Once daily in the morning\n Enoxaparin (Lovenox) 0.2 mL Subcutaneous In the evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Oral Morning and evening\n Leuprorelin (Lupron Depot) 3.75 mg Depot Subcutaneous Every 4 weeks\n Fentanyl Transdermal System (Duragesic) 12 μg/hr Transdermal Changed every 3 days\n Pantoprazole (Protonix) 40 mg Oral Once daily in the morning\n Sevelamer (Renagel) 800 mg Oral Once daily in the morning\n Multivitamin One tablet Oral Once daily in the morning\n Torsemide (Demadex) 200 mg Oral Once daily in the morning\n Cholecalciferol (Dekristol) 20,000 IU Oral Once weekly\n Sodium Bicarbonate (Bicanorm) One tablet Oral Once daily in the morning\n Calcitriol (Rocaltrol) 0.25 μg Oral Once daily in the morning\n Valacyclovir (Valtrex) 500 mg Oral Half-tablet daily in the morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Oral Mornings on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Oral In the morning on day 1 and day 2 following daratumumab administration\n\n\n\n### text_1\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 10/23/2020 to\n11/01/2020.\n\n- Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\n according to UICC.\n\n- Therapies to date:\n\n- Resection of primary tumor (malignant melanoma) on the left upper\n back (02/2018)\n\n- 01/20 Microsurgical resection right frontal tumor\n\n- 02/20 Excision of empyema\n\n- 02-03/20: Radiation therapy\n\n- 05/02/20: Start of immunotherapy with Nivolumab & 05/26/20: Start of\n combination immunotherapy 60 mg nivolumab, 200 mg ipilimumab (-\\>\n drug exanthema)\n\n**Physical examination findings: **\n\nOn admission, the patient was awake and adequately oriented. Height:\n166cm, weight: 56kg. Nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement regular. Pupils equal, pupillary\nreflex responsive to accommodation and light. Regular, normocardial\nheart rate on admission. Heart and lung: auscultatory and percutaneous\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall Liver\nand spleen are not enlarged, no tenderness, no rebound palpable.\nResistences palpable, loud bowel sounds. No enlarged No enlarged\ncervical, submandibular, supra- and infraclavicular lymph nodes\npalpable. **Skin findings:** Pronounced xerosis cutis, raised skin\nfolds, some with erythema and fine lamellar scale and fine lamellar\nscale, especially on the arms and face. **Microbiology:** Nasal swab:\nnormal flora, no MRSA. Throat swab: Normal flora, no MRSA Virology:\n10/23/2020: No detection of SARS-CoV-2 by PCR in the submitted material.\n\n**Therapy and Progression:**\n\n**Summary:** The patient presented with exsiccation eczema on the arms,\nlegs, and face.\n\n**Treatment Details:** Topical Treatment for Eczema: Applied Desonide\nCream once daily to the affected areas. For maintenance, applied Eucerin\nCream daily to the body and a moisturizing ointment like Cetaphil to the\nface.\n\n**Antipruritic Treatment:** Prescribed Benadryl tablets, to be taken as\nneeded.\n\n**Oncology Consultation:** The patient was educated by our oncologist,\nDr. Ex, regarding adjuvant therapy options. The potential benefits and\nrisks of a combination immunotherapy with Nivolumab and Ipilimumab were\ndiscussed. The patient had already started Nivolumab 200 mg therapy on\n05/26/2020.\n\n**Incident on 10/28/2020**: The patient had an unattended fall,\nresulting in a hematoma on the left forehead. An emergency CT scan\nshowed no new fractures or acute hemorrhage but confirmed the presence\nof previously known cystic metastasis.\n\n**Operation report (01/02/2020): **\n\n**Diagnosis:** Hemorrhaged right frontal metastasis from previously\ndiagnosed malignant melanoma (ID 2018)\n\n**Procedure:** Microsurgical resection of right frontal mass with\nintraoperative neuromonitoring (MEPs stable) and neuronavigation via a\nleft frontolateral craniotomy.\n\nTime: 10:34 am Closure Time: 1:04 pm. Total Duration: 2 hours 30 minutes\n\n**Preoperative Evaluation:** Imaging identified a hemorrhage in the\nright frontal lobe. Given the patient\\'s history of malignant melanoma,\na hemorrhagic melanoma metastasis was suspected. No other intracranial\nmetastases were detected. The patient and their family were informed of\nthe surgical benefits and risks. After ample time for consideration and\nquestions, written informed consent was obtained.\n\n**Procedure Details:** The patient was positioned supine and intubated.\nThe head was secured in a Mayfield clamp and rotated 60° to the right.\nThe navigation dataset was reviewed. Using the navigation system, a left\nfrontotemporal craniotomy was planned. An arcuate incision line was\ndrawn. The surgical area was shaved, cleaned, and sterilized.\nProphylactic antibiotics and mannitol were administered. A time-out was\nconducted preoperatively. The skin was incised, and Raney clips were\ninserted. The left temporal muscle was split. Using the navigation\nsystem for guidance, a left frontolateral craniotomy was performed. The\nbone flap was carefully removed and preserved in an antibiotic solution\nfor later reimplantation. The dura mater was opened, and the operating\nmicroscope was introduced. Upon inspection, the tumor was evident.\n\n**MRI brain report (01/04/2020): **\n\n**Clinical Information:** Postoperative assessment following\nmicrosurgical resection of a left frontal hemorrhaged metastasis from\npreviously diagnosed malignant melanoma.\n\n**Technique:** Multiplanar, multisequence MRI of the brain, including\nT1-weighted, T2-weighted, FLAIR, diffusion-weighted imaging (DWI), and\npost-contrast T1-weighted sequences.\n\n**Findings:** There is evidence of a right frontotemporal craniotomy\nwith associated post-surgical changes in the right frontal region.\nTitanium plates and screws are noted securing the bone flap, causing\nminimal artifact. The previous tumor site in the right frontal lobe\nshows post-surgical changes with a well-circumscribed cavity. There is\nno evidence of residual enhancing tumor within this cavity on\npost-contrast sequences, suggesting complete resection. Surrounding this\ncavity, there\\'s mild edema, consistent with expected post-operative\nchanges. No other intracranial metastases. The ventricles are of normal\nsize and symmetric. There is no evidence of hydrocephalus. No midline\nshift or mass effect is observed. There are scattered foci of\nsusceptibility artifact in the surgical bed on gradient echo sequences,\nconsistent with expected postoperative blood products. Major\nintracranial vessels appear patent with no evidence of vascular\nocclusion or significant stenosis. The remaining brain parenchyma\nappears normal in signal intensity and morphology on all sequences. No\nother significant abnormalities are identified.\n\n**Impression:** Post-surgical changes in the left frontal lobe\nconsistent with recent tumor resection. There is no evidence of residual\ntumor in the surgical bed. Expected postoperative edema and blood\nproducts adjacent to the resection site. No new metastatic foci\nidentified. No evidence of complications such as hydrocephalus, midline\nshift, or vascular abnormalities.\n\n**Operation report (02/04/2020): **\n\n**Diagnosis:** Subfascial, epidural, and subdural empyema following\nresection of right frontal metastasis for malignant melanoma.\n\n**Procedure:** Empyema removal (subfascial, epidural, subdural) S\nIncision Time: 15:23 Closure Time: 04:01 PM Total Duration: 2 hours 31\nminutes\n\n**Preoperative Evaluation:** The patient had a prior surgical resection\nof a right frontal metastasis due to known malignant melanoma. On a\nrecent outpatient visit, a cerebrospinal fluid (CSF) cushion was\nidentified and punctured, revealing the presence of pathogens. Imaging\nindicated deep and subcutaneous abscesses, necessitating revision\nsurgery. The patient was adequately informed about the procedure,\nunderstood the associated risks, and provided written consent.\n\n**Procedure Details:** The patient was positioned supine with the head\nrotated approximately 60° in a Mayfield clamp. The surgical area was\nwashed and sterilized, focusing on the pre-existing access point. A team\ntime-out was conducted. Perioperative antibiotics were withheld until\nall samples for microbiology were obtained. The skin was incised,\nrevealing multiple layers of muscle. These were carefully dissected,\nleading to the identification and evacuation of the subcutaneous\nepifascial abscess. Infected muscle tissue and abscess walls were\nresected. The skull flap appeared loosened. A miniplate was removed, and\nupon further inspection, the dura mater appeared strained. It was\nincised and revealed turbid fluid, indicating a deep abscess. The dura\nmater was mobilized, though adherence to the cortex was observed around\nthe resection cavity, suggesting possible tumor regrowth. Affected areas\nwere carefully resected. After thorough irrigation, a drainage system\nwas inserted into the resection cavity. A duraplasty was performed,\nfollowed by the reimplantation of the bone flap using a miniplate. The\npatient was also included in a bone flap study and was randomized for\nflap reimplantation. After further irrigation, the wound was\nmeticulously closed, and a subfascial drain was inserted. The final\nclosure was completed with single button sutures. Under the guidance of\nthe operating microscope, the tumor was meticulously dissected from the\nsurrounding healthy tissue. Special care was taken to minimize damage to\nthe surrounding brain structures. The intraoperative neuromonitoring\nindicated stable MEPs throughout, suggesting that motor pathways\nremained undisturbed during the procedure. Throughout the resection,\nperiodic hemostasis was achieved using bipolar electrocautery to control\nbleeding. Following the complete resection of the tumor, the surgical\ncavity was irrigated with sterile saline to remove any residual debris.\nThe integrity of the surrounding brain tissue was assessed, and no\nimmediate complications were observed. The dura mater was sutured,\nensuring a watertight closure. A synthetic dural graft was used to\nreinforce the suture line. The preserved bone flap was reimplanted and\nsecured in place using titanium plates and screws. The temporal muscle\nand soft tissues were reapproximated and sutured in layers. The skin was\nclosed using a combination of absorbable sutures for the subcutaneous\nlayer and non-absorbable sutures for the skin. Sterile dressings were\napplied to the incision site. Postoperative Assessment: The procedure\nwas completed without complications. Immediate postoperative\nneurological examination revealed no new deficits. The patient was\ntransferred to the recovery room in stable condition, awaiting\nextubation by the anesthesiology team.\n\n**Recommendations:** Close monitoring in the neurological intensive care\nunit (NICU) is advised for the first 24 hours. Postoperative imaging,\ntypically an MRI, should be scheduled within the next 48 hours to assess\nthe extent of tumor resection and to rule out any postoperative\ncomplications.\n\n**Summary:** Mrs. Done\\'s recent hospital course was complicated by the\ndetection and subsequent excision of a hemorrhagic metastasis from a\nknown history of malignant melanoma. She continues to be on targeted\ntherapy with close monitoring. No new metastasis or recurrence has been\ndetected as of the last evaluation. The interdisciplinary approach\ninvolving the neurosurgery and oncology teams has been pivotal in her\nmanagement. Given the aggressive nature of melanoma, regular\nsurveillance and immediate action upon detection of new\nlesions/metastasis are paramount for her prognosis.\n\n**02-03/20: Radiation therapy **\n\nDiagnosis: Metastatic malignant melanoma with a focus on the right\nfrontal metastasis. Technique: Stereotactic radiosurgery (SRS) using a\nlinear accelerator (LINAC). Fractionation: Given the aggressive nature\nof malignant melanoma, a hypofractionated regimen was adopted. The\npatient underwent five sessions, each delivering a dose of 6 Gy for a\ncumulative total dose of 30 Gy.\n\nTreatment Planning: A simulation CT scan with a 1mm slice thickness was\nperformed in the treatment position, with a thermoplastic mask for\nimmobilization. The treatment planning system utilized the simulation\nCT, along with MRI for better tumor delineation. The target volume and\ncritical structures like the eyes, optic nerves, chiasm, and brainstem\nwere contoured. The radiation plan was optimized to ensure maximal dose\nto the target while sparing the critical structures.\n\nProcedure: At each session, patient positioning was verified using\ncone-beam CT (CBCT) to ensure precise targeting. Real-time monitoring\nwas employed to account for any intrafraction motion.\n\nSide Effects: The patient tolerated the treatment well. She reported\ntransient fatigue and mild scalp irritation, which resolved with\nconservative measures. No acute radiation-induced neurotoxicity was\nobserved.\n\n**Patient History Update: Mrs. Jane Done (DOB: 01/01/1966)**\n\n**General Status (10/03/2020):**\n\nMrs. Done presented in stable condition with stable vital signs.\nNeurologically, she\\'s intact with no new focal deficits. The surgical\nscars in the frontal region from previous operations are not fully\nhealed and there is some dehiscence and swelling, indicative of\ninfection. This wound complication can be traced back to her previous\nhistory of an empyema which required surgical intervention.\n\n**Dermatological Assessment:**\n\nThe previous exsiccation eczema, prominent on her arms, legs, and face,\nhas improved markedly. The treatment regimen involving consistent\nmoisturization and targeted topical therapies seems effective.\nImportantly, there were no new suspicious skin lesions or nodules noted\nduring her most recent full-body skin check.\n\n**Oncology Status:**\n\nMrs. Done remains on her immunotherapy regimen, specifically the\ncombination of Nivolumab and Ipilimumab. Her response has been positive,\nwith no new metastatic sites identified in the latest assessments. She\nhas displayed commendable compliance with this regimen and regular\nfollow-up evaluations.\n\n**Recent MRI Brain (09/30/2020):**\n\nHer latest multiplanar, multisequence MRI revealed post-surgical\nalterations in the right frontal lobe, consistent with previous\nobservations. Encouragingly, there was no sign of any residual or\nrecurrent tumor activity. Moreover, the MRI did not show any new\nintracranial metastatic sites or other significant abnormalities.\n\n**Thoracic CT Scan (10/01/2020): **\n\nTechnique: Post complication-free bolus i.v. administration of Imeron\n400, a multiline spiral CT was performed through the thorax during the\nvenous contrast phase, supplemented with thin-section, coronary, and\nsagittal secondary reconstructions.\n\nFindings: Multiple roundish subsolid nodules found bipulmonary, notably\na 4mm nodule in the right upper lobe. Blurred subpleural condensations\nin the left upper lobe. Another blurred bronchus-associated\nconsolidation was observed in the left upper lobe and pleurally in the\nleft dorsal lower lobe. No evidence of pathologically enlarged lymph\nnodes in the hilar, mediastinal, or axillary regions. Unchanged\npresentation of the left adrenal gland from the preliminary examination.\nThickened imprinting of the gastric wall noted. Ventrally emphasized\nspondylophytic attachments observed in the thoracic spine. No\nosteodestructive processes detected.\n\n**Impression:** Presence of multiple subsolid pulmonary nodules;\nrecommended follow-up in 4-6 weeks for potential (post-) inflammatory or\nmalignant genesis. No evidence of pathologically enlarged lymph nodes.\n\n**Abdomen/Pelvis CT Scan (10/01/2023): **\n\nTechnique: A low dose CT scan was taken of the abdomen and pelvis.\n\n**Findings:** Regular visualization of the acquired basal lung sections.\nOrthotopic kidneys without urinary stasis. No evidence of urinary\ncalculi. Suspected uterine fibroids attached to the uterus wall.\nEnlarged right ovary with minor calcifications. Assessment: Absence of\nurinary calculi. Possible uterine fibroids and an enlarged right ovary,\nsuggesting a specialized gynecological examination.\n\n**PICC Line Installation (10/02/2020)**\n\n**Diagnosis:**\n\nHome antibiotics required for wound healing disorder following discharge\ndue to an empyema.\n\n**Type of Surgery:**\n\nInstallation of a PICC line in the left basilic vein.\n\n**Anesthesia:**\n\nLocal anesthesia\n\n**Procedure Details:**\n\nThe patient was presented for long-term antibiotic treatment due to a\nwound healing disturbance post the discharge of an epidural abscess. The\nprimary aim was to apply a PICC-line catheter for the antibiotic\nregimen. A written informed consent was duly obtained prior to the\nprocedure.\n\nThe standard procedure began with the washing off and draping of the\npatient. A preoperative sonography of the arm veins was conducted. Based\non the sonographic results, it was decided to insert the catheter via\nthe left basilica vein.\n\nUnder venous congestion and following local anesthesia with 2mL Mecain,\na 2mm skin incision was made. The sonographically guided puncture was\nperformed successfully. Post this, the peel-away sheath was inserted.\nWith the wire in place, the catheter was advanced with its tip\npositioned approximately 2cm below the carina. The wire was subsequently\nremoved. Following this, the catheter was aspirated and flushed with\nNaCl to ensure its patency. A sterile fixation was then applied, and the\nwound was dressed.\n\n**Notes:**\n\nNo complications were observed during the procedure. The patient was\nadvised on the care and maintenance of the PICC line. Regular follow-ups\nare recommended to monitor the wound healing and the effectiveness of\nthe antibiotic treatment.\n\nThe patient was discharged with instructions and is scheduled for a\nfollow-up in two weeks.\n\n**Additional Therapeutic Engagements:**\n\nFor her overall well-being and to counter the side effects of her\ntreatment journey, Mrs. Done has been actively involved in physical\ntherapy sessions. These sessions focus on enhancing her strength and\nbalance, especially given the previous incident of an unattended fall.\nTo address the inevitable psychological strains of her diagnosis, she\nhas also been attending counseling sessions.\n\n**Current Recommendations:**\n\n-Continue the ongoing immunotherapy without changes.\n\n-Dermatological check-ups every month are advised for early detection of\nany potential skin abnormalities.\n\n-Regular neurological evaluations are crucial to ensure no emergence of\nnew deficits.\n\n-Imaging should be scheduled every six months for proactive monitoring.\n\n-Her physical therapy regimen should be ongoing to maintain and improve\nmobility.\n\n-Continue counseling to support her emotional and psychological\nwell-being.\n\n**Summary and Notes:**\n\nMrs. Done\\'s resilience and adherence to her treatments are commendable.\nHer progress is a testament to the integrated care approach she has been\nreceiving. Maintaining a proactive surveillance stance will be essential\nfor her long-term prognosis and quality of life.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe wish to provide an update regarding our mutual patient, Mrs. Jane\nDone, born on 01.01.1966. She was admitted to our clinic from 11/23/2020\nto 12/01/2020.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done presented for a follow-up visit on 11/23/2020. Over the past\nfew months, she reported fatigue and intermittent bouts of nausea. Of\nsignificant concern were newly identified skin changes located on her\nright arm.\n\n**Clinical Findings:**\n\nSkin: Multiple macules and patches on the right arm, the largest\nmeasuring about 1.5cm in diameter, hyperpigmented with irregular\nborders.\n\n**US: **\n\nUltrasound imaging of the right arm revealed no deep extension or\ninvasion of underlying structures. This preliminary assessment was\ncrucial, suggesting that if malignancy is present, it might be in early\nstages.\n\n**Histology: **\n\nHistological examination: Gross Description: The sample consists of\nmultiple tan-pink soft tissue fragments, aggregating to 1.8 cm in the\ngreatest dimension.\n\nMicroscopic description: Sections show a proliferation of atypical\nmelanocytes arranged in nests and as single units at the dermoepidermal\njunction. Some of these cells infiltrate the papillary dermis.\n\nImmunohistochemistry: The atypical cells are positive for HMB-45 and\nS-100. Melan A is focally positive. Ki-67 proliferation index is about\n10%.\n\nFinal Diagnosis: Dysplastic nevus with severe atypia; margins appear\nclear. Further excision is recommended to ensure complete removal and to\nrule out invasive melanoma.\n\n**Lab results: **\n\nComplete Blood Count (CBC):\n\nHemoglobin: 12.3 g/dL (Normal range: 12-16 g/dL)\n\nWhite Blood Cell Count: 6,200 cells/µL (Normal range: 4,000-11,000\ncells/µL)\n\nPlatelet Count: 290,000 cells/µL (Normal range: 150,000-450,000\ncells/µL)\n\nDifferential:\n\nNeutrophils 65%, Lymphocytes 25%, Monocytes 8%, Eosinophils 2%. B.\n\nLiver Function Tests (LFTs):\n\nALT (Alanine Aminotransferase): 40 U/L (Normal range: 7-56 U/L)\n\nAST (Aspartate Aminotransferase): 38 U/L (Normal range: 10-40 U/L)\n\nALP (Alkaline Phosphatase): 90 U/L (Normal range: 44-147 U/L)\n\nTotal Bilirubin: 1.0 mg/dL (Normal range: 0.1-1.2 mg/dL)\n\nAlbumin: 4.2 g/dL (Normal range: 3.4-5.4 g/dL)\n\nAssessment/Recommendations:\n\nGiven her history and the suspicious nature of the new skin changes, we\nhave decided to send the biopsy for urgent histological assessment.\n\nFurthermore, considering her reported symptoms, we have conducted a\nthorough internal check-up, including blood tests and liver function\ntests, to rule out any systemic side effects of the immunotherapy.\n\nWe recommend continuous monitoring of Mrs. Done's condition and kindly\nrequest your valuable input in managing her case optimally. A\nmultidisciplinary approach, given her complicated medical history, will\nbe most beneficial for the patient.\n\nPlease find attached the detailed examination and investigative reports\nfor your reference.\n\nWith kind regards,\n\n\n\n### text_3\n**Dear colleague, **\n\nWe wish to provide a comprehensive update regarding our mutual patient,\nMrs. Jane Done, born on 01.01.1966. She has had a history of various\nmedical conditions and treatments, which we believe is essential to\ndiscuss for her optimal management and was admitted to our clinical from\n01/01/2021 to 01/28/2021.\n\n**Previous Diagnoses and Therapies:**\n\nMetastatic malignant melanoma (presumed ID 2018); M1, stage IV according\nto UICC. Resection of primary tumor (malignant melanoma) on the left\nupper back (02/2018)\n\n01/20 Microsurgical resection right frontal tumor\n\n02/20 Excision of empyema\n\n02-03/20: Radiation therapy\n\n05/02/20: Start of immunotherapy with Nivolumab\n\n05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\nImaging 01/02/2021: PET/CT: Cervical lymph node metastasis;\n\ncMRI: no evidence of metastases. Contrast-enhancing meninges.\n\n**Virology: **\n\nUpon Admission: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load\nof 7,000 Geq/mL and a Ct value of 32.\n\nAt Discharge: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load of\n2,350 Geq/mL and a Ct value of 32.\n\n**Microbiology: **\n\nMRSA Screening Upon Admission: Nasal Swab: Normal flora detected; MRSA\nnot present. Throat Swab: Normal flora detected; MRSA not present.\n\nProcedures:\n\n\\- Presentation to neurology for CSF puncture (e.g., exclude\nmeningeosis)\n\n\\- Panel sequencing complement\n\n\\- Surgery/therapy: Neck dissection followed by adjuvant therapy with\npembrolizumab.\n\nClinical examination:\n\nExamination findings: Patient in normal general and nutritional\ncondition, consciousness unremarkable. Cranial mobility free, ocular\nmobility normal. Pupils are isocor, pupillary reflex prompt to\naccommodation and light. Regular, normocardial heart rate on admission.\nNo typical heart murmurs. Abdomen: abdominal wall soft, liver and spleen\nnot enlarged, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged in the axillary or inguinal region palpable.\n\nPET-CT from 01/02/2021:\n\nIntense metabolically active lymph node metastases, otherwise no\nevidence of vital tumor tissue in the study area.\n\n**PET CT report from 01/02/2021: **\n\nProcedure: PET/CT with 246 MBq (F-18)-fluorodeoxyglucose and a 60-minute\nuptake period.\n\nFindings: CT Findings: Neck: Right Level II: Three lymph nodes, largest\nmeasuring 2.1 x 1.8 cm with central necrosis. Right Level III: Two lymph\nnodes, largest measuring 1.5 x 1.2 cm. Left Level II: One lymph node\nmeasuring 1.3 x 1.1 cm. Left Level IV: Two lymph nodes, largest\nmeasuring 1.7 x 1.4 cm. Retropharyngeal space: One lymph node measuring\n1.0 x 0.9 cm.\n\nPET Findings: Neck: Right Level II: Increased FDG uptake with SUVmax of\n7.8, consistent with metastatic disease. Right Level III: Increased FDG\nuptake with SUVmax of 6.5. Left Level II: Increased FDG uptake with\nSUVmax of 6.0. Left Level IV: Increased FDG uptake with SUVmax of 7.2.\nRetropharyngeal space: Increased FDG uptake with SUVmax of 6.1.\nImpression: Cervical Lymph Nodes: Multiple pathologically enlarged\ncervical lymph nodes in bilateral level II, right level III, left level\nIV, and retropharyngeal space with increased FDG uptake, highly\nsuggestive of metastatic involvement from the known primary melanoma.\n\n**Surgery report 01/05/2021: **\n\nThe surgery commenced with a collaborative discussion with the\nanesthesia team and a standard team time-out was executed. The patient\nwas properly positioned, and the surgical site was aseptically draped.\nThe facial neuromonitoring system was set up and verified. Local\nanesthesia was then administered at the site of the skin incision, which\nwas located near the previous scar. This incision followed the anterior\nborder of the sternocleidomastoid muscle in a curved pattern. Upon\nincising the subcutaneous tissue, the external jugular vein became\nvisible and was selectively ligated. The encountered tissue appeared\nnotably fibrotic and scarred. A skin incision extended from the mastoid\nregion down nearly to the clavicle. The platysma muscle was subsequently\ncut. Due to the presence of a lymph node mass, the auricularis magnus\nnerve had to be severed. The sternocleidomastoid muscle and the\nposterior belly of the digastric muscle were then exposed. Multiple\ndarkened lymph node metastases were identified, both beneath the skin\nand within the sternocleidomastoid muscle. In subsequent steps, efforts\nwere made to distinguish the internal jugular vein from the surrounding\nscarred tissue. A lymph node mass, which exhibited characteristics\nhighly suggestive of metastasis (given its darkened color), was removed.\nThe accessory nerve was identified and preserved. Further dissection was\ndone posteriorly to the sternocleidomastoid muscle, in the direction of\nlevel V. An expansive mass of lymph nodes was excised in this region.\nThe trapezoid branch of the accessory nerve was visualized, and its\nfunction was monitored and preserved with the aid of neuromonitoring.\nThe removed lymph node mass, some excised tissue, and portions of the\nsternocleidomastoid muscle with embedded lymph nodes were sent for\nhistological analysis. During the procedure, care was taken to avoid\ndamaging major neck vessels and nerves. Concluding the procedure, 8 and\n10 French Redon drains were placed, the wound was closed in layers, and\nthen covered with a spray-on bandage, steristrips, and a pressure\ndressing. The surgical site appeared bloodless at the conclusion of the\nsurgery.\n\n**Macroscopy:**\n\n**Macroscopic Description:**\n\nDimensions: 6.8 x 0.7 x 0.4 cm spindle-shaped, non-oriented skin and\nsubcutaneous tissue resection. Central area shows an irritation-free,\nfine scar measuring up to 6.3 x 4.8 cm. The cut surface appears\nconsistently off-white.\n\nInk markings: soft tissue margin of specimen = green. A: central\nlamellae B: spindle tips perpendicular\n\nAnterior Margin of Upper Third of Sternocleidomastoid Muscle:\nDimensions: Four combined tissue samples totaling 4.7 x 3.8 x 1.1 cm.\n\nAppearance: Tan, fibrous soft tissues with multiple uniformly dark\nnodules on the cut surface, each measuring up to 1.1 cm.\n\nA, B: one nodule each halved C, D: other nodular sections E: remaining\ntan fibrous sections Anterior Margin of Lower Third of\nSternocleidomastoid Muscle: Largest measurement: 3.4 cm.\n\nAppearance: Grayish-brown with some fibrous regions and homogeneously\ndark-brown nodes up to 1.5 cm in size on the cut surface. A, B: one node\neach halved C: other nodes D: brown-fibrous sections Region V Occipital:\nLargest measurement: Two samples, each up to 3.8 cm.\n\nAppearance: Mixture of grayish-tan and light brown fibrous soft tissue\nwith nodes up to 2.2 cm, uniformly dark brown.\n\nA, B: one node halved C, D: another node halved each Processing: 16\nparaffin blocks, HE stained.\n\nMicroscopic Description: Dermis and subcutaneous resection shows\nscarring with fibrosis. Epidermis is regular, without any atypical\ncells. No evidence of melanoma or carcinoma. 2./3.\n\nMultiple nodular tumor clusters present in the soft tissue and skeletal\nmuscles, lacking lymph node structure. Tumor cells are polygonal, with\nsome spindle-shaped cells having moderately large, irregular nuclei and\nnoticeable nucleoli. Cytoplasm appears slightly granular with a light\nbrownish pigment.\n\nSeven lymph nodes (measuring up to 3.6 cm) indicate metastasis from the\npreviously mentioned tumor, with extracapsular spread. Four other lymph\nnodes are free from the tumor.\n\n**Critical Findings:** Multiple nodular soft tissue metastases, with the\nlargest measuring 1.3 cm, indicative of melanoma present in both soft\ntissue and muscle. Resection margins are mostly free of tumor, with the\nclosest approach being less than 0.15 cm (points 2 and 3). Seven lymph\nnodes (up to 3.6 cm in size) show metastasis from the melanoma, with\nextracapsular spread. Four lymph nodes are tumor-free (7 out of 11\nnodes, ECE positive) (point 4). Dermis and subcutaneous excision shows\nscarring fibrosis (point 1).\n\nFor the optimal management of Mrs. Done, close monitoring and a\nmultidisciplinary approach will be essential. Thank you for your\ncontinued collaboration in ensuring the best care for our mutual\npatient.\n\n**Lab values upon discharge: **\n\n **Parameter** **Result** **Reference Range** **Interpretation**\n -------------------------------- -------------- ---------------------------------------- ---------------------\n **Complete Blood Count (CBC)** \n Hemoglobin (Hb) 12.4 g/dL 12.0 - 16.0 g/dL Within normal range\n White Blood Cell (WBC) 9.2 x10\\^9/L 4.0 - 10.0 x10\\^9/L Within normal range\n Platelets 250 x10\\^9/L 150 - 400 x10\\^9/L Within normal range\n **Liver Function Tests (LFT)** \n AST 28 U/L 10 - 35 U/L Within normal range\n ALT 32 U/L 10 - 40 U/L Within normal range\n Total Bilirubin 0.8 mg/dL 0.2 - 1.2 mg/dL Within normal range\n **Kidney Function Test** \n Serum Creatinine 0.9 mg/dL 0.5 - 1.2 mg/dL Within normal range\n Blood Urea Nitrogen (BUN) 15 mg/dL 7 - 20 mg/dL Within normal range\n **Electrolytes** \n Sodium 138 mEq/L 135 - 145 mEq/L Within normal range\n Potassium 4.2 mEq/L 3.5 - 5.0 mEq/L Within normal range\n Chloride 101 mEq/L 95 - 105 mEq/L Within normal range\n **Thyroid Function Tests** \n TSH 3.1 mU/L 0.5 - 5.0 mU/L Within normal range\n Free T4 1.4 ng/dL 0.9 - 2.4 ng/dL Within normal range\n **Lipid Profile** \n Total Cholesterol 190 mg/dL \\< 200 mg/dL Desirable\n LDL Cholesterol 100 mg/dL \\< 100 mg/dL Optimal\n HDL Cholesterol 55 mg/dL \\> 40 mg/dL (Men), \\> 50 mg/dL (Women) Normal\n Triglycerides 110 mg/dL \\< 150 mg/dL Normal\n\n**Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ---------------- ------------ ----------- -----------------------------\n Pembrolizumab 200mg IV Every 3 weeks\n Nivolumab 60mg IV As per oncologist\\'s advice\n Ipilimumab 200mg IV As per oncologist\\'s advice\n Paracetamol 500mg Oral Every 4-6 hours as needed\n Omeprazole 20mg Oral Once daily\n\n\n\n### text_4\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/14/2022 to\n03/01/2022.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done showed multiple metastases in her CT examination. On physical\nexamination, Mrs. Done appears well-nourished and in no acute distress.\nHer vital signs are stable. Cardiovascular examination reveals regular\nheart sounds with no murmurs. Respiratory examination shows clear breath\nsounds bilaterally. Abdominal examination reveals no palpable masses or\norganomegaly. Neurological examination is within normal limits.\n\n**Radiology/Nuclear Medicine**\n\n**CT thorax/abdomen/pelvis + Contrast from 02/10/2022**\n\n**Technique:** Multi-phase, multi-slice computed tomography of the\nthorax, abdomen, and pelvis was performed following the intravenous\nadministration of contrast material. Coronal and sagittal\nreconstructions were obtained.\n\n**Thorax:** In the thoracic region, the lungs are notable for multiple\nnodular opacities across both lung fields, consistent with metastatic\ndeposits. The most sizable lesion is seen in the right upper lobe,\napproximately 1.5 cm in diameter. No associated cavitation or pleural\neffusion is detected. A concerning 2 cm mass abutting the lateral wall\nof the left ventricle is noted, raising the suspicion for cardiac\nmetastasis. The mediastinum also exhibits lymphadenopathy with a\ndominant node in the prevascular space, measuring 2.2 cm. Further, there\nare lytic lesions involving the sternum and right 4th rib, consistent\nwith osseous metastatic disease.\n\n**Abdomen/pelvis**: Liver shows multiple hypodense lesions throughout\nboth lobes, indicative of metastatic spread. The dominant lesion in the\nright lobe measures 3 cm. The kidneys, however, are unremarkable without\ndiscernible metastatic deposits. Retroperitoneal lymphadenopathy is also\npresent, highlighted by a node anterior to the aorta of 1.8 cm. In\naddition, there is a 2.5 cm mass identified within the left psoas\nmuscle, consistent with muscular metastasis. Both the left acetabulum\nand the right iliac wing manifest with lytic lesions, suggestive of\nmetastatic involvement. There is also enlargement of the bilateral\ninternal iliac lymph nodes, with the left side\\'s node measuring up to\n1.6 cm. Bladder, prostate, and rectum with no discernible pathology.\n\n**Impression**: Multiple pulmonary nodules consistent with pulmonary\nmetastases. Cardiac lesion suggestive of metastatic involvement.\nEvidence of skeletal metastases in the thorax and pelvis. Hepatic and\nmuscular metastases, indicative of disseminated disease. Lymphadenopathy\nin the mediastinal, retroperitoneal, and pelvic regions.\n\n**PET-CT scan from 02/11/2022**\n\n**Clinical Indication:** Follow-up evaluation of a known case of\nMetastatic Melanoma, Stage IV, M1c with notable findings from a CT scan\ndated 12/01/2014.\n\n**Technique:** Whole-body PET-CT scan was conducted after intravenous\nadministration of 18F-FDG. The patient fasted for 6 hours prior to the\nscan, and blood glucose levels were confirmed to be within the\nacceptable range. Both CT and PET images were acquired, and images were\nco-registered for optimal evaluation. Standard uptake values (SUVs) were\ncalculated for areas of interest.\n\n**Findings: **\n\n**Thorax:** Both lungs depict several hypermetabolic foci, corroborating\nthe CT findings of multiple nodules. The largest lesion in the right\nupper lobe demonstrates an SUVmax of 8.2, indicative of active metabolic\ndisease. The cardiac mass adjacent to the left ventricle, measuring\napproximately 2 cm, also reveals increased 18F-FDG uptake with an SUVmax\nof 9.5, strengthening the suspicion of cardiac metastasis. Enlarged\nmediastinal lymph nodes, particularly the node in the prevascular space,\nshows marked hypermetabolism with an SUVmax of 7.4. Notably, the lytic\nskeletal lesions identified on the CT in the sternum and right 4th rib\nalso display increased metabolic activity, consistent with metastatic\nbone disease.\n\n**Abdomen/Pelvis:** Hepatic lesions are congruent with the findings of\nthe preceding CT, showing heightened metabolic activity. The most\nprominent lesion in the right lobe exhibits an SUVmax of 8.8.\nRetroperitoneal lymph nodes are metabolically active, with the anterior\naortic node demonstrating an SUVmax of 6.9. The 2.5 cm left psoas muscle\nmass also reveals increased uptake with an SUVmax of 7.3, suggesting\nactive muscular metastasis. In the pelvic region, the lytic lesions\nidentified in the left acetabulum and right iliac wing on the CT confirm\ntheir malignant nature with notable metabolic activity. Bilateral\ninternal iliac lymph nodes show hypermetabolism with the left node\\'s\nSUVmax reaching 7.1. Other pelvic organs, including the bladder,\nprostate, and rectum, did not show any significant 18F-FDG uptake, in\nline with the unremarkable CT findings.\n\n**Impression:** The PET-CT findings are consistent with active\nmetastatic disease. There is evidence of hypermetabolic pulmonary\nnodules, a likely cardiac metastasis, hepatic and muscular metastases,\nand metabolically active skeletal lesions in both the thorax and pelvis.\nAdditionally, there is hypermetabolism in the lymph nodes across\nmultiple regions. These findings align closely with the previously\ndiagnosed metastatic melanoma, Stage IV, M1c**. **\n\n**Discussion**\n\nMrs. Done has been diagnosed with recurrent metastatic melanoma with\nlymph node involvement. This poses significant implications for her\nprognosis, emphasizing the need for urgent and comprehensive\nintervention.\n\nHer molecular profile has revealed the presence of the BRAF V600E\nmutation.\n\nOur recommended therapeutic combination includes Vemurafenib and\nCobimetinib, both of which are aimed at disrupting the aberrant BRAF-MEK\nsignaling cascade. Complementing this, we suggest the administration of\nPembrolizumab.\n\nMrs. Done is scheduled for six cycles of this treatment regimen. We will\nmonitor her laboratory parameters, such as blood counts, electrolytes,\nand hepatic and renal profiles, bi-weekly. It is imperative to note that\nany fevers surpassing 38.3°C warrant immediate medical attention.\n\nComprehensive patient education module has been designed to enable Mrs.\nDone to identify and manage any potential side effects efficiently.\n\nWe will ensure rigorous monitoring of her blood pressure and lipid\nmetrics, with the possibility of introducing alternative medications if\nclinical scenarios demand.\n\nWe deeply value your collaboration in Mrs. Done\\'s healthcare journey.\nOur team remains at your disposal for any queries or clarifications.\n\n\n\n\n\nHere is the query:\nFollowing Mrs. Done's microsurgical resection on 01/02/2020, what did the MRI brain report dated 01/04/2020 primarily indicate about the surgical site?\n\nChoose the correct answer from the following options:\nA. Evidence of residual tumor in the surgical bed\nB. Hydrocephalus and midline shift\nC. Evidence of new metastatic foci\nD. Post-surgical changes with no evidence of residual tumor\nE. Post-surgical abscess formation\n\n\nYour response:\n", "role": "user" }, { "content": "Post-surgical changes with no evidence of residual tumor", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/18/2018 to\n03/01/2018.\n\n**Diagnoses: **\n\n- Malignant melanoma of the left scapula, TD 16 mm, exophytic\n ulcerating, invasion stage - III, R0\n\n- **Mutation analysis:** BRAF status: mutated. PD-L1 status: PD-L1\n tumor proportion score (TPS): \\<1%. Immune cell infiltrate (IC): 2%\n of tumor area. PD-L1 combined-positive score (CPS): 2.\n\n- **History:** Ms. Done was admitted to the hospital with high grade\n suspicion of malignant melanoma of the back. The patient reported a\n skin lesion that had been present for approximately 4 weeks. The\n lesion had grown rapidly during this time and appeared to be oozing\n and bleeding. She presented to our outpatient clinic, where she was\n advised to undergo surgical excision in case of suspected\n malignancy.\n\n- Questions about B-symptoms, AP complaints, stool or urine\n abnormalities were negated.\n\n- System Therapy (Adjuvant Treatment for Stage III Melanoma): 1\n\n02/22/18: 1st dose pembrolizumab 200mg\n\n03/15/18: 2nd dose Pembrolizumab 200mg\n\n04/05/18: 3rd dose Pembrolizumab 200mg\n\n04/26/18: 4th dose Pembrolizumab 200mg\n\n05/17/18: 5th dose Pembrolizumab 200mg\n\n06/07/18: 6th dose Pembrolizumab 200mg\n\n06/28/18: 7th dose Pembrolizumab 200mg\n\n07/19/18: 8th dose Pembrolizumab 200mg\n\n08/09/18: 9th dose Pembrolizumab 200mg i.v.\n\n**Physical examination findings:** 52-year-old female patient in normal\ngeneral condition, nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement normal. Pupils are equal and\nreactive to light and accommodation. Regular, normocardial heart rate\nduring recording. Cor and pulmo auscultatory and percutaneously\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall, liver\nand spleen not enlarged, no pain to palpation, no resistance to\npalpation, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged cervical, submandibular, supra- and infraclavicular, axillary\nand inguinal lymph nodes palpable. inguinal lymph nodes palpable.\nFurther internal and orienting neurological examination neurological\nexamination remained without pathological findings.\n\n**Skin findings:** In the area of the left scapula, a table tennis-ball\nsized area with a slightly fissured, oozing, pink-black pigmented\nsurface. On the cranial side an irregularly black-brown pigmented macula\nof about 3.2x1.2 cm is visible.\n\n**PET/CT with 203 MBq (F-18)-Fluorodeoxyglucose from 02/18/2018: **\n\nWeight: 66 kg, blood glucose: 118 mg/dL. 20 mg furosemide; acquisition\nstart 91 min after tracer injection; 821 mm scan length á () mm/s in\nflow technique (neck to proximal thigh); oral and i.v. contrast (1.5\nmL/kg, i.v., max. 120 mL). Quantitative analysis of\nattenuation-corrected image data using SUV calculation.\n\n**Findings:**\n\nCT: In case of known contrast agent allergy, premedication was performed\nwith one ampoule each of H1 and H2 antihistamine. The contrast-enhanced\nexamination proceeded without complications during the course.\n\nNeck: Symmetrical visualization of the soft tissues of the neck. No\nevidence of pathologically enlarged cervical lymph nodes. Struma nodosa\nwith several hypodense nodes on the right side up to max. approx. 1 cm.\n\nThorax: Cutaneous/subcutaneous irregular-shaped lesion caudal to the\nright scapula. Limited assessability in the lung window with motion\nartifacts and shallow inspiration depth. As far as assessable, no\nevidence of larger suspicious intrapulmonary pulmonary round foci. No\ninfiltrate. No pleural effusion. No evidence of pathologically enlarged\nlymph nodes mediastinal, hilar and axillary bilaterally.\n\nAbdomen/pelvis: Normal contrast of liver parenchyma without evidence of\nsuspicious focal liver lesions. Portal vein and hepatic veins perfused\nregularly. Gallbladder without irritation. Spleen with accessory spleen,\npancreas and adrenal glands bds. regular. Kidneys perfused at the same\nside. No urinary retention. Nephrolithiasis on the right side.\nVisualization of the parenchymatous upper abdominal organs. No evidence\nof pathologically enlarged coeliacal, mesenteric, retroperitoneal,\niliac, and inguinal lymph nodes. Inhomogeneously contrasted enlarged\nprostate. Urinary bladder wall, as far as assessable with low filling\ncircumferentially wall thickened.\n\nSkeleton: no evidence of suspicious osteodestructive lesions. Osteopenia\nwith degenerative skeletal changes.\n\nPET:\n\nIncreased tracer enhancement of the suspicious lesion caudal to left\nscapula, indicative of a melanoma (SUVmax 67). Focal intense tracer\nenhancement in the right thyroid lobe (SUVmax approximately 7.9).\nElongated intense tracer enhancement in the lower abdomen ventrally\nmedian without clear correlate, most consistent with contamination.\nOtherwise, unremarkable activity distribution in the study area.\n\nAssessment:\n\nNo evidence of metabolically active metastases in the study area.\n\n**Operation report from** **02/22/2018**:\n\nProcedure: Excision of malignant melanoma on the left upper back.\n\nPreoperative Diagnosis: Malignant melanoma, left upper back.\n\nPostoperative Diagnosis: Malignant melanoma, left upper back.\n\nAnesthesia: Local anesthesia using 70 mL tumescent solution comprising\n0.21% Lidocaine/Ropivacaine with epinephrine.\n\nProcedure Details: The surgical area was prepped using Betadine. The\narea was draped in a sterile fashion. Excision of the exophytic tumor\nwas performed, measuring 51 x 20 x 15 mm. A safety margin of 10 mm was\nmaintained in depth, with the excision extending slightly into the\nsubcutaneous tissue but not beyond the fascia. This resulted in a total\ndefect size of 75 x 45 mm. The defect could not be closed with a simple\nprimary suture. Perforator vessels were coagulated, and the defect was\nbridged using skin flaps. Additional resection of Burow triangles was\ndone according to aesthetic units. The wound was closed using an\nintracutaneous suture technique. A continuous overhand blocked suture\nwas used with 3-0 Vicryl. The patient was advised that the visible\nsuture material could be removed between postoperative days 14 and 16. A\ndressing was applied, followed by a pressure dressing to minimize\nswelling and promote healing. Comments: The patient tolerated the\nprocedure well and was provided postoperative care instructions.\n\nPlan: Follow up in clinic for suture removal and wound assessment\nbetween postoperative days 14 and 16.\n\n**Histology Dermatohistology:** **02/23/2018.**\n\n**Gross Examination:** A roughly oval excision specimen measuring 48 x\n36 x 14 mm. The specimen is serially sectioned into lamellar stages A\nthrough H (8 cassettes).\n\n**Microscopic Examination:**\n\nStage A: Displays a benign epidermis and dermis without evidence of\nmelanocytic tumor cells.\n\nStage B: Features an irregularly thickened epidermis. At the center of\nthe section, melanocytic tumor cells are observed at the dermoepidermal\njunction (positive for MelanA stain). Additionally, abundant\nmelanophages and pigment deposits are noted. The lateral safety margin\nmeasures at least 8 mm.\n\nStage C: Resembles stage B. Atypical melanocytic tumor cells are present\nat the dermoepidermal junction. Upper dermis displays fibrosis,\ninflammation, and numerous melanophages (confirmed by positive MelanA\nstaining). The lateral safety margin is at least 6 mm.\n\nStage D: Central region shows melanocytic tumor cells in both the\nepidermis and upper dermis. There is significant inflammation,\nmelanophages, and pigment deposition (confirmed by MelanA staining).\n\nThe maximum lateral safety margin here is approximately 8 mm. A small\nlymph node in the subcutaneous fat tissue is also seen, infiltrated by\nmelanocytic tumor cells.\n\nThe tumor shows stages E, F, G and H: Exophytic, bovist-like growing\nulcerated hemorrhagic tumor consisting of completely pleomorphic tumor\ncells. These cells vary in morphology, appearing both nested and\nspindle-shaped, with clear cytoplasm and conspicuous nucleoli. Notable\npigment production is observed, as are numerous atypical mitoses.\nControl staining in stage F with MelanA is completely positive. The\nsections are entirely excised.\n\n**Diagnosis:** Exophytic, ulcerated malignant melanoma with a tumor\nthickness of at least 15 mm. The tumor invasion is categorized as stage\nIII.\n\n**Medication upon discharge: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ----------------------------------------- --------------- -------------- ------------------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Oral Once daily in the morning\n Enoxaparin (Lovenox) 0.2 mL Subcutaneous In the evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Oral Morning and evening\n Leuprorelin (Lupron Depot) 3.75 mg Depot Subcutaneous Every 4 weeks\n Fentanyl Transdermal System (Duragesic) 12 μg/hr Transdermal Changed every 3 days\n Pantoprazole (Protonix) 40 mg Oral Once daily in the morning\n Sevelamer (Renagel) 800 mg Oral Once daily in the morning\n Multivitamin One tablet Oral Once daily in the morning\n Torsemide (Demadex) 200 mg Oral Once daily in the morning\n Cholecalciferol (Dekristol) 20,000 IU Oral Once weekly\n Sodium Bicarbonate (Bicanorm) One tablet Oral Once daily in the morning\n Calcitriol (Rocaltrol) 0.25 μg Oral Once daily in the morning\n Valacyclovir (Valtrex) 500 mg Oral Half-tablet daily in the morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Oral Mornings on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Oral In the morning on day 1 and day 2 following daratumumab administration\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 10/23/2020 to\n11/01/2020.\n\n- Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\n according to UICC.\n\n- Therapies to date:\n\n- Resection of primary tumor (malignant melanoma) on the left upper\n back (02/2018)\n\n- 01/20 Microsurgical resection right frontal tumor\n\n- 02/20 Excision of empyema\n\n- 02-03/20: Radiation therapy\n\n- 05/02/20: Start of immunotherapy with Nivolumab & 05/26/20: Start of\n combination immunotherapy 60 mg nivolumab, 200 mg ipilimumab (-\\>\n drug exanthema)\n\n**Physical examination findings: **\n\nOn admission, the patient was awake and adequately oriented. Height:\n166cm, weight: 56kg. Nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement regular. Pupils equal, pupillary\nreflex responsive to accommodation and light. Regular, normocardial\nheart rate on admission. Heart and lung: auscultatory and percutaneous\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall Liver\nand spleen are not enlarged, no tenderness, no rebound palpable.\nResistences palpable, loud bowel sounds. No enlarged No enlarged\ncervical, submandibular, supra- and infraclavicular lymph nodes\npalpable. **Skin findings:** Pronounced xerosis cutis, raised skin\nfolds, some with erythema and fine lamellar scale and fine lamellar\nscale, especially on the arms and face. **Microbiology:** Nasal swab:\nnormal flora, no MRSA. Throat swab: Normal flora, no MRSA Virology:\n10/23/2020: No detection of SARS-CoV-2 by PCR in the submitted material.\n\n**Therapy and Progression:**\n\n**Summary:** The patient presented with exsiccation eczema on the arms,\nlegs, and face.\n\n**Treatment Details:** Topical Treatment for Eczema: Applied Desonide\nCream once daily to the affected areas. For maintenance, applied Eucerin\nCream daily to the body and a moisturizing ointment like Cetaphil to the\nface.\n\n**Antipruritic Treatment:** Prescribed Benadryl tablets, to be taken as\nneeded.\n\n**Oncology Consultation:** The patient was educated by our oncologist,\nDr. Ex, regarding adjuvant therapy options. The potential benefits and\nrisks of a combination immunotherapy with Nivolumab and Ipilimumab were\ndiscussed. The patient had already started Nivolumab 200 mg therapy on\n05/26/2020.\n\n**Incident on 10/28/2020**: The patient had an unattended fall,\nresulting in a hematoma on the left forehead. An emergency CT scan\nshowed no new fractures or acute hemorrhage but confirmed the presence\nof previously known cystic metastasis.\n\n**Operation report (01/02/2020): **\n\n**Diagnosis:** Hemorrhaged right frontal metastasis from previously\ndiagnosed malignant melanoma (ID 2018)\n\n**Procedure:** Microsurgical resection of right frontal mass with\nintraoperative neuromonitoring (MEPs stable) and neuronavigation via a\nleft frontolateral craniotomy.\n\nTime: 10:34 am Closure Time: 1:04 pm. Total Duration: 2 hours 30 minutes\n\n**Preoperative Evaluation:** Imaging identified a hemorrhage in the\nright frontal lobe. Given the patient\\'s history of malignant melanoma,\na hemorrhagic melanoma metastasis was suspected. No other intracranial\nmetastases were detected. The patient and their family were informed of\nthe surgical benefits and risks. After ample time for consideration and\nquestions, written informed consent was obtained.\n\n**Procedure Details:** The patient was positioned supine and intubated.\nThe head was secured in a Mayfield clamp and rotated 60° to the right.\nThe navigation dataset was reviewed. Using the navigation system, a left\nfrontotemporal craniotomy was planned. An arcuate incision line was\ndrawn. The surgical area was shaved, cleaned, and sterilized.\nProphylactic antibiotics and mannitol were administered. A time-out was\nconducted preoperatively. The skin was incised, and Raney clips were\ninserted. The left temporal muscle was split. Using the navigation\nsystem for guidance, a left frontolateral craniotomy was performed. The\nbone flap was carefully removed and preserved in an antibiotic solution\nfor later reimplantation. The dura mater was opened, and the operating\nmicroscope was introduced. Upon inspection, the tumor was evident.\n\n**MRI brain report (01/04/2020): **\n\n**Clinical Information:** Postoperative assessment following\nmicrosurgical resection of a left frontal hemorrhaged metastasis from\npreviously diagnosed malignant melanoma.\n\n**Technique:** Multiplanar, multisequence MRI of the brain, including\nT1-weighted, T2-weighted, FLAIR, diffusion-weighted imaging (DWI), and\npost-contrast T1-weighted sequences.\n\n**Findings:** There is evidence of a right frontotemporal craniotomy\nwith associated post-surgical changes in the right frontal region.\nTitanium plates and screws are noted securing the bone flap, causing\nminimal artifact. The previous tumor site in the right frontal lobe\nshows post-surgical changes with a well-circumscribed cavity. There is\nno evidence of residual enhancing tumor within this cavity on\npost-contrast sequences, suggesting complete resection. Surrounding this\ncavity, there\\'s mild edema, consistent with expected post-operative\nchanges. No other intracranial metastases. The ventricles are of normal\nsize and symmetric. There is no evidence of hydrocephalus. No midline\nshift or mass effect is observed. There are scattered foci of\nsusceptibility artifact in the surgical bed on gradient echo sequences,\nconsistent with expected postoperative blood products. Major\nintracranial vessels appear patent with no evidence of vascular\nocclusion or significant stenosis. The remaining brain parenchyma\nappears normal in signal intensity and morphology on all sequences. No\nother significant abnormalities are identified.\n\n**Impression:** Post-surgical changes in the left frontal lobe\nconsistent with recent tumor resection. There is no evidence of residual\ntumor in the surgical bed. Expected postoperative edema and blood\nproducts adjacent to the resection site. No new metastatic foci\nidentified. No evidence of complications such as hydrocephalus, midline\nshift, or vascular abnormalities.\n\n**Operation report (02/04/2020): **\n\n**Diagnosis:** Subfascial, epidural, and subdural empyema following\nresection of right frontal metastasis for malignant melanoma.\n\n**Procedure:** Empyema removal (subfascial, epidural, subdural) S\nIncision Time: 15:23 Closure Time: 04:01 PM Total Duration: 2 hours 31\nminutes\n\n**Preoperative Evaluation:** The patient had a prior surgical resection\nof a right frontal metastasis due to known malignant melanoma. On a\nrecent outpatient visit, a cerebrospinal fluid (CSF) cushion was\nidentified and punctured, revealing the presence of pathogens. Imaging\nindicated deep and subcutaneous abscesses, necessitating revision\nsurgery. The patient was adequately informed about the procedure,\nunderstood the associated risks, and provided written consent.\n\n**Procedure Details:** The patient was positioned supine with the head\nrotated approximately 60° in a Mayfield clamp. The surgical area was\nwashed and sterilized, focusing on the pre-existing access point. A team\ntime-out was conducted. Perioperative antibiotics were withheld until\nall samples for microbiology were obtained. The skin was incised,\nrevealing multiple layers of muscle. These were carefully dissected,\nleading to the identification and evacuation of the subcutaneous\nepifascial abscess. Infected muscle tissue and abscess walls were\nresected. The skull flap appeared loosened. A miniplate was removed, and\nupon further inspection, the dura mater appeared strained. It was\nincised and revealed turbid fluid, indicating a deep abscess. The dura\nmater was mobilized, though adherence to the cortex was observed around\nthe resection cavity, suggesting possible tumor regrowth. Affected areas\nwere carefully resected. After thorough irrigation, a drainage system\nwas inserted into the resection cavity. A duraplasty was performed,\nfollowed by the reimplantation of the bone flap using a miniplate. The\npatient was also included in a bone flap study and was randomized for\nflap reimplantation. After further irrigation, the wound was\nmeticulously closed, and a subfascial drain was inserted. The final\nclosure was completed with single button sutures. Under the guidance of\nthe operating microscope, the tumor was meticulously dissected from the\nsurrounding healthy tissue. Special care was taken to minimize damage to\nthe surrounding brain structures. The intraoperative neuromonitoring\nindicated stable MEPs throughout, suggesting that motor pathways\nremained undisturbed during the procedure. Throughout the resection,\nperiodic hemostasis was achieved using bipolar electrocautery to control\nbleeding. Following the complete resection of the tumor, the surgical\ncavity was irrigated with sterile saline to remove any residual debris.\nThe integrity of the surrounding brain tissue was assessed, and no\nimmediate complications were observed. The dura mater was sutured,\nensuring a watertight closure. A synthetic dural graft was used to\nreinforce the suture line. The preserved bone flap was reimplanted and\nsecured in place using titanium plates and screws. The temporal muscle\nand soft tissues were reapproximated and sutured in layers. The skin was\nclosed using a combination of absorbable sutures for the subcutaneous\nlayer and non-absorbable sutures for the skin. Sterile dressings were\napplied to the incision site. Postoperative Assessment: The procedure\nwas completed without complications. Immediate postoperative\nneurological examination revealed no new deficits. The patient was\ntransferred to the recovery room in stable condition, awaiting\nextubation by the anesthesiology team.\n\n**Recommendations:** Close monitoring in the neurological intensive care\nunit (NICU) is advised for the first 24 hours. Postoperative imaging,\ntypically an MRI, should be scheduled within the next 48 hours to assess\nthe extent of tumor resection and to rule out any postoperative\ncomplications.\n\n**Summary:** Mrs. Done\\'s recent hospital course was complicated by the\ndetection and subsequent excision of a hemorrhagic metastasis from a\nknown history of malignant melanoma. She continues to be on targeted\ntherapy with close monitoring. No new metastasis or recurrence has been\ndetected as of the last evaluation. The interdisciplinary approach\ninvolving the neurosurgery and oncology teams has been pivotal in her\nmanagement. Given the aggressive nature of melanoma, regular\nsurveillance and immediate action upon detection of new\nlesions/metastasis are paramount for her prognosis.\n\n**02-03/20: Radiation therapy **\n\nDiagnosis: Metastatic malignant melanoma with a focus on the right\nfrontal metastasis. Technique: Stereotactic radiosurgery (SRS) using a\nlinear accelerator (LINAC). Fractionation: Given the aggressive nature\nof malignant melanoma, a hypofractionated regimen was adopted. The\npatient underwent five sessions, each delivering a dose of 6 Gy for a\ncumulative total dose of 30 Gy.\n\nTreatment Planning: A simulation CT scan with a 1mm slice thickness was\nperformed in the treatment position, with a thermoplastic mask for\nimmobilization. The treatment planning system utilized the simulation\nCT, along with MRI for better tumor delineation. The target volume and\ncritical structures like the eyes, optic nerves, chiasm, and brainstem\nwere contoured. The radiation plan was optimized to ensure maximal dose\nto the target while sparing the critical structures.\n\nProcedure: At each session, patient positioning was verified using\ncone-beam CT (CBCT) to ensure precise targeting. Real-time monitoring\nwas employed to account for any intrafraction motion.\n\nSide Effects: The patient tolerated the treatment well. She reported\ntransient fatigue and mild scalp irritation, which resolved with\nconservative measures. No acute radiation-induced neurotoxicity was\nobserved.\n\n**Patient History Update: Mrs. Jane Done (DOB: 01/01/1966)**\n\n**General Status (10/03/2020):**\n\nMrs. Done presented in stable condition with stable vital signs.\nNeurologically, she\\'s intact with no new focal deficits. The surgical\nscars in the frontal region from previous operations are not fully\nhealed and there is some dehiscence and swelling, indicative of\ninfection. This wound complication can be traced back to her previous\nhistory of an empyema which required surgical intervention.\n\n**Dermatological Assessment:**\n\nThe previous exsiccation eczema, prominent on her arms, legs, and face,\nhas improved markedly. The treatment regimen involving consistent\nmoisturization and targeted topical therapies seems effective.\nImportantly, there were no new suspicious skin lesions or nodules noted\nduring her most recent full-body skin check.\n\n**Oncology Status:**\n\nMrs. Done remains on her immunotherapy regimen, specifically the\ncombination of Nivolumab and Ipilimumab. Her response has been positive,\nwith no new metastatic sites identified in the latest assessments. She\nhas displayed commendable compliance with this regimen and regular\nfollow-up evaluations.\n\n**Recent MRI Brain (09/30/2020):**\n\nHer latest multiplanar, multisequence MRI revealed post-surgical\nalterations in the right frontal lobe, consistent with previous\nobservations. Encouragingly, there was no sign of any residual or\nrecurrent tumor activity. Moreover, the MRI did not show any new\nintracranial metastatic sites or other significant abnormalities.\n\n**Thoracic CT Scan (10/01/2020): **\n\nTechnique: Post complication-free bolus i.v. administration of Imeron\n400, a multiline spiral CT was performed through the thorax during the\nvenous contrast phase, supplemented with thin-section, coronary, and\nsagittal secondary reconstructions.\n\nFindings: Multiple roundish subsolid nodules found bipulmonary, notably\na 4mm nodule in the right upper lobe. Blurred subpleural condensations\nin the left upper lobe. Another blurred bronchus-associated\nconsolidation was observed in the left upper lobe and pleurally in the\nleft dorsal lower lobe. No evidence of pathologically enlarged lymph\nnodes in the hilar, mediastinal, or axillary regions. Unchanged\npresentation of the left adrenal gland from the preliminary examination.\nThickened imprinting of the gastric wall noted. Ventrally emphasized\nspondylophytic attachments observed in the thoracic spine. No\nosteodestructive processes detected.\n\n**Impression:** Presence of multiple subsolid pulmonary nodules;\nrecommended follow-up in 4-6 weeks for potential (post-) inflammatory or\nmalignant genesis. No evidence of pathologically enlarged lymph nodes.\n\n**Abdomen/Pelvis CT Scan (10/01/2023): **\n\nTechnique: A low dose CT scan was taken of the abdomen and pelvis.\n\n**Findings:** Regular visualization of the acquired basal lung sections.\nOrthotopic kidneys without urinary stasis. No evidence of urinary\ncalculi. Suspected uterine fibroids attached to the uterus wall.\nEnlarged right ovary with minor calcifications. Assessment: Absence of\nurinary calculi. Possible uterine fibroids and an enlarged right ovary,\nsuggesting a specialized gynecological examination.\n\n**PICC Line Installation (10/02/2020)**\n\n**Diagnosis:**\n\nHome antibiotics required for wound healing disorder following discharge\ndue to an empyema.\n\n**Type of Surgery:**\n\nInstallation of a PICC line in the left basilic vein.\n\n**Anesthesia:**\n\nLocal anesthesia\n\n**Procedure Details:**\n\nThe patient was presented for long-term antibiotic treatment due to a\nwound healing disturbance post the discharge of an epidural abscess. The\nprimary aim was to apply a PICC-line catheter for the antibiotic\nregimen. A written informed consent was duly obtained prior to the\nprocedure.\n\nThe standard procedure began with the washing off and draping of the\npatient. A preoperative sonography of the arm veins was conducted. Based\non the sonographic results, it was decided to insert the catheter via\nthe left basilica vein.\n\nUnder venous congestion and following local anesthesia with 2mL Mecain,\na 2mm skin incision was made. The sonographically guided puncture was\nperformed successfully. Post this, the peel-away sheath was inserted.\nWith the wire in place, the catheter was advanced with its tip\npositioned approximately 2cm below the carina. The wire was subsequently\nremoved. Following this, the catheter was aspirated and flushed with\nNaCl to ensure its patency. A sterile fixation was then applied, and the\nwound was dressed.\n\n**Notes:**\n\nNo complications were observed during the procedure. The patient was\nadvised on the care and maintenance of the PICC line. Regular follow-ups\nare recommended to monitor the wound healing and the effectiveness of\nthe antibiotic treatment.\n\nThe patient was discharged with instructions and is scheduled for a\nfollow-up in two weeks.\n\n**Additional Therapeutic Engagements:**\n\nFor her overall well-being and to counter the side effects of her\ntreatment journey, Mrs. Done has been actively involved in physical\ntherapy sessions. These sessions focus on enhancing her strength and\nbalance, especially given the previous incident of an unattended fall.\nTo address the inevitable psychological strains of her diagnosis, she\nhas also been attending counseling sessions.\n\n**Current Recommendations:**\n\n-Continue the ongoing immunotherapy without changes.\n\n-Dermatological check-ups every month are advised for early detection of\nany potential skin abnormalities.\n\n-Regular neurological evaluations are crucial to ensure no emergence of\nnew deficits.\n\n-Imaging should be scheduled every six months for proactive monitoring.\n\n-Her physical therapy regimen should be ongoing to maintain and improve\nmobility.\n\n-Continue counseling to support her emotional and psychological\nwell-being.\n\n**Summary and Notes:**\n\nMrs. Done\\'s resilience and adherence to her treatments are commendable.\nHer progress is a testament to the integrated care approach she has been\nreceiving. Maintaining a proactive surveillance stance will be essential\nfor her long-term prognosis and quality of life.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding our mutual patient, Mrs. Jane\nDone, born on 01.01.1966. She was admitted to our clinic from 11/23/2020\nto 12/01/2020.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done presented for a follow-up visit on 11/23/2020. Over the past\nfew months, she reported fatigue and intermittent bouts of nausea. Of\nsignificant concern were newly identified skin changes located on her\nright arm.\n\n**Clinical Findings:**\n\nSkin: Multiple macules and patches on the right arm, the largest\nmeasuring about 1.5cm in diameter, hyperpigmented with irregular\nborders.\n\n**US: **\n\nUltrasound imaging of the right arm revealed no deep extension or\ninvasion of underlying structures. This preliminary assessment was\ncrucial, suggesting that if malignancy is present, it might be in early\nstages.\n\n**Histology: **\n\nHistological examination: Gross Description: The sample consists of\nmultiple tan-pink soft tissue fragments, aggregating to 1.8 cm in the\ngreatest dimension.\n\nMicroscopic description: Sections show a proliferation of atypical\nmelanocytes arranged in nests and as single units at the dermoepidermal\njunction. Some of these cells infiltrate the papillary dermis.\n\nImmunohistochemistry: The atypical cells are positive for HMB-45 and\nS-100. Melan A is focally positive. Ki-67 proliferation index is about\n10%.\n\nFinal Diagnosis: Dysplastic nevus with severe atypia; margins appear\nclear. Further excision is recommended to ensure complete removal and to\nrule out invasive melanoma.\n\n**Lab results: **\n\nComplete Blood Count (CBC):\n\nHemoglobin: 12.3 g/dL (Normal range: 12-16 g/dL)\n\nWhite Blood Cell Count: 6,200 cells/µL (Normal range: 4,000-11,000\ncells/µL)\n\nPlatelet Count: 290,000 cells/µL (Normal range: 150,000-450,000\ncells/µL)\n\nDifferential:\n\nNeutrophils 65%, Lymphocytes 25%, Monocytes 8%, Eosinophils 2%. B.\n\nLiver Function Tests (LFTs):\n\nALT (Alanine Aminotransferase): 40 U/L (Normal range: 7-56 U/L)\n\nAST (Aspartate Aminotransferase): 38 U/L (Normal range: 10-40 U/L)\n\nALP (Alkaline Phosphatase): 90 U/L (Normal range: 44-147 U/L)\n\nTotal Bilirubin: 1.0 mg/dL (Normal range: 0.1-1.2 mg/dL)\n\nAlbumin: 4.2 g/dL (Normal range: 3.4-5.4 g/dL)\n\nAssessment/Recommendations:\n\nGiven her history and the suspicious nature of the new skin changes, we\nhave decided to send the biopsy for urgent histological assessment.\n\nFurthermore, considering her reported symptoms, we have conducted a\nthorough internal check-up, including blood tests and liver function\ntests, to rule out any systemic side effects of the immunotherapy.\n\nWe recommend continuous monitoring of Mrs. Done's condition and kindly\nrequest your valuable input in managing her case optimally. A\nmultidisciplinary approach, given her complicated medical history, will\nbe most beneficial for the patient.\n\nPlease find attached the detailed examination and investigative reports\nfor your reference.\n\nWith kind regards,\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe wish to provide a comprehensive update regarding our mutual patient,\nMrs. Jane Done, born on 01.01.1966. She has had a history of various\nmedical conditions and treatments, which we believe is essential to\ndiscuss for her optimal management and was admitted to our clinical from\n01/01/2021 to 01/28/2021.\n\n**Previous Diagnoses and Therapies:**\n\nMetastatic malignant melanoma (presumed ID 2018); M1, stage IV according\nto UICC. Resection of primary tumor (malignant melanoma) on the left\nupper back (02/2018)\n\n01/20 Microsurgical resection right frontal tumor\n\n02/20 Excision of empyema\n\n02-03/20: Radiation therapy\n\n05/02/20: Start of immunotherapy with Nivolumab\n\n05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\nImaging 01/02/2021: PET/CT: Cervical lymph node metastasis;\n\ncMRI: no evidence of metastases. Contrast-enhancing meninges.\n\n**Virology: **\n\nUpon Admission: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load\nof 7,000 Geq/mL and a Ct value of 32.\n\nAt Discharge: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load of\n2,350 Geq/mL and a Ct value of 32.\n\n**Microbiology: **\n\nMRSA Screening Upon Admission: Nasal Swab: Normal flora detected; MRSA\nnot present. Throat Swab: Normal flora detected; MRSA not present.\n\nProcedures:\n\n\\- Presentation to neurology for CSF puncture (e.g., exclude\nmeningeosis)\n\n\\- Panel sequencing complement\n\n\\- Surgery/therapy: Neck dissection followed by adjuvant therapy with\npembrolizumab.\n\nClinical examination:\n\nExamination findings: Patient in normal general and nutritional\ncondition, consciousness unremarkable. Cranial mobility free, ocular\nmobility normal. Pupils are isocor, pupillary reflex prompt to\naccommodation and light. Regular, normocardial heart rate on admission.\nNo typical heart murmurs. Abdomen: abdominal wall soft, liver and spleen\nnot enlarged, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged in the axillary or inguinal region palpable.\n\nPET-CT from 01/02/2021:\n\nIntense metabolically active lymph node metastases, otherwise no\nevidence of vital tumor tissue in the study area.\n\n**PET CT report from 01/02/2021: **\n\nProcedure: PET/CT with 246 MBq (F-18)-fluorodeoxyglucose and a 60-minute\nuptake period.\n\nFindings: CT Findings: Neck: Right Level II: Three lymph nodes, largest\nmeasuring 2.1 x 1.8 cm with central necrosis. Right Level III: Two lymph\nnodes, largest measuring 1.5 x 1.2 cm. Left Level II: One lymph node\nmeasuring 1.3 x 1.1 cm. Left Level IV: Two lymph nodes, largest\nmeasuring 1.7 x 1.4 cm. Retropharyngeal space: One lymph node measuring\n1.0 x 0.9 cm.\n\nPET Findings: Neck: Right Level II: Increased FDG uptake with SUVmax of\n7.8, consistent with metastatic disease. Right Level III: Increased FDG\nuptake with SUVmax of 6.5. Left Level II: Increased FDG uptake with\nSUVmax of 6.0. Left Level IV: Increased FDG uptake with SUVmax of 7.2.\nRetropharyngeal space: Increased FDG uptake with SUVmax of 6.1.\nImpression: Cervical Lymph Nodes: Multiple pathologically enlarged\ncervical lymph nodes in bilateral level II, right level III, left level\nIV, and retropharyngeal space with increased FDG uptake, highly\nsuggestive of metastatic involvement from the known primary melanoma.\n\n**Surgery report 01/05/2021: **\n\nThe surgery commenced with a collaborative discussion with the\nanesthesia team and a standard team time-out was executed. The patient\nwas properly positioned, and the surgical site was aseptically draped.\nThe facial neuromonitoring system was set up and verified. Local\nanesthesia was then administered at the site of the skin incision, which\nwas located near the previous scar. This incision followed the anterior\nborder of the sternocleidomastoid muscle in a curved pattern. Upon\nincising the subcutaneous tissue, the external jugular vein became\nvisible and was selectively ligated. The encountered tissue appeared\nnotably fibrotic and scarred. A skin incision extended from the mastoid\nregion down nearly to the clavicle. The platysma muscle was subsequently\ncut. Due to the presence of a lymph node mass, the auricularis magnus\nnerve had to be severed. The sternocleidomastoid muscle and the\nposterior belly of the digastric muscle were then exposed. Multiple\ndarkened lymph node metastases were identified, both beneath the skin\nand within the sternocleidomastoid muscle. In subsequent steps, efforts\nwere made to distinguish the internal jugular vein from the surrounding\nscarred tissue. A lymph node mass, which exhibited characteristics\nhighly suggestive of metastasis (given its darkened color), was removed.\nThe accessory nerve was identified and preserved. Further dissection was\ndone posteriorly to the sternocleidomastoid muscle, in the direction of\nlevel V. An expansive mass of lymph nodes was excised in this region.\nThe trapezoid branch of the accessory nerve was visualized, and its\nfunction was monitored and preserved with the aid of neuromonitoring.\nThe removed lymph node mass, some excised tissue, and portions of the\nsternocleidomastoid muscle with embedded lymph nodes were sent for\nhistological analysis. During the procedure, care was taken to avoid\ndamaging major neck vessels and nerves. Concluding the procedure, 8 and\n10 French Redon drains were placed, the wound was closed in layers, and\nthen covered with a spray-on bandage, steristrips, and a pressure\ndressing. The surgical site appeared bloodless at the conclusion of the\nsurgery.\n\n**Macroscopy:**\n\n**Macroscopic Description:**\n\nDimensions: 6.8 x 0.7 x 0.4 cm spindle-shaped, non-oriented skin and\nsubcutaneous tissue resection. Central area shows an irritation-free,\nfine scar measuring up to 6.3 x 4.8 cm. The cut surface appears\nconsistently off-white.\n\nInk markings: soft tissue margin of specimen = green. A: central\nlamellae B: spindle tips perpendicular\n\nAnterior Margin of Upper Third of Sternocleidomastoid Muscle:\nDimensions: Four combined tissue samples totaling 4.7 x 3.8 x 1.1 cm.\n\nAppearance: Tan, fibrous soft tissues with multiple uniformly dark\nnodules on the cut surface, each measuring up to 1.1 cm.\n\nA, B: one nodule each halved C, D: other nodular sections E: remaining\ntan fibrous sections Anterior Margin of Lower Third of\nSternocleidomastoid Muscle: Largest measurement: 3.4 cm.\n\nAppearance: Grayish-brown with some fibrous regions and homogeneously\ndark-brown nodes up to 1.5 cm in size on the cut surface. A, B: one node\neach halved C: other nodes D: brown-fibrous sections Region V Occipital:\nLargest measurement: Two samples, each up to 3.8 cm.\n\nAppearance: Mixture of grayish-tan and light brown fibrous soft tissue\nwith nodes up to 2.2 cm, uniformly dark brown.\n\nA, B: one node halved C, D: another node halved each Processing: 16\nparaffin blocks, HE stained.\n\nMicroscopic Description: Dermis and subcutaneous resection shows\nscarring with fibrosis. Epidermis is regular, without any atypical\ncells. No evidence of melanoma or carcinoma. 2./3.\n\nMultiple nodular tumor clusters present in the soft tissue and skeletal\nmuscles, lacking lymph node structure. Tumor cells are polygonal, with\nsome spindle-shaped cells having moderately large, irregular nuclei and\nnoticeable nucleoli. Cytoplasm appears slightly granular with a light\nbrownish pigment.\n\nSeven lymph nodes (measuring up to 3.6 cm) indicate metastasis from the\npreviously mentioned tumor, with extracapsular spread. Four other lymph\nnodes are free from the tumor.\n\n**Critical Findings:** Multiple nodular soft tissue metastases, with the\nlargest measuring 1.3 cm, indicative of melanoma present in both soft\ntissue and muscle. Resection margins are mostly free of tumor, with the\nclosest approach being less than 0.15 cm (points 2 and 3). Seven lymph\nnodes (up to 3.6 cm in size) show metastasis from the melanoma, with\nextracapsular spread. Four lymph nodes are tumor-free (7 out of 11\nnodes, ECE positive) (point 4). Dermis and subcutaneous excision shows\nscarring fibrosis (point 1).\n\nFor the optimal management of Mrs. Done, close monitoring and a\nmultidisciplinary approach will be essential. Thank you for your\ncontinued collaboration in ensuring the best care for our mutual\npatient.\n\n**Lab values upon discharge: **\n\n **Parameter** **Result** **Reference Range** **Interpretation**\n -------------------------------- -------------- ---------------------------------------- ---------------------\n **Complete Blood Count (CBC)** \n Hemoglobin (Hb) 12.4 g/dL 12.0 - 16.0 g/dL Within normal range\n White Blood Cell (WBC) 9.2 x10\\^9/L 4.0 - 10.0 x10\\^9/L Within normal range\n Platelets 250 x10\\^9/L 150 - 400 x10\\^9/L Within normal range\n **Liver Function Tests (LFT)** \n AST 28 U/L 10 - 35 U/L Within normal range\n ALT 32 U/L 10 - 40 U/L Within normal range\n Total Bilirubin 0.8 mg/dL 0.2 - 1.2 mg/dL Within normal range\n **Kidney Function Test** \n Serum Creatinine 0.9 mg/dL 0.5 - 1.2 mg/dL Within normal range\n Blood Urea Nitrogen (BUN) 15 mg/dL 7 - 20 mg/dL Within normal range\n **Electrolytes** \n Sodium 138 mEq/L 135 - 145 mEq/L Within normal range\n Potassium 4.2 mEq/L 3.5 - 5.0 mEq/L Within normal range\n Chloride 101 mEq/L 95 - 105 mEq/L Within normal range\n **Thyroid Function Tests** \n TSH 3.1 mU/L 0.5 - 5.0 mU/L Within normal range\n Free T4 1.4 ng/dL 0.9 - 2.4 ng/dL Within normal range\n **Lipid Profile** \n Total Cholesterol 190 mg/dL \\< 200 mg/dL Desirable\n LDL Cholesterol 100 mg/dL \\< 100 mg/dL Optimal\n HDL Cholesterol 55 mg/dL \\> 40 mg/dL (Men), \\> 50 mg/dL (Women) Normal\n Triglycerides 110 mg/dL \\< 150 mg/dL Normal\n\n**Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ---------------- ------------ ----------- -----------------------------\n Pembrolizumab 200mg IV Every 3 weeks\n Nivolumab 60mg IV As per oncologist\\'s advice\n Ipilimumab 200mg IV As per oncologist\\'s advice\n Paracetamol 500mg Oral Every 4-6 hours as needed\n Omeprazole 20mg Oral Once daily\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/14/2022 to\n03/01/2022.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done showed multiple metastases in her CT examination. On physical\nexamination, Mrs. Done appears well-nourished and in no acute distress.\nHer vital signs are stable. Cardiovascular examination reveals regular\nheart sounds with no murmurs. Respiratory examination shows clear breath\nsounds bilaterally. Abdominal examination reveals no palpable masses or\norganomegaly. Neurological examination is within normal limits.\n\n**Radiology/Nuclear Medicine**\n\n**CT thorax/abdomen/pelvis + Contrast from 02/10/2022**\n\n**Technique:** Multi-phase, multi-slice computed tomography of the\nthorax, abdomen, and pelvis was performed following the intravenous\nadministration of contrast material. Coronal and sagittal\nreconstructions were obtained.\n\n**Thorax:** In the thoracic region, the lungs are notable for multiple\nnodular opacities across both lung fields, consistent with metastatic\ndeposits. The most sizable lesion is seen in the right upper lobe,\napproximately 1.5 cm in diameter. No associated cavitation or pleural\neffusion is detected. A concerning 2 cm mass abutting the lateral wall\nof the left ventricle is noted, raising the suspicion for cardiac\nmetastasis. The mediastinum also exhibits lymphadenopathy with a\ndominant node in the prevascular space, measuring 2.2 cm. Further, there\nare lytic lesions involving the sternum and right 4th rib, consistent\nwith osseous metastatic disease.\n\n**Abdomen/pelvis**: Liver shows multiple hypodense lesions throughout\nboth lobes, indicative of metastatic spread. The dominant lesion in the\nright lobe measures 3 cm. The kidneys, however, are unremarkable without\ndiscernible metastatic deposits. Retroperitoneal lymphadenopathy is also\npresent, highlighted by a node anterior to the aorta of 1.8 cm. In\naddition, there is a 2.5 cm mass identified within the left psoas\nmuscle, consistent with muscular metastasis. Both the left acetabulum\nand the right iliac wing manifest with lytic lesions, suggestive of\nmetastatic involvement. There is also enlargement of the bilateral\ninternal iliac lymph nodes, with the left side\\'s node measuring up to\n1.6 cm. Bladder, prostate, and rectum with no discernible pathology.\n\n**Impression**: Multiple pulmonary nodules consistent with pulmonary\nmetastases. Cardiac lesion suggestive of metastatic involvement.\nEvidence of skeletal metastases in the thorax and pelvis. Hepatic and\nmuscular metastases, indicative of disseminated disease. Lymphadenopathy\nin the mediastinal, retroperitoneal, and pelvic regions.\n\n**PET-CT scan from 02/11/2022**\n\n**Clinical Indication:** Follow-up evaluation of a known case of\nMetastatic Melanoma, Stage IV, M1c with notable findings from a CT scan\ndated 12/01/2014.\n\n**Technique:** Whole-body PET-CT scan was conducted after intravenous\nadministration of 18F-FDG. The patient fasted for 6 hours prior to the\nscan, and blood glucose levels were confirmed to be within the\nacceptable range. Both CT and PET images were acquired, and images were\nco-registered for optimal evaluation. Standard uptake values (SUVs) were\ncalculated for areas of interest.\n\n**Findings: **\n\n**Thorax:** Both lungs depict several hypermetabolic foci, corroborating\nthe CT findings of multiple nodules. The largest lesion in the right\nupper lobe demonstrates an SUVmax of 8.2, indicative of active metabolic\ndisease. The cardiac mass adjacent to the left ventricle, measuring\napproximately 2 cm, also reveals increased 18F-FDG uptake with an SUVmax\nof 9.5, strengthening the suspicion of cardiac metastasis. Enlarged\nmediastinal lymph nodes, particularly the node in the prevascular space,\nshows marked hypermetabolism with an SUVmax of 7.4. Notably, the lytic\nskeletal lesions identified on the CT in the sternum and right 4th rib\nalso display increased metabolic activity, consistent with metastatic\nbone disease.\n\n**Abdomen/Pelvis:** Hepatic lesions are congruent with the findings of\nthe preceding CT, showing heightened metabolic activity. The most\nprominent lesion in the right lobe exhibits an SUVmax of 8.8.\nRetroperitoneal lymph nodes are metabolically active, with the anterior\naortic node demonstrating an SUVmax of 6.9. The 2.5 cm left psoas muscle\nmass also reveals increased uptake with an SUVmax of 7.3, suggesting\nactive muscular metastasis. In the pelvic region, the lytic lesions\nidentified in the left acetabulum and right iliac wing on the CT confirm\ntheir malignant nature with notable metabolic activity. Bilateral\ninternal iliac lymph nodes show hypermetabolism with the left node\\'s\nSUVmax reaching 7.1. Other pelvic organs, including the bladder,\nprostate, and rectum, did not show any significant 18F-FDG uptake, in\nline with the unremarkable CT findings.\n\n**Impression:** The PET-CT findings are consistent with active\nmetastatic disease. There is evidence of hypermetabolic pulmonary\nnodules, a likely cardiac metastasis, hepatic and muscular metastases,\nand metabolically active skeletal lesions in both the thorax and pelvis.\nAdditionally, there is hypermetabolism in the lymph nodes across\nmultiple regions. These findings align closely with the previously\ndiagnosed metastatic melanoma, Stage IV, M1c**. **\n\n**Discussion**\n\nMrs. Done has been diagnosed with recurrent metastatic melanoma with\nlymph node involvement. This poses significant implications for her\nprognosis, emphasizing the need for urgent and comprehensive\nintervention.\n\nHer molecular profile has revealed the presence of the BRAF V600E\nmutation.\n\nOur recommended therapeutic combination includes Vemurafenib and\nCobimetinib, both of which are aimed at disrupting the aberrant BRAF-MEK\nsignaling cascade. Complementing this, we suggest the administration of\nPembrolizumab.\n\nMrs. Done is scheduled for six cycles of this treatment regimen. We will\nmonitor her laboratory parameters, such as blood counts, electrolytes,\nand hepatic and renal profiles, bi-weekly. It is imperative to note that\nany fevers surpassing 38.3°C warrant immediate medical attention.\n\nComprehensive patient education module has been designed to enable Mrs.\nDone to identify and manage any potential side effects efficiently.\n\nWe will ensure rigorous monitoring of her blood pressure and lipid\nmetrics, with the possibility of introducing alternative medications if\nclinical scenarios demand.\n\nWe deeply value your collaboration in Mrs. Done\\'s healthcare journey.\nOur team remains at your disposal for any queries or clarifications.\n\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n\n\n\n\nHere is the query:\nWhat can be inferred about Spironolactone in Mr. Nilsson's treatment from 2005 to 2008?\n\nChoose the correct answer from the following options:\nA. It was consistently used at the same dosage and frequency.\nB. Its frequency of use increased over time.\nC. It was not included in the medication regimen in March 2008.\nD. The dosage was increased by July 2008.\nE. Only used during hospital admissions.\n\n\nYour response:\n", "role": "user" }, { "content": "It was not included in the medication regimen in March 2008.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, ****Dear colleague, **\n\n \n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who was treated in our clinic from 05/28/14 to 06/20/14.\n\n \n\n**Diagnoses: **\n\n- pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left\n midline tongue carcinoma\n\n- Arterial hypertension\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Idiopathic thrombocytopenia\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Hypothyroidism\n\n- Nicotine abuse\n\n<!-- -->\n\n- Panendoscopy with sampling on 04/14/2014 and 04/26/2014\n\n \n\n**Current Presentation**: With histologically confirmed carcinoma in the\nregion of the base of the tongue on the left side, Mr. Doe presents for\nsurgical treatment of the findings. In accordance with the tumor board\ndecision, resection is performed via a lateral pharyngotomy and neck\ndissection on both sides.\n\n \n\n**Physical Examination:** Patient in stable general condition (85 kg,\n188 cm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I° (L-thyroxine increased to 150 μg 1-0-0), hoarseness\n0°, hearing loss 0° (subjectively reduced), dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\nA tumorous mass can be inspected at the base of the left tongue. Tongue\nmobility is unremarkable.\n\n**CT chest, abdomen, pelvis on 05/28/14:**\n\nEmphasized mediastinal as well as abdominal lymph\nnodes.** **Vasosclerosis. Otherwise, there is no evidence for the\npresence of distant metastases with a suspected base of tongue\ncarcinoma. Liver cirrhosis.\n\n \n\n**CT neck on 06/11/14:**\n\nSuspected left tongue base carcinoma crossing midline with extension\ninto the left vallecula and compression of the left piriform sinus with\nsuspected lymph node metastases in levels I-III ipsilateral.\nContralateral prominent but not certainly suspicious lymph nodes. The\nprominent structure on the left supraclavicular side can also be\ninterpreted as circumscribed cystiform ectasia of the thoracic duct.\n\n \n\n**Ultrasound abdomen on 06/15/14:**\n\nImage of liver cirrhosis status post cholecystectomy.\nHepatosplenomegaly. Moderate aortic sclerosis.\n\n \n\n**X-ray pap swallow on 06/17/14:**\n\nClear tracheal aspiration in the absence of epiglottis envelope. The\ncough reflex is preserved. Otherwise, essentially unremarkable\nswallowing act. \n\n \n\n**Histology**: Invasive, moderately differentiated, squamous cell\ncarcinoma with keratinization of the medial left base of the tongue,\nmaximum extent 1.0 cm. Carcinoma- and dysplasia-free biopsies of the\nleft tonsil, the oropharyngeal tumor/tongue base on the left, deep\nresection of the tumor, lower tonsillar pole transition on the left\ntongue base, tongue base on the left and medial left tongue base, as\nwell as median tongue base.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** pT1. pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n \n\n**Therapy and Progression**: After the usual clinical and laboratory\npreparations, we performed the above-mentioned therapy on 05/29/14 in\nintubation anesthesia without complications. For perioperative infection\nprophylaxis, the patient received intravenous antibiotic therapy with\nAmpicillin and Sulbactam 3g three times daily for the duration of his\nhospital stay.\n\nDuring this procedure, the left lingual artery was interrupted\nprophylactically. No postoperative bleeding and no wound healing\ndisturbances occurred.\n\nA porridge swallow examination showed no evidence of a fistula. On the\nfollowing day, the patient was decannulated in consultation with the\ncolleagues of the speech therapy. After this, a food build-up was\ncarried out in cooperation with speech therapists. At the time of\ndischarge, the patient was receiving regular oral nutrition. The stoma\ncontinued to shrink. The patient was monitored, and if necessary, the\ntracheostoma was closed with local anesthesia. Histological findings\nwere pT1. Due to an RX status, adjuvant radiotherapy will be performed\nas decided by the tumor board. A prophylactic presentation at the\ncolleagues of the MKG as a preparatory measure for the upcoming\nradiotherapy. We asked for a control re-presentation in our outpatient\nclinic on 06/26/14 at 3:00 PM. Further controls take place at the half\nand at the end of the radiotherapy and further in 4-6 weeks rhythm. In\ncase of acute complaints, an immediate re-presentation is possible at\nany time.\n\n \n\n**Type of surgery**: Lateral pharyngotomy with resection of the base of\nthe tongue on the left as well as selective neck dissection on both\nsides level II-IV with ligature of the lingual artery on the left side,\ncreation of a stable tracheostoma and tonsillectomy on the left side.\n\n**Surgery report: **First, tracheotomy in a typical manner. A horizontal\nincision was made on the skin, positioned approximately two transverse\nfinger widths above the jugulum. Subsequently, the subcutaneous tissue\nand the platysma colli were incised. To facilitate access to the\ntrachea, the laryngeal muscles were carefully displaced to the side. The\nthyroid isthmus was undermined and clamped bilaterally. A precise\ntransection of the thyroid isthmus followed, with both halves of the\nthyroid gland being meticulously sutured using 0- Vicryl. The thyroid\nhalves were repositioned to expose the trachea. A visceral tracheotomy\nwas performed, and re-intubation was achieved utilizing a U-tube. The\nsurgical procedure then transitioned to a neck dissection on the left\nside. This phase began with an incision along the anterior edge of the\nsternocleidomastoid muscle. The subcutaneous tissue and platysma colli\nwere carefully cut, with due respect to the auricularis magnus nerve.\nDissection continued dorsally along the sternocleidomastoid muscle to\nreach the anterior border of the trapezius muscle. Further exposure\ninvolved the accessorius nerve in a cranialward direction, with\npreservation of this neural structure. Dissection proceeded along the\ncervical vascular sheath, revealing the common carotid artery, internal\njugular vein, and vagus nerve up to the digastric muscle. Below this\nlevel, exposure of the hypoglossal nerve was achieved.\n\nSuccessive dissection involved the lymph node fat package, progressing\nfrom level II to level IV in a cranial to caudal and ventral to dorsal\ndirection. Throughout this process, careful attention was paid to\nsparing the aforementioned neural and vascular structures. Subsequently,\naccess to the lateral pharyngectomy area was gained, allowing\nvisualization of the external carotid artery along with its branches,\nincluding the superior thyroid artery, superior laryngeal artery, and\nlingual artery. Notably, the lingual artery was interrupted during this\nstage.\n\nFurther exploration revealed the superior laryngeal nerve and\nhypoglossal nerve intersecting in a loop above the internal carotid\nartery and externally below the external jugular vein. Additional\ndissection in a ventral direction followed. The hypoglossal nerve was\nprepared meticulously. Exposure of the hyoid bone was achieved, with a\nposterior resection of half of the hyoid bone. Importantly, the\nhypoglossal nerve was spared during this procedure. Subsequent to these\nsteps, the lateral pharynx wall was opened, exposing the base of the\nhyoid. The next phase of the procedure involved enoral tumor\ntonsillectomy on the left side. Starting from the left side, the\nsurgical team identified the tonsil capsule at the anterior palatal arch\nusing a Henke spatula. The upper tonsillar pole was then dislodged and\ndissected with the Rosenblatt instrument, proceeding from cranial to\ncaudal. Hemostasis was meticulously achieved through swab pressure and\nelectrocautery. The excised tonsil tissue was sent for frozen section\nexamination for further analysis.\n\n**Frozen Section Report: **No evidence of malignancy was found. The\nresection was carried out at the junction of the caudal tonsillar pole\nand the base of the tongue. At this location, tissue from the base of\nthe tongue was resected and sent for a frozen section examination, which\nrevealed no indication of malignancy. Subsequently, a medial resection\nof the base of the tongue was performed, confirming the presence of\nsquamous cell carcinoma in the frozen section analysis. Mucosal suturing\nwith inverting sutures was then conducted. On the left side, a neck\ndissection procedure was performed. The dissection extended along the\nsternocleidomastoid muscle, reaching dorsally to the anterior border of\nthe trapezius muscle. This approach allowed for cranial exposure of the\naccessorius nerve while sparing the same. Dissection continued along the\ncervical vascular sheath, exposing the common carotid artery, internal\njugular vein, and the vagus nerve up to the digastric muscle. Below\nthis, the hypoglossal nerve was exposed. Subsequently, the lymph node\nfat package was dissected systematically from level II to level IV,\nprogressing from cranial to caudal and ventral to dorsal, while\ncarefully preserving the mentioned structures. The surgical procedure\nconcluded with the placement of a drain, subcutaneous suturing, and skin\nsuturing.\n\n**Frozen section report:** Invasive squamous cell carcinoma.\n\n \n\n**Microscopy:**\n\nEven after paraffin embedding, mucosal cross-sections show a covering of\nstratified, non-keratinizing squamous epithelium with occasional\nsignificant stratification disturbances extending into superficial cell\nlayers. This transitions into invasive growth with solid clusters of\npolygonal tumor cells, some of which exhibit identifiable intercellular\nbridges. The cell nuclei are enlarged, round to oval, with occasional\nsmall nucleoli and mild to moderate nuclear pleomorphism. Dyskeratosis\nis observed in some areas.\n\n**Lab results upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- ----------------------- -----------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.0 mg/dL 0.7 - 1.3 mg/dL\n Calcium 9.04 mg/dL 8.8 - 10.6 mg/dL\n GFR (MDRD) \\> 60 mL/min/1.73m\\^2 \\> 60 mL/min/1.73m\\^2\n GFR (CKD-EPI,CREA) 80 mL/min/1.73m\\^2 \\> 90 mL/min/1.73m\\^2\n C-reactive protein 1.0 mg/dL \\< 0.5 mg/dL\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who presented to our outpatient clinic on 09/14/2014.\n\n**Diagnosis: **Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21)\nL0 V0 Pn0 G2 RX\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n- Since 03/2014: Odynophagia\n\n<!-- -->\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Histology:**\n\nInvasive, moderately differentiated, squamous cell carcinoma with\nkeratinization of the medial left base of the tongue, maximum extent 1.0\ncm. Carcinoma- and dysplasia-free biopsies of the left tonsil, the\noropharyngeal tumor/tongue base on the left, deep resection of the\ntumor, lower tonsillar pole transition on the left tongue base, tongue\nbase on the left and medial left tongue base, as well as median tongue\nbase.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** min pT1, pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n**Current Radiotherapy:**\n\n**Indication**: According to the decision made by the interdisciplinary\ntumor board for head and neck tumors, it was determined by our medical\nteam that, in the postoperative condition following the resection of a\ntongue base carcinoma with an unclear resection status, there is an\nindication for radiation therapy of the former tumor site.\n\n**Technique:** Percutaneous radiotherapy of the former primary tumor\nregion with 6-MeVPhotons, in Rapid-Arc technique, with a single dose of\n2 Gy up to a total dose of 60 Gy.\n\n**Radiotherapy 07/27/2014 - 09/06/2014:**\n\nDuring the course of radiotherapy, the patient experienced enoral\nmucositis (grade II according to CTCAE) leading to subsequent\nodynophagia and dysphagia. We managed these symptoms with oral rinses\nand initiated pain management using Acetaminophen, resulting in an\nacceptable reduction of pain over time. At the end of the therapy, the\npatient\\'s general condition remained stable (ECOG performance status:\n70%). Second-degree mucositis enoral persisted, causing ongoing\ndysphagia and odynophagia. Additionally, the patient exhibited localized\nradiodermatitis (grade II according to CTCAE) within the radiation\nfield. The patient did not report xerostomia or dysgeusia.\n\n**Current Recommendations:**\n\nThe patient received comprehensive instructions on continued skincare\nand side-effect management. An initial follow-up appointment with the\nradio-oncology team has been scheduled in our outpatient clinic. We\nkindly request the patient to provide a renewed referral for\nradiotherapy on the day of the appointment.\n\nThe ongoing oncological treatment plan will be determined by the\npatient\\'s Ear, Nose, and Throat specialists. Regular follow-up\nexaminations are strongly recommended. Additionally, for patients who\nhave completed radiation therapy in the ENT region, we advise lifelong\nadherence to fluoride prophylaxis and antibiotic therapy during any\ndental procedures.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965, who presented\nto our outpatient clinic for phoniatrics and pedaudiology on 10/10/2014.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Medical History: **We may kindly assume the detailed history as known.\n\n**Phoniatrics: Fiberoptic endoscopic swallow examination:**\n\nTongue motor function is well preserved, sensitivity of lip and tongue\nlaterally equal,\n\nMucous membranes non-irritant on all sides. Tracheal mucosa\nnon-irritant, no evidence of saliva intratracheal. Neopharynx\ninconspicuous, air bubbles visible above Provox outlet on pressing\nattempt. Tongue retraction slightly limited. Velopharyngeal closure\ngood.\n\n**Therapy and Course:** After completion of the adjuvant radiotherapy\napproximately 6 weeks ago, phonation via the Provox voice prosthesis was\nno longer possible after this had initially worked after the operation.\nAdditionally, there were issues with regurgitation of ingested\nsubstances, regardless of their consistency. In some cases, nasal\npenetration with fluids occurred. There were no indications of\naspiration. A self-assessment, involving the use of blue-colored liquid,\nrevealed no signs of leakage from the Provox device.\n\n**Current Recommendations:** Oncological follow-up in 12 months.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965 who presented\nat our outpatient clinic for radio-oncological follow-up on 10/09/2020.\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n \n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for a radio-oncological follow-up on 10/09/2020 in the\npresence of his wife.\n\n**Physical Examination**: Patient in stable general condition (85 kg,188\ncm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I°, hoarseness 0°, hearing loss 0° (subjectively\nreduced), dyspnea: 0°, pneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\n**MRI scan of the neck from 10/09/2020:** \n\nClear post-therapeutic changes in the resection and radiation area after\nadjuvant RTx following tumor resection with laryngectomy for extensive\nrecurrence of oropharyngeal cancer. \n\nSize constant, but still clearly accentuated lymph nodes in level Ib/IIa\non the left. Regredience of seroma formation under the left\nsternocleidomastoid muscle.\n\n**Current Recommendations: **Primary oncological care and follow-up,\nincluding imaging, will be provided by the ENT clinic according to the\nguidelines. A re-appointment for a further radio-oncological follow-up\nat the follow-up appointment at the Radiation Therapy Tumor Therapy\nCenter has been scheduled. After head and neck radiation therapy,\nregular fluoridation of the teeth and guideline-based antibiotic\nprophylaxis is required prior to major dental procedures. We also\nrecommend temporomandibular joint opening exercises to prevent\ntemporomandibular joint fibrosis and consecutive temporomandibular joint\nopening obstruction. We also refer to regular control of thyroid\nfunction parameters and, if necessary, initiation of substitution\ntherapy after radiotherapy to the neck.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe hereby report on our patient Mr. Paul Doe, born 08/08/1965 for\nradio-oncological follow-up on 09/24/2021.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for radio-oncological follow-up on 09/24/2021. \n\n**Physical Examination: **Patient in reduced general condition (KPS 60%,\n86 kg,188 cm). Weight loss 0°, MUST score: 0, pain VAS 1-2/10, fatigue\nI°, dysphagia I° with solid food (liquids occasionally flow out of the\nnose again when swallowing), aspiration 0°, ulcer 0°, trismus 0°, taste\ndisorder I° (present in approx. 80%), xerostomia I°, osteonecrosis 0°,\nhypothyroidism II°, hoarseness II°, hearing loss, I°, dyspnea: 0°,\npneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**MR neck plain + contrast agent on 09/24/2021**:\n\n[Technique]{.underline}: STIR triplanar, T1 ax -/+ contrast agent, T1\nmDixon cor after\n\ncontrast agent.\n\n[Findings]{.underline}: Known status post tumor resection with\nlaryngectomy for extensive recurrence of oropharyngeal Carcinoma;\nFollow-up after RTx. Somewhat increasing swelling of nasopharynx to\noropharynx. From the uvula the swelling is stable. As far as can be\nassessed, no clear recurrence-specific tissue proliferation or contrast\nuptake. Unchanged accentuated lymph nodes in level Ib/IIa on the left\n(one exemplary measured lymph node borderline large, idem to preliminary\nexamination). Mastoid cells minimally displaced on the left. Moderate\ndegenerative changes of the cervical spine. Assessment. Increasing\nswelling of the naso- to oropharynx. Neopharynx unchanged swollen. No\nevidence of malignancy-suspicious lymph nodes.\n\n**CT scan of the thorax on 09/24/2021**:\n\nSize-constant visualization of interlobar oval compaction in the left\nupper lobe corresponding to an interlobar lymph node. New to the\nprevious examination, two small nodular condensations appear, basal in\nthe right and in the left lower lobe, differentially inflammatory;\nfollow-up is recommended. Unchanged the prominent mediastinal lymph\nnodes, constant in size and number.\n\n**Current Recommendations:**\n\nPrimary oncologic care and follow-up including imaging will take place\nvia the ENT clinic on 01/14/22 at 11:00 AM. A re-appointment for the\nnext radio-oncological follow-up has been arranged for 01/14/2022 at\n1:00 PM in our radiotherapy outpatient clinic in the Tumor Therapy\nCenter.\n\n**Lab results upon Discharge:**\n\n**Hematology**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- -----------------------\n WBC 6,900 /μL 4,500 - 11,000 /μL\n RBC 2.7M /μL 4.5M - 5.9M /μL\n Hemoglobin 8.2 g/dL 14 - 18 g/dL\n Hematocrit 25.1 % 40 - 48 %\n MCH 31.27 pg 27 - 33 pg\n MCV 94 fL 82 - 92 fL\n MCHC 32.7 g/dL 32 - 36 g/dL\n Platelets 638,000 /μL 150,000 - 450,000 /μL\n\n**Serum chemistry**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ -----------------\n Sodium 144 mEq/L 135 - 145 mEq/L\n Potassium 4.8 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.3 mg/dL 0.7 - 1.3 mg/dL\n ALT 21 U/L 10 - 50 U/L\n eGFR 55 mL/min \\> 90 mL/min\n CRP 2.9 mg/dL \\< 0.5 mg/dL\n\n**Coagulation**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ ---------------\n PT 93 % 70 - 120 %\n INR 1.1 0.8 - 1.2\n aPTT 31 sec 26 - 37 sec\n\n**Thyroid hormones**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- ------------------\n TSH 1.16 μIU/mL 0.4 - 4.2 μIU/mL\n fT3 2.38 pg/mL 2.3 - 4.2 pg/mL\n fT4 1.70 ng/dL 0.9 - 1.7 ng/dL\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who was admitted\nto our hospital from 01/10/2022 to 01/27/2022.\n\n**Diagnosis**: Metachronous pulmonary metastatic squamous cell carcinoma\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014 Odynophagia\n\n- 05/14/2014 Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014 Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Planned Surgical Procedure:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Medical History**: Mr. Paul Doe initially presented with a diagnosis\nof pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left midline\ntongue carcinoma. Panendoscopy with specimen collection on 04/14/2014\nand 04/26/2014 confirmed carcinoma.\n\nSurgical resection was performed via lateral pharyngotomy and neck\ndissection. Histology confirmed squamous cell carcinoma. He subsequently\nreceived radiotherapy.\n\nDuring a follow-up CT examination, a suspicious lesion was identified in\nthe lung, which raised concerns regarding the possibility of metastasis\noriginating from the previously diagnosed left midline tongue carcinoma\n(pT1, pN0, G2, RX).\n\n**Current Presentation:** Mr. Doe was admitted for further examination\nand treatment to assess the behavior and extent of the lesion.\nClinically, Mr. Doe was in stable general condition and had no symptoms\nsuggestive of B symptoms.\n\n**Therapy and Progression**: The above-mentioned procedure was performed\nwithout complications on 01/10/2022. Histologically, the final resection\nspecimen confirmed the presence of a 2.9 cm squamous cell carcinoma,\nconsistent with a metastatic recurrence of the previously known\nhypopharyngeal carcinoma. The dissected lymph nodes were free of tumor.\nThe postoperative course was uneventful. In the absence of any\ncomplications, surgical sutures were removed on day 10 after surgery. A\ncurrent chest X-ray showed a regular postoperative outcome with\nsufficient expansion of the left lobe. Further monitoring is recommended\nby the treating colleagues in this regard. Mr. Doe is also connected to\nthe radiation therapy team for ongoing follow-up.\n\nIf there are any complications or questions, please contact the relevant\nward or reach out to our Central Patient Management. Outside regular\nworking hours, you can contact the on-call colleague in the Abdominal\nSurgery department for assistance.\n\nFor further information on the patient\\'s discharge management, treating\nproviders are available for inquiries from Monday to Friday, 9 AM to 7\nPM, as well as on weekends and holidays from 10 AM to 2 PM.\n\nMr. Doe was discharged from the hospital on 01/27/2022.\n\n**Addition:**\n\n**Histology Report:** Resected left upper lobe specimen with a 2.9 cm\nsolid carcinoma. The histological picture is consistent with a\nmetastasis from the previously diagnosed non-keratinizing squamous cell\ncarcinoma. There were focal vascular invasions. No pleural invasion was\nobserved. The resection was complete, with all dissected lymph nodes\nshowing no tumor involvement.\n\n**Chest X-ray, anterior-posterior view from 01/21/2022**:\n\n[Clinical Information:]{.underline} History of VATS with wedge\nresection, yesterday\\'s drain removal\n\n[Question:]{.underline} Follow-up, pneumothorax after drain removal?\nInfiltrates? Atelectasis?\n\n[Findings:]{.underline} Left chest drainage tube has been removed. Left\napical pneumothorax line, measuring approximately 2.3 cm. Continued\nextensive shadowing of the left upper field, most likely postoperative,\ninfiltrate cannot be definitively ruled out. Slightly hypotransparent\nleft lung in comparison, most likely due to residual postoperative\nreduced ventilation. No effusion. Widened cardiac silhouette. Regression\nof dystelectasis in the right lower field. No acute signs of pulmonary\nvenous congestion. Trachea is mid-positioned and not stenosed.\nLeft-sided port catheter still in place.\n\n[Summary]{.underline}: Left apical corax with a width of 2.3 cm.\nContinued extensive shadowing of the left upper field, most likely\npostoperative, with infiltrate not definitively excluded. Residual\npostoperative reduced ventilation on the left side. Regression of\ndystelectasis in the right lower field. No effusion. No acute signs of\npulmonary venous congestion. Follow-up recommended.\n\n**Examinations Chest X-ray, anterior-posterior view from 01/23/2022:**\n\n[Question]{.underline}**:** Follow-up.\n\n[Findings]{.underline}: Left apical pneumothorax, measuring\napproximately 1.4 cm. Extensive shadowing in projection onto the left\nupper lobe, differentials include postoperative changes, incipient\ninfiltrate not excluded. Dystelectasis of the right lower field. No\nevidence of pleural effusion or acute pulmonary venous congestion.\nCardiomegaly. Indwelling chest drainage with the catheter tip projecting\nonto the left upper lobe. Well-positioned port catheter tip projecting\nonto the right atrial entrance plane. No evidence of pleural effusion.\nAssessment Left apical pneumothorax, measuring approximately 1.4 cm,\nwith indwelling left chest drainage. Extensive shadowing in projection\nonto the left upper lobe, differentials include postoperative changes,\nincipient infiltrate not excluded. Dystelectasis of the right lower\nfield. No significant pleural effusion. No acute pulmonary venous\ncongestion. Cardiomegaly.\n\n**Chest X-ray, anterior-posterior view from 01/25/2022**\n\n[Previous Examinations]{.underline}: Appearance of a diffuse\npostoperative shadow in the left upper field. No evidence of pleural\neffusion, inflammatory infiltrate, or pulmonary venous congestion.\n\n[Findings]{.underline}: Left-sided chest port with the tip projecting\nonto the superior vena cava. The upper mediastinum is narrow, the\ntrachea is mid-positioned and patent.\n\n[Assessment]{.underline}: The pneumothorax appears to be largely\nresolved.\n\n**Urinanalysis**:\n\nMaterial: Urine, midstream sample collected on 01/11/2022\n\n- Antimicrobial inhibitors negative\n\n- No evidence of growth-inhibiting substances in the sample material.\n\n- Colony Count (CFU) / mL \\<1,000, Assessment: A low colony count\n typically does not support a urinary tract infection.\n\n- Epithelial cells (microscopic) \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic) \\<20 leukocytes/μL\n\n- Microorganisms (microscopic) 20-100 microorganisms/μL Pathogen\n Enterococci\n\n**Lab values upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- --------------------- ---------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n Calcium 10.4 mg/dL 8.8 - 10.6 mg/dL\n eGFR (MDRD) \\> 60 mL/min/1.73m² \\> 60 mL/min/1.73m²\n eGFR (CKD-EPI) 85 mL/min/1.73m² \\> 90 mL/min/1.73m²\n C-Reactive Protein 5.0 mg/dL \\< 0.5 mg/dL\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgical Procedure from 01/11/2022:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015: radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n- OSAS with CPAP incompliance\n\n<!-- -->\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for postoperative follow-up\nafter his left-sided videothoracoscopic upper lobe resection due to\npreviously diagnosed pulmonary metastatic hypopharyngeal carcinoma.\n\n**Medical History:** The patient\\'s general condition is good. He is\ncurrently on intermittent as-needed analgesia with Acetaminophen. The\nfinal resection specimen histologically confirmed the presence of a 2.9\ncm squamous cell carcinoma, consistent with a metastatic recurrence of\nthe previously known hypopharyngeal carcinoma. The dissected lymph nodes\nwere free of tumor.\n\n**Therapy and Progression**: During the follow-up appointment, Mr. Doe\nunderwent a clinical examination and a chest X-ray to assess his\npostoperative condition. The examination revealed no new concerning\nfindings, and Mr. Doe continued to remain in stable general condition.\nHis surgical incision site was inspected, showing signs of satisfactory\nhealing without any signs of infection or complications.\n\nFurthermore, Mr. Doe\\'s lung function was evaluated through spirometry,\nwhich indicated adequate pulmonary function post-surgery. He was also\nprovided with personalized recommendations for respiratory exercises to\noptimize his lung function during the recovery period.\n\n**Current Recommendations:**\n\n- Mr. Doe is connected to the radiation therapy team for ongoing\n follow-up.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgery on 01/11/2022:**\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015 Radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n**Other Diagnoses:**\n\n- OSAS with CPAP incompliance\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for routine follow-up.\nClinically, he remains in stable general condition, with no signs of\nB-symptoms.\n\n**Medical History**: The surgical procedure performed on 01/11/2022\ninvolved perioperative bronchoscopy, left VATS, pleurolysis, anatomical\nupper lobe resection, systematic mediastinal, hilar, and interlobar\nlymph node dissection, as well as the placement of double chest drains.\nHistologically, the final resection specimen confirmed a 2.9 cm solid\ncarcinoma, consistent with metastasis from the previously diagnosed\nsquamous cell carcinoma. Lymph nodes dissected during the procedure were\ntumor-free. Mr. Doe\\'s postoperative course was uneventful, and surgical\nsutures were removed on day 10 after surgery.\n\n**Physical Examination:** Patient in good general condition. Weight loss\n0°, MUST score: 0, pain VAS 1-2/10, fatigue I°, dysphagia I° with solid\nfood (liquids occasionally flow out of the nose again when swallowing),\naspiration 0°, ulcer 0°, trismus 0°, taste disorder I° (present in\napprox. 80%), xerostomia I°, osteonecrosis 0°, hypothyroidism II°,\nhoarseness II°, hearing loss, I°, dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**Current Recommendations:** Mr. Doe is advised to continue his\nfollow-up appointments.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------- ---------------------\n Neutrophils 72.2 % 42.0-77.0 %\n Lymphocytes 8.6 % 20.0-44.0 %\n Monocytes 11.6 % 2.0-9.5 %\n Basophils 1.4 % 0.0-1.8 %\n Eosinophils 6.0 % 0.5-5.5 %\n Immature Granulocytes 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 9.24 mg/dL 8.8-10.2 mg/dL\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n CRP 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n GGT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5 % 37.0-49.0 %\n RBC 3.3 M/µL 4.0-5.6 M/µL\n WBC 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Absolute Neutrophils 3.59 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.010 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.43 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.58 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.30 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94 % 0.50-2.00 %\n Ret-Hb 33.9 pg 28.5-34.5 pg\n PT 112 % \\> 78 %\n INR 0.95 \\< 1.25\n aPTT 30.2 sec. 25.0-38.0 sec.\n\n\n\n\nHere is the query:\nIn Paul Doe's frozen section report, what feature was NOT observed in the tumor cells?\n\nChoose the correct answer from the following options:\nA. Intercellular bridges\nB. Enlarged nuclei\nC. Nuclear pleomorphism\nD. Presence of large vacuoles\nE. Dyskeratosis\n\n\nYour response:\n", "role": "user" }, { "content": "Presence of large vacuoles", "role": "assistant" } ]

[ { "content": "**Dear colleague, ****Dear colleague, **\n\n \n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who was treated in our clinic from 05/28/14 to 06/20/14.\n\n \n\n**Diagnoses: **\n\n- pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left\n midline tongue carcinoma\n\n- Arterial hypertension\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Idiopathic thrombocytopenia\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Hypothyroidism\n\n- Nicotine abuse\n\n<!-- -->\n\n- Panendoscopy with sampling on 04/14/2014 and 04/26/2014\n\n \n\n**Current Presentation**: With histologically confirmed carcinoma in the\nregion of the base of the tongue on the left side, Mr. Doe presents for\nsurgical treatment of the findings. In accordance with the tumor board\ndecision, resection is performed via a lateral pharyngotomy and neck\ndissection on both sides.\n\n \n\n**Physical Examination:** Patient in stable general condition (85 kg,\n188 cm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I° (L-thyroxine increased to 150 μg 1-0-0), hoarseness\n0°, hearing loss 0° (subjectively reduced), dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\nA tumorous mass can be inspected at the base of the left tongue. Tongue\nmobility is unremarkable.\n\n**CT chest, abdomen, pelvis on 05/28/14:**\n\nEmphasized mediastinal as well as abdominal lymph\nnodes.** **Vasosclerosis. Otherwise, there is no evidence for the\npresence of distant metastases with a suspected base of tongue\ncarcinoma. Liver cirrhosis.\n\n \n\n**CT neck on 06/11/14:**\n\nSuspected left tongue base carcinoma crossing midline with extension\ninto the left vallecula and compression of the left piriform sinus with\nsuspected lymph node metastases in levels I-III ipsilateral.\nContralateral prominent but not certainly suspicious lymph nodes. The\nprominent structure on the left supraclavicular side can also be\ninterpreted as circumscribed cystiform ectasia of the thoracic duct.\n\n \n\n**Ultrasound abdomen on 06/15/14:**\n\nImage of liver cirrhosis status post cholecystectomy.\nHepatosplenomegaly. Moderate aortic sclerosis.\n\n \n\n**X-ray pap swallow on 06/17/14:**\n\nClear tracheal aspiration in the absence of epiglottis envelope. The\ncough reflex is preserved. Otherwise, essentially unremarkable\nswallowing act. \n\n \n\n**Histology**: Invasive, moderately differentiated, squamous cell\ncarcinoma with keratinization of the medial left base of the tongue,\nmaximum extent 1.0 cm. Carcinoma- and dysplasia-free biopsies of the\nleft tonsil, the oropharyngeal tumor/tongue base on the left, deep\nresection of the tumor, lower tonsillar pole transition on the left\ntongue base, tongue base on the left and medial left tongue base, as\nwell as median tongue base.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** pT1. pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n \n\n**Therapy and Progression**: After the usual clinical and laboratory\npreparations, we performed the above-mentioned therapy on 05/29/14 in\nintubation anesthesia without complications. For perioperative infection\nprophylaxis, the patient received intravenous antibiotic therapy with\nAmpicillin and Sulbactam 3g three times daily for the duration of his\nhospital stay.\n\nDuring this procedure, the left lingual artery was interrupted\nprophylactically. No postoperative bleeding and no wound healing\ndisturbances occurred.\n\nA porridge swallow examination showed no evidence of a fistula. On the\nfollowing day, the patient was decannulated in consultation with the\ncolleagues of the speech therapy. After this, a food build-up was\ncarried out in cooperation with speech therapists. At the time of\ndischarge, the patient was receiving regular oral nutrition. The stoma\ncontinued to shrink. The patient was monitored, and if necessary, the\ntracheostoma was closed with local anesthesia. Histological findings\nwere pT1. Due to an RX status, adjuvant radiotherapy will be performed\nas decided by the tumor board. A prophylactic presentation at the\ncolleagues of the MKG as a preparatory measure for the upcoming\nradiotherapy. We asked for a control re-presentation in our outpatient\nclinic on 06/26/14 at 3:00 PM. Further controls take place at the half\nand at the end of the radiotherapy and further in 4-6 weeks rhythm. In\ncase of acute complaints, an immediate re-presentation is possible at\nany time.\n\n \n\n**Type of surgery**: Lateral pharyngotomy with resection of the base of\nthe tongue on the left as well as selective neck dissection on both\nsides level II-IV with ligature of the lingual artery on the left side,\ncreation of a stable tracheostoma and tonsillectomy on the left side.\n\n**Surgery report: **First, tracheotomy in a typical manner. A horizontal\nincision was made on the skin, positioned approximately two transverse\nfinger widths above the jugulum. Subsequently, the subcutaneous tissue\nand the platysma colli were incised. To facilitate access to the\ntrachea, the laryngeal muscles were carefully displaced to the side. The\nthyroid isthmus was undermined and clamped bilaterally. A precise\ntransection of the thyroid isthmus followed, with both halves of the\nthyroid gland being meticulously sutured using 0- Vicryl. The thyroid\nhalves were repositioned to expose the trachea. A visceral tracheotomy\nwas performed, and re-intubation was achieved utilizing a U-tube. The\nsurgical procedure then transitioned to a neck dissection on the left\nside. This phase began with an incision along the anterior edge of the\nsternocleidomastoid muscle. The subcutaneous tissue and platysma colli\nwere carefully cut, with due respect to the auricularis magnus nerve.\nDissection continued dorsally along the sternocleidomastoid muscle to\nreach the anterior border of the trapezius muscle. Further exposure\ninvolved the accessorius nerve in a cranialward direction, with\npreservation of this neural structure. Dissection proceeded along the\ncervical vascular sheath, revealing the common carotid artery, internal\njugular vein, and vagus nerve up to the digastric muscle. Below this\nlevel, exposure of the hypoglossal nerve was achieved.\n\nSuccessive dissection involved the lymph node fat package, progressing\nfrom level II to level IV in a cranial to caudal and ventral to dorsal\ndirection. Throughout this process, careful attention was paid to\nsparing the aforementioned neural and vascular structures. Subsequently,\naccess to the lateral pharyngectomy area was gained, allowing\nvisualization of the external carotid artery along with its branches,\nincluding the superior thyroid artery, superior laryngeal artery, and\nlingual artery. Notably, the lingual artery was interrupted during this\nstage.\n\nFurther exploration revealed the superior laryngeal nerve and\nhypoglossal nerve intersecting in a loop above the internal carotid\nartery and externally below the external jugular vein. Additional\ndissection in a ventral direction followed. The hypoglossal nerve was\nprepared meticulously. Exposure of the hyoid bone was achieved, with a\nposterior resection of half of the hyoid bone. Importantly, the\nhypoglossal nerve was spared during this procedure. Subsequent to these\nsteps, the lateral pharynx wall was opened, exposing the base of the\nhyoid. The next phase of the procedure involved enoral tumor\ntonsillectomy on the left side. Starting from the left side, the\nsurgical team identified the tonsil capsule at the anterior palatal arch\nusing a Henke spatula. The upper tonsillar pole was then dislodged and\ndissected with the Rosenblatt instrument, proceeding from cranial to\ncaudal. Hemostasis was meticulously achieved through swab pressure and\nelectrocautery. The excised tonsil tissue was sent for frozen section\nexamination for further analysis.\n\n**Frozen Section Report: **No evidence of malignancy was found. The\nresection was carried out at the junction of the caudal tonsillar pole\nand the base of the tongue. At this location, tissue from the base of\nthe tongue was resected and sent for a frozen section examination, which\nrevealed no indication of malignancy. Subsequently, a medial resection\nof the base of the tongue was performed, confirming the presence of\nsquamous cell carcinoma in the frozen section analysis. Mucosal suturing\nwith inverting sutures was then conducted. On the left side, a neck\ndissection procedure was performed. The dissection extended along the\nsternocleidomastoid muscle, reaching dorsally to the anterior border of\nthe trapezius muscle. This approach allowed for cranial exposure of the\naccessorius nerve while sparing the same. Dissection continued along the\ncervical vascular sheath, exposing the common carotid artery, internal\njugular vein, and the vagus nerve up to the digastric muscle. Below\nthis, the hypoglossal nerve was exposed. Subsequently, the lymph node\nfat package was dissected systematically from level II to level IV,\nprogressing from cranial to caudal and ventral to dorsal, while\ncarefully preserving the mentioned structures. The surgical procedure\nconcluded with the placement of a drain, subcutaneous suturing, and skin\nsuturing.\n\n**Frozen section report:** Invasive squamous cell carcinoma.\n\n \n\n**Microscopy:**\n\nEven after paraffin embedding, mucosal cross-sections show a covering of\nstratified, non-keratinizing squamous epithelium with occasional\nsignificant stratification disturbances extending into superficial cell\nlayers. This transitions into invasive growth with solid clusters of\npolygonal tumor cells, some of which exhibit identifiable intercellular\nbridges. The cell nuclei are enlarged, round to oval, with occasional\nsmall nucleoli and mild to moderate nuclear pleomorphism. Dyskeratosis\nis observed in some areas.\n\n**Lab results upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- ----------------------- -----------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.0 mg/dL 0.7 - 1.3 mg/dL\n Calcium 9.04 mg/dL 8.8 - 10.6 mg/dL\n GFR (MDRD) \\> 60 mL/min/1.73m\\^2 \\> 60 mL/min/1.73m\\^2\n GFR (CKD-EPI,CREA) 80 mL/min/1.73m\\^2 \\> 90 mL/min/1.73m\\^2\n C-reactive protein 1.0 mg/dL \\< 0.5 mg/dL\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who presented to our outpatient clinic on 09/14/2014.\n\n**Diagnosis: **Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21)\nL0 V0 Pn0 G2 RX\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n- Since 03/2014: Odynophagia\n\n<!-- -->\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Histology:**\n\nInvasive, moderately differentiated, squamous cell carcinoma with\nkeratinization of the medial left base of the tongue, maximum extent 1.0\ncm. Carcinoma- and dysplasia-free biopsies of the left tonsil, the\noropharyngeal tumor/tongue base on the left, deep resection of the\ntumor, lower tonsillar pole transition on the left tongue base, tongue\nbase on the left and medial left tongue base, as well as median tongue\nbase.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** min pT1, pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n**Current Radiotherapy:**\n\n**Indication**: According to the decision made by the interdisciplinary\ntumor board for head and neck tumors, it was determined by our medical\nteam that, in the postoperative condition following the resection of a\ntongue base carcinoma with an unclear resection status, there is an\nindication for radiation therapy of the former tumor site.\n\n**Technique:** Percutaneous radiotherapy of the former primary tumor\nregion with 6-MeVPhotons, in Rapid-Arc technique, with a single dose of\n2 Gy up to a total dose of 60 Gy.\n\n**Radiotherapy 07/27/2014 - 09/06/2014:**\n\nDuring the course of radiotherapy, the patient experienced enoral\nmucositis (grade II according to CTCAE) leading to subsequent\nodynophagia and dysphagia. We managed these symptoms with oral rinses\nand initiated pain management using Acetaminophen, resulting in an\nacceptable reduction of pain over time. At the end of the therapy, the\npatient\\'s general condition remained stable (ECOG performance status:\n70%). Second-degree mucositis enoral persisted, causing ongoing\ndysphagia and odynophagia. Additionally, the patient exhibited localized\nradiodermatitis (grade II according to CTCAE) within the radiation\nfield. The patient did not report xerostomia or dysgeusia.\n\n**Current Recommendations:**\n\nThe patient received comprehensive instructions on continued skincare\nand side-effect management. An initial follow-up appointment with the\nradio-oncology team has been scheduled in our outpatient clinic. We\nkindly request the patient to provide a renewed referral for\nradiotherapy on the day of the appointment.\n\nThe ongoing oncological treatment plan will be determined by the\npatient\\'s Ear, Nose, and Throat specialists. Regular follow-up\nexaminations are strongly recommended. Additionally, for patients who\nhave completed radiation therapy in the ENT region, we advise lifelong\nadherence to fluoride prophylaxis and antibiotic therapy during any\ndental procedures.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965, who presented\nto our outpatient clinic for phoniatrics and pedaudiology on 10/10/2014.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Medical History: **We may kindly assume the detailed history as known.\n\n**Phoniatrics: Fiberoptic endoscopic swallow examination:**\n\nTongue motor function is well preserved, sensitivity of lip and tongue\nlaterally equal,\n\nMucous membranes non-irritant on all sides. Tracheal mucosa\nnon-irritant, no evidence of saliva intratracheal. Neopharynx\ninconspicuous, air bubbles visible above Provox outlet on pressing\nattempt. Tongue retraction slightly limited. Velopharyngeal closure\ngood.\n\n**Therapy and Course:** After completion of the adjuvant radiotherapy\napproximately 6 weeks ago, phonation via the Provox voice prosthesis was\nno longer possible after this had initially worked after the operation.\nAdditionally, there were issues with regurgitation of ingested\nsubstances, regardless of their consistency. In some cases, nasal\npenetration with fluids occurred. There were no indications of\naspiration. A self-assessment, involving the use of blue-colored liquid,\nrevealed no signs of leakage from the Provox device.\n\n**Current Recommendations:** Oncological follow-up in 12 months.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965 who presented\nat our outpatient clinic for radio-oncological follow-up on 10/09/2020.\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n \n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for a radio-oncological follow-up on 10/09/2020 in the\npresence of his wife.\n\n**Physical Examination**: Patient in stable general condition (85 kg,188\ncm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I°, hoarseness 0°, hearing loss 0° (subjectively\nreduced), dyspnea: 0°, pneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\n**MRI scan of the neck from 10/09/2020:** \n\nClear post-therapeutic changes in the resection and radiation area after\nadjuvant RTx following tumor resection with laryngectomy for extensive\nrecurrence of oropharyngeal cancer. \n\nSize constant, but still clearly accentuated lymph nodes in level Ib/IIa\non the left. Regredience of seroma formation under the left\nsternocleidomastoid muscle.\n\n**Current Recommendations: **Primary oncological care and follow-up,\nincluding imaging, will be provided by the ENT clinic according to the\nguidelines. A re-appointment for a further radio-oncological follow-up\nat the follow-up appointment at the Radiation Therapy Tumor Therapy\nCenter has been scheduled. After head and neck radiation therapy,\nregular fluoridation of the teeth and guideline-based antibiotic\nprophylaxis is required prior to major dental procedures. We also\nrecommend temporomandibular joint opening exercises to prevent\ntemporomandibular joint fibrosis and consecutive temporomandibular joint\nopening obstruction. We also refer to regular control of thyroid\nfunction parameters and, if necessary, initiation of substitution\ntherapy after radiotherapy to the neck.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe hereby report on our patient Mr. Paul Doe, born 08/08/1965 for\nradio-oncological follow-up on 09/24/2021.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for radio-oncological follow-up on 09/24/2021. \n\n**Physical Examination: **Patient in reduced general condition (KPS 60%,\n86 kg,188 cm). Weight loss 0°, MUST score: 0, pain VAS 1-2/10, fatigue\nI°, dysphagia I° with solid food (liquids occasionally flow out of the\nnose again when swallowing), aspiration 0°, ulcer 0°, trismus 0°, taste\ndisorder I° (present in approx. 80%), xerostomia I°, osteonecrosis 0°,\nhypothyroidism II°, hoarseness II°, hearing loss, I°, dyspnea: 0°,\npneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**MR neck plain + contrast agent on 09/24/2021**:\n\n[Technique]{.underline}: STIR triplanar, T1 ax -/+ contrast agent, T1\nmDixon cor after\n\ncontrast agent.\n\n[Findings]{.underline}: Known status post tumor resection with\nlaryngectomy for extensive recurrence of oropharyngeal Carcinoma;\nFollow-up after RTx. Somewhat increasing swelling of nasopharynx to\noropharynx. From the uvula the swelling is stable. As far as can be\nassessed, no clear recurrence-specific tissue proliferation or contrast\nuptake. Unchanged accentuated lymph nodes in level Ib/IIa on the left\n(one exemplary measured lymph node borderline large, idem to preliminary\nexamination). Mastoid cells minimally displaced on the left. Moderate\ndegenerative changes of the cervical spine. Assessment. Increasing\nswelling of the naso- to oropharynx. Neopharynx unchanged swollen. No\nevidence of malignancy-suspicious lymph nodes.\n\n**CT scan of the thorax on 09/24/2021**:\n\nSize-constant visualization of interlobar oval compaction in the left\nupper lobe corresponding to an interlobar lymph node. New to the\nprevious examination, two small nodular condensations appear, basal in\nthe right and in the left lower lobe, differentially inflammatory;\nfollow-up is recommended. Unchanged the prominent mediastinal lymph\nnodes, constant in size and number.\n\n**Current Recommendations:**\n\nPrimary oncologic care and follow-up including imaging will take place\nvia the ENT clinic on 01/14/22 at 11:00 AM. A re-appointment for the\nnext radio-oncological follow-up has been arranged for 01/14/2022 at\n1:00 PM in our radiotherapy outpatient clinic in the Tumor Therapy\nCenter.\n\n**Lab results upon Discharge:**\n\n**Hematology**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- -----------------------\n WBC 6,900 /μL 4,500 - 11,000 /μL\n RBC 2.7M /μL 4.5M - 5.9M /μL\n Hemoglobin 8.2 g/dL 14 - 18 g/dL\n Hematocrit 25.1 % 40 - 48 %\n MCH 31.27 pg 27 - 33 pg\n MCV 94 fL 82 - 92 fL\n MCHC 32.7 g/dL 32 - 36 g/dL\n Platelets 638,000 /μL 150,000 - 450,000 /μL\n\n**Serum chemistry**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ -----------------\n Sodium 144 mEq/L 135 - 145 mEq/L\n Potassium 4.8 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.3 mg/dL 0.7 - 1.3 mg/dL\n ALT 21 U/L 10 - 50 U/L\n eGFR 55 mL/min \\> 90 mL/min\n CRP 2.9 mg/dL \\< 0.5 mg/dL\n\n**Coagulation**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ ---------------\n PT 93 % 70 - 120 %\n INR 1.1 0.8 - 1.2\n aPTT 31 sec 26 - 37 sec\n\n**Thyroid hormones**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- ------------------\n TSH 1.16 μIU/mL 0.4 - 4.2 μIU/mL\n fT3 2.38 pg/mL 2.3 - 4.2 pg/mL\n fT4 1.70 ng/dL 0.9 - 1.7 ng/dL\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who was admitted\nto our hospital from 01/10/2022 to 01/27/2022.\n\n**Diagnosis**: Metachronous pulmonary metastatic squamous cell carcinoma\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014 Odynophagia\n\n- 05/14/2014 Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014 Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Planned Surgical Procedure:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Medical History**: Mr. Paul Doe initially presented with a diagnosis\nof pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left midline\ntongue carcinoma. Panendoscopy with specimen collection on 04/14/2014\nand 04/26/2014 confirmed carcinoma.\n\nSurgical resection was performed via lateral pharyngotomy and neck\ndissection. Histology confirmed squamous cell carcinoma. He subsequently\nreceived radiotherapy.\n\nDuring a follow-up CT examination, a suspicious lesion was identified in\nthe lung, which raised concerns regarding the possibility of metastasis\noriginating from the previously diagnosed left midline tongue carcinoma\n(pT1, pN0, G2, RX).\n\n**Current Presentation:** Mr. Doe was admitted for further examination\nand treatment to assess the behavior and extent of the lesion.\nClinically, Mr. Doe was in stable general condition and had no symptoms\nsuggestive of B symptoms.\n\n**Therapy and Progression**: The above-mentioned procedure was performed\nwithout complications on 01/10/2022. Histologically, the final resection\nspecimen confirmed the presence of a 2.9 cm squamous cell carcinoma,\nconsistent with a metastatic recurrence of the previously known\nhypopharyngeal carcinoma. The dissected lymph nodes were free of tumor.\nThe postoperative course was uneventful. In the absence of any\ncomplications, surgical sutures were removed on day 10 after surgery. A\ncurrent chest X-ray showed a regular postoperative outcome with\nsufficient expansion of the left lobe. Further monitoring is recommended\nby the treating colleagues in this regard. Mr. Doe is also connected to\nthe radiation therapy team for ongoing follow-up.\n\nIf there are any complications or questions, please contact the relevant\nward or reach out to our Central Patient Management. Outside regular\nworking hours, you can contact the on-call colleague in the Abdominal\nSurgery department for assistance.\n\nFor further information on the patient\\'s discharge management, treating\nproviders are available for inquiries from Monday to Friday, 9 AM to 7\nPM, as well as on weekends and holidays from 10 AM to 2 PM.\n\nMr. Doe was discharged from the hospital on 01/27/2022.\n\n**Addition:**\n\n**Histology Report:** Resected left upper lobe specimen with a 2.9 cm\nsolid carcinoma. The histological picture is consistent with a\nmetastasis from the previously diagnosed non-keratinizing squamous cell\ncarcinoma. There were focal vascular invasions. No pleural invasion was\nobserved. The resection was complete, with all dissected lymph nodes\nshowing no tumor involvement.\n\n**Chest X-ray, anterior-posterior view from 01/21/2022**:\n\n[Clinical Information:]{.underline} History of VATS with wedge\nresection, yesterday\\'s drain removal\n\n[Question:]{.underline} Follow-up, pneumothorax after drain removal?\nInfiltrates? Atelectasis?\n\n[Findings:]{.underline} Left chest drainage tube has been removed. Left\napical pneumothorax line, measuring approximately 2.3 cm. Continued\nextensive shadowing of the left upper field, most likely postoperative,\ninfiltrate cannot be definitively ruled out. Slightly hypotransparent\nleft lung in comparison, most likely due to residual postoperative\nreduced ventilation. No effusion. Widened cardiac silhouette. Regression\nof dystelectasis in the right lower field. No acute signs of pulmonary\nvenous congestion. Trachea is mid-positioned and not stenosed.\nLeft-sided port catheter still in place.\n\n[Summary]{.underline}: Left apical corax with a width of 2.3 cm.\nContinued extensive shadowing of the left upper field, most likely\npostoperative, with infiltrate not definitively excluded. Residual\npostoperative reduced ventilation on the left side. Regression of\ndystelectasis in the right lower field. No effusion. No acute signs of\npulmonary venous congestion. Follow-up recommended.\n\n**Examinations Chest X-ray, anterior-posterior view from 01/23/2022:**\n\n[Question]{.underline}**:** Follow-up.\n\n[Findings]{.underline}: Left apical pneumothorax, measuring\napproximately 1.4 cm. Extensive shadowing in projection onto the left\nupper lobe, differentials include postoperative changes, incipient\ninfiltrate not excluded. Dystelectasis of the right lower field. No\nevidence of pleural effusion or acute pulmonary venous congestion.\nCardiomegaly. Indwelling chest drainage with the catheter tip projecting\nonto the left upper lobe. Well-positioned port catheter tip projecting\nonto the right atrial entrance plane. No evidence of pleural effusion.\nAssessment Left apical pneumothorax, measuring approximately 1.4 cm,\nwith indwelling left chest drainage. Extensive shadowing in projection\nonto the left upper lobe, differentials include postoperative changes,\nincipient infiltrate not excluded. Dystelectasis of the right lower\nfield. No significant pleural effusion. No acute pulmonary venous\ncongestion. Cardiomegaly.\n\n**Chest X-ray, anterior-posterior view from 01/25/2022**\n\n[Previous Examinations]{.underline}: Appearance of a diffuse\npostoperative shadow in the left upper field. No evidence of pleural\neffusion, inflammatory infiltrate, or pulmonary venous congestion.\n\n[Findings]{.underline}: Left-sided chest port with the tip projecting\nonto the superior vena cava. The upper mediastinum is narrow, the\ntrachea is mid-positioned and patent.\n\n[Assessment]{.underline}: The pneumothorax appears to be largely\nresolved.\n\n**Urinanalysis**:\n\nMaterial: Urine, midstream sample collected on 01/11/2022\n\n- Antimicrobial inhibitors negative\n\n- No evidence of growth-inhibiting substances in the sample material.\n\n- Colony Count (CFU) / mL \\<1,000, Assessment: A low colony count\n typically does not support a urinary tract infection.\n\n- Epithelial cells (microscopic) \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic) \\<20 leukocytes/μL\n\n- Microorganisms (microscopic) 20-100 microorganisms/μL Pathogen\n Enterococci\n\n**Lab values upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- --------------------- ---------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n Calcium 10.4 mg/dL 8.8 - 10.6 mg/dL\n eGFR (MDRD) \\> 60 mL/min/1.73m² \\> 60 mL/min/1.73m²\n eGFR (CKD-EPI) 85 mL/min/1.73m² \\> 90 mL/min/1.73m²\n C-Reactive Protein 5.0 mg/dL \\< 0.5 mg/dL\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgical Procedure from 01/11/2022:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015: radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n- OSAS with CPAP incompliance\n\n<!-- -->\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for postoperative follow-up\nafter his left-sided videothoracoscopic upper lobe resection due to\npreviously diagnosed pulmonary metastatic hypopharyngeal carcinoma.\n\n**Medical History:** The patient\\'s general condition is good. He is\ncurrently on intermittent as-needed analgesia with Acetaminophen. The\nfinal resection specimen histologically confirmed the presence of a 2.9\ncm squamous cell carcinoma, consistent with a metastatic recurrence of\nthe previously known hypopharyngeal carcinoma. The dissected lymph nodes\nwere free of tumor.\n\n**Therapy and Progression**: During the follow-up appointment, Mr. Doe\nunderwent a clinical examination and a chest X-ray to assess his\npostoperative condition. The examination revealed no new concerning\nfindings, and Mr. Doe continued to remain in stable general condition.\nHis surgical incision site was inspected, showing signs of satisfactory\nhealing without any signs of infection or complications.\n\nFurthermore, Mr. Doe\\'s lung function was evaluated through spirometry,\nwhich indicated adequate pulmonary function post-surgery. He was also\nprovided with personalized recommendations for respiratory exercises to\noptimize his lung function during the recovery period.\n\n**Current Recommendations:**\n\n- Mr. Doe is connected to the radiation therapy team for ongoing\n follow-up.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgery on 01/11/2022:**\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015 Radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n**Other Diagnoses:**\n\n- OSAS with CPAP incompliance\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for routine follow-up.\nClinically, he remains in stable general condition, with no signs of\nB-symptoms.\n\n**Medical History**: The surgical procedure performed on 01/11/2022\ninvolved perioperative bronchoscopy, left VATS, pleurolysis, anatomical\nupper lobe resection, systematic mediastinal, hilar, and interlobar\nlymph node dissection, as well as the placement of double chest drains.\nHistologically, the final resection specimen confirmed a 2.9 cm solid\ncarcinoma, consistent with metastasis from the previously diagnosed\nsquamous cell carcinoma. Lymph nodes dissected during the procedure were\ntumor-free. Mr. Doe\\'s postoperative course was uneventful, and surgical\nsutures were removed on day 10 after surgery.\n\n**Physical Examination:** Patient in good general condition. Weight loss\n0°, MUST score: 0, pain VAS 1-2/10, fatigue I°, dysphagia I° with solid\nfood (liquids occasionally flow out of the nose again when swallowing),\naspiration 0°, ulcer 0°, trismus 0°, taste disorder I° (present in\napprox. 80%), xerostomia I°, osteonecrosis 0°, hypothyroidism II°,\nhoarseness II°, hearing loss, I°, dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**Current Recommendations:** Mr. Doe is advised to continue his\nfollow-up appointments.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------- ---------------------\n Neutrophils 72.2 % 42.0-77.0 %\n Lymphocytes 8.6 % 20.0-44.0 %\n Monocytes 11.6 % 2.0-9.5 %\n Basophils 1.4 % 0.0-1.8 %\n Eosinophils 6.0 % 0.5-5.5 %\n Immature Granulocytes 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 9.24 mg/dL 8.8-10.2 mg/dL\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n CRP 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n GGT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5 % 37.0-49.0 %\n RBC 3.3 M/µL 4.0-5.6 M/µL\n WBC 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Absolute Neutrophils 3.59 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.010 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.43 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.58 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.30 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94 % 0.50-2.00 %\n Ret-Hb 33.9 pg 28.5-34.5 pg\n PT 112 % \\> 78 %\n INR 0.95 \\< 1.25\n aPTT 30.2 sec. 25.0-38.0 sec.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Anna Sample, born on\n01.01.1970. She was admitted to our clinic from 01/01/2017 to\n01/02/2017.\n\n**Diagnosis:** Diffuse large B-cell lymphoma of germinal center type; ID\n01/2017\n\n- Ann-Arbor: Stage IV\n\n- R-IPI: 2 (LDH, stage)\n\n- CNS-IPI: 2\n\n- Histology: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\n translocation. Ki-67 at 40%. Positive reaction to MUM1, numerous\n CD68-positive macrophages. Negative reaction to ALK1 and TdT.\n\n- cMRI: Chronic inflammatory lesions suggestive of Multiple Sclerosis (MS)\n\n- CSF: no evidence of malignancy\n\n- Bone marrow aspiration: no infiltration from the pre-existing\n lymphoma.\n\n**Current treatment: **\n\nInitiated R-Pola-CHP regimen q21\n\n- Polatuzumab vedotin: 1.8mg/kg on Day 1.\n\n- Rituximab: 375mg/m² on Day 0.\n\n- Cyclophosphamide: 750mg/m² on Day 1.\n\n- Doxorubicin: 50mg/m on Day 1.\n\n- Prednisone: 100mg orally from Day 1-5.\n\n**Previous therapy and course**\n\nFrom 12/01/2016: Discomfort in the dorsal calf and thoracic spine,\nweakness in the arms with limited ability to lift and grasp, occasional\ndizziness.\n\n12/19/2016 cMRI: chronic inflammatory marks indicative of MS. \n\n12/20/2016 MRI: thoracic/lumbar spinal cord: Indication of a\nmetastatic mass starting from the left pedicle T1 with a significant\nextraosseous tumor element and full spinal narrowing at the level of\nT10-L1 with pressure on the myelon and growth into the neuroforamen\nT11/T12 on the right and T12/L1 left. More lesions suggestive for\nmetastasis are L2, L3, and L4, once more with extraosseous tumor element\nand invasion of the left pedicle.\n\n12/21/2016 Fixed dorsal support T8-9 to L3-4. Decompression via\nlaminectomy T10 and partial laminectomy lumbar vertebra 3.\n\n12/24/2016 CT chest/abdomen/pelvis: Magnified left axillary lymph node.\nIn the ventral left upper lobe, indication of a round, loose, cloudy\ndeposit, i.e., of inflammatory origin, follow-up in 5-7 weeks.\nNodule-like deposit in the upper inner quadrant of the right breast,\nsenological examination suggested.\n\n**Pathology**: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\ntranslocation. Ki-67 staining was at 40%. Positive reaction to MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\n**Other diagnoses**\n\n- Primary progressive type of multiple sclerosis (ID 03/02) \n\n- Mood disorder.\n\n- 2-vessel CHD\n\n**Medical History**\n\nMrs. Sample was transferred inpatient from DC for the initiation of\nchemotherapy (R-Pola-CHP) for her DLBCL. In the context of her\npre-existing ALS, she presented on 12/19/2016 with acute pains and\nrestricted mobility in her upper limbs. After her admission to HK\nFlowermoon, an MRI was performed which revealed a thoracic neoplastic\ngrowth especially at the level of T10-L1, but also affecting lumbar\nvertebra 3, L4 and L6. Surgical intervention on 12/21/2016 at DC\nresulted in symptom relief. Presently, her complaints are restricted to\npost-operative spine discomfort, shoulder hypoesthesia, and intermittent\nhand numbness. She reported a weight loss of 5 kg during her\nhospitalization. She denied having respiratory symptoms, infections,\nsystemic symptoms, or gastrointestinal complaints. Mrs. Sample currently\nhas a urinary catheter in place.\n\n**Physical examination on admission**\n\nGeneral: The patient has a satisfactory nutritional status, normal\nweight, and is dependent on a walker. Her functional status is evaluated\nas ECOG 2. Cardiovascular: Regular heart rhythm at a normal rate. Heart\nsounds are clear with no detected murmurs. Respiratory: Normal alveolar\nbreath sounds. No wheezing, stridor, or other abnormal sounds.\nAbdominal: The abdomen is soft, non-tender, and non-distended with\nnormal bowel sounds in all quadrants. There is no palpable enlargement\nof the liver or spleen, and the kidneys are not palpable.\nMusculoskeletal: Tenderness noted in the cervical and thoracic spine\narea, but no other remarkable findings. This is consistent with her\npost-operative status. Lymphatic: No enlargement detected in the\ntemporal, occipital, cubital, or popliteal lymph nodes. Oral: The oral\nmucosa is moist and well-perfused. The oropharynx is unremarkable, and\nthe tongue appears normal. Peripheral Vascular: Pulses in the hands are\nstrong and regular. No edema observed. Neurological: Cranial nerves are\nintact. There is numbness in both hands and mild hypoesthesia in the\nshoulders. Motor strength is 3/5 in the right arm, attributed to her\nknown ALS diagnosis. No other motor or sensory deficits noted.\nOccasional bladder incontinence and intermittent gastrointestinal\ndisturbances are reported.\n\n**Medications on admission**\n\nAcetylsalicylic acid (Aspirin®) 100 mg: Take 1 tablet in the morning.\nAtorvastatin (Lipitor®) 40 mg: Take 1 tablet in the evening. Fingolimod\n(Gilenya®) 0.5 mg: Take 1 capsule in the evening. Sertraline (Zoloft®)\n50 mg: Take 2 tablets in the morning. Hydromorphone (Dilaudid® or\nExalgo® for extended-release) 2 mg: Take 1 capsule in the morning and 1\nin the evening. Lorazepam (Ativan®) 1 mg: 1 tablet as needed.\n\n**Radiology/Nuclear Medicine**\n\n**MR Head 3D unenhanced + contrast from 12/19/2016 10:30 AM**\n\n**Technique:** Sequences obtained include 3D FLAIR, 3D DIR, 3D T2, SWI,\nDTI/DWI, plain MPRAGE, and post-contrast MPRAGE. All images are of good\nquality. Imaging area: Brain.\n\nThere are 20 FLAIR hyperintense lesions in the brain parenchyma,\nspecifically located periventricularly and in the cortical/juxtacortical\nregions (right and left frontal, left temporal, and right and left\ninsular). No contrast-enhancing lesions are identified. There are also\nsubcortical/nonspecific lesions present, with some lesions appearing\nconfluent. The spinal cord is visualized up to the C4 level. No spinal\nlesions are noted.\n\n[Incidental findings:]{.underline}\n\n- Brain volume assessment: no indication of reduced brain volume.\n\n- CSF space: age-appropriate usual wide, moderate, and symmetric CSF\n spacing with no signs of CSF flow abnormalities.\n\n- Cortical-Subcortical Differentiation: Clear cortical-subcortical\n distinction.\n\n- RML-characteristic alterations: none detected.\n\n- Eye socket: appears normal.\n\n- Nasal cavities: Symmetric mucosal thickening with a focus on the\n right ethmoidal sinus.\n\n- Pituitary and peri-auricular region: no abnormalities.\n\n- Subcutaneous lesion measuring 14.4 x 21.3 mm, right parietal likely\n representing an inflamed cyst or abscess, differential includes soft\n tissue growth.\n\n[Evaluation]{.underline}\n\nDissemination: MRI standards for spatial distribution are satisfied. MRI\ncriteria for temporal distribution are unfulfilled. Comprehensive\nneurological review: The findings are consistent with a chronic\ninflammatory CNS disease in the sense of Multiple Sclerosis.\n\n**MR Spine plain + post-contrast from 12/20/2016 10:00 AM**\n\n**Technique:** GE 3T MRI Scanner\n\nMRI was conducted under anesthesia due to claustrophobia.\n\n**Sequences**: Holospinal T2 Dixon sagittal, T1 pre-contrast, T1 fs\npost-contrast. The spine is visualized from the craniocervical junction\nto S2.\n\n**Thoracic spine: **\n\nOn T2-STIR and T2, there is a hyperintense signal of vertebral bodies T5\nand T6 with inconsistent delineation of the vertebral endplates,\nindicative of age-related changes. There is a reduction in the height of\nthe disc spaces T4/5 and T5/6 with subligamentous disc protrusion\nleading to a spongy appearance of the spinal cord at this location.\nMyelon atrophy is noted at T5/6, along with a T2 bright lesion\nsuggestive of MS at the level of T3 and also T4/5. Spine: A large\nintraspinal mass extends from T10-L1, causing an anterior spongy\nappearance of the spinal cord and resulting in complete spinal canal\nstenosis at this level. On fat-only imaging, there is almost total\nreplacement of the marrow space of vertebral body T11 with external\ntumor extension and infiltration into the lateral structures (more on\nthe left than the right) and neural foramen T11 on both sides. There is\nmild disc herniation at T8/9 with slight sponginess of the spinal cord.\nMS-characteristic spinal cord lesions are noted at segments T5 and T8/9.\n\n**Lumbar spine: **\n\nT2-DIXON shows bright signal intensity of the anterior part of lumbar\nvertebra 1, a patchy appearance of lumbar vertebra 2, and lumbar\nvertebra 4. Almost the entire marrow space is replaced in the fat-only\nimaging. There is an external tumor mass posterior to lumbar vertebra 4\nwithout significant spinal canal stenosis, which involves the left\nlateral structure and a pronounced appearance of the cauda equina at\nlumbar vertebra 1. A call to communicate the results was made at 11:15\na.m. to the on-duty orthopedic surgeon and to colleagues in neurology.\nEvaluation Evidence of a metastatic lesion originating from the left\npedicle of T10 with a significant extramedullary tumor mass and full\nspinal canal narrowing at the level of T10 with compression of the\nspinal cord and extension into the neural foramen T11-T12 on the right,\nand T12-L1 on the left. Additional sites suggestive of metastasis\ninclude L2, L3, and L4, again with extramedullary tumor components and\ninvasion of the left lateral structure. Contrast enhancement of the\ndistal cord is noted. There are MS-characteristic spinal cord lesions at\nthe levels of T3, T4-5, T5, and T8-9. The conus medullaris is not\nvisualized due to spinal cord displacement.\n\n\n**CT Thoracic Spine from 01/03/2017**\n\n[Clinical Findings]{.underline}\n\nLateral and medial alignment is stable. No sign of vertebral column\ndamage. Multiple segment degenerative alterations in the spine. No\nindications of mineralization in the recognized space at the level of\nT10/L2. Invasion of T10 and L4 with composite osteolytic-osteoblastic\ndefects starting from the left pedicle into the vertebral column. More\ncortical inconsistency with enhanced sclerosis at the endplate of L2.\nReview with prior MRI indicative of a different composite defect. Defect\npit at the endplate of lumbar vertebra 2.\n\nMinor pericardial effusion with nearby superior ventilation. Intubation\ntube placed. Mild cardiomediastinum. Splenomegaly. Standard display of\nthe tissue organs of the mid-abdomen, as naturally observed. Normal\nspleen. Thin adrenals. Tightly raised kidney bowls and leading ureter\nfrom both aspects, e.g., upon entry during the exhalation period after\ngadolinium inclusion in the earlier MRI. No bowel obstruction.\nIntestinal stasis. No sign of abnormally magnified lymphatic vessels.\nRemaining pin holes in the femoral head on both sides.\n\n[Evaluation]{.underline}\n\nComposite osteolytic-osteoblastic defects starting from the left pedicle\nin T10 and lumbar vertebra 4, and at the endplate of lumbar vertebra 2.\n\n**CT Thoracic Spine from 01/04/2017 **\n\nIntraoperative CT imaging for enhanced guidance.\n\nTwo intraoperative CT scans were undertaken in total.\n\nOn the concluding CT scan, recently implanted non-radiopaque pedicle\nscrews T8-9 to L2-L3 at tumor band T10. Regular screw placement. No\nevident sign of material breakage.\n\nApart from this, no notable alteration in findings from CT of\n01/03/2017.\n\nEvaluation Intraoperative CT imaging for better guidance. Recently\ninserted pedicle screws T8/T9 and L2/L3 in tumor indication T10,\nultimate standard screw positioning done transpedicular.\n\n**CT Chest/Abdomen/Pelvis + Contrast from 01/09/2017**\n\nResults: After uneventful intravenous administration of Omnipaque 320, a\nmulti-slice helical CT of the chest, abdomen, and pelvis was performed\nduring the venous phase of contrast enhancement. Additional oral\ncontrast was given using Gastrografin (diluted 1:35). Thin slice\nreconstructions were obtained, along with secondary coronal and sagittal\nreconstructions.\n\n[Thorax]{.underline}:\n\nUniform presentation of the apical thoracic sections when included. No \nevidence of subclavian lymphadenopathy. Uniform visualization of the pectoral \ntissues. No evidence of mediastinal lymphadenopathy. The anterior segment \nof the left upper lobe (series 205, image 88 of 389) shows a subpleural \nground-glass opaque solid consolidation. There is an enlarged lymph node \nin the left hilar region measuring approximately 1.2 cm laterally. Otherwise, \nthere are no signs of suspicious intrapulmonary markings, no new inflammatory \ninfiltrates, no pneumothorax, no pericardial effusion. In the upper inner \nquadrant of the right breast there is an oval mass, DD cystadenoma, \nDD glandular cluster (measuring 1.2 cm).\n\n[Abdomen/pelvis: ]{.underline}\n\nDominant display of the gastrocolic junction; absence of oral contrast\nin this zone prevents more detailed analysis. Uniformly displayed\nhepatic tissue with no signs of focal, density-varied lesions. Portal\nand liver veins are well filled. Liver with minor auxiliary liver.\nAdrenal nodes thin on both sides. Natural kidneys on both sides. Urinary\nsac with placed transurethral tube and intravesical gas pockets.\nGallbladder typical. Paravertebral and within vertebral and in the\ndomain of the superior hepatic artery multiple pronounced lymph nodes,\nthese up to a maximum of 8 mm. Typical representation of the organs in\nthe pelvic region.\n\n[Skeleton: ]{.underline}\n\nCondition post dorsal reinforcement (T8-T9-L2-L3). After surgery,\nepidermal air pockets and bloated tissue inflammation in the access path\nzone. Signs of a resin in a pre-spinal vessel anterior to T8 and T9.\nKnown mixed osteoblastic/osteolytic bony metastasis of lumbar vertebra 4\nand the cap plate of lumbar vertebra 2. State post-cutting of the\npedicle of T10. L5 also with slightly multiple solidified core\nosteolytic defects.\n\n[Evaluation:]{.underline}\n\n- No sign of primary malignancy in the previously mentioned mixed\n osteoblastic/osteolytic lesions in the vertebra (to be deemed\n suspicious in coordination with the MR review of 12/20/2016).\n\n- A magnified lymph node exists in the left hilar territory. In the\n anterior left upper lobe, evidence of a solid cloudy consolidation,\n i.e., of inflammatory origin, revisitation in 5-7 weeks recommended.\n\n- Rounded consolidation in the upper inner quadrant of the right\n breast, further breast examination advised.\n\n**Functional Diagnostics**\n\nExtended Respiratory Function (Diffusion) from 01/15/2017\n\n[Evaluation]{.underline}\n\nPatient cooperation: satisfactory. No detectable obstructive ventilation\nissue. No pulmonary over-expansion after RV/TLC. No identified\nrestrictive ventilation impairment. Standard O2 diffusion ability. No\nevidence of low oxygen levels, no blockage.\n\n[Consultations / Therapy Reports]{.underline}\n\nPsychological Support Consultation from 01/22/2017\n\n[Current Situation/History:]{.underline}\n\nThe patient initially discussed \\\"night episodes\\\" in the calves, which\nover time manifested during the day and were coupled with discomfort in\nthe cervical region. Prior, she had visited the Riverside Medical Center\nmultiple times before an MRI was executed. A \\\"mass in the neck\\\" was\nidentified. Since she suffers from fear of heights and fear of crowds,\nthe MRI could only be done under mild sedation. The phobias emerged\nabruptly in 2011 with no apparent cause, leading to multiple hospital\nvisits. She is now in outpatient care. Additionally, she battles with\nMS, with the most recent flare-up in 2012. She declined a procedure,\nwhich was set for the MRI is day, because \\\"two sedatives in one day\nfelt excessive.\\\" She anticipates avoiding a repeated procedure.\nCurrently, however, she still experiences spasms in her right hand and a\nnumbing sensation in her fingers. She still encounters discomfort (NRS\n5/10). She was previously informed that relief might be gradual, but she\nis \\\"historically been restless\\\". Therefore, \\\"resting and inactivity\\\"\nnegatively impact her spirits and rest.\n\n[Medical background:]{.underline}\n\nSeveral in-patient and day clinic admissions since 2011.\n\nNow, from 2015, continuous outpatient psychological counseling (CBT),\nsomatic therapy, particular sessions for driving anxieties. Also\nundergoing outpatient psychiatric care (fluoxetine 90mg).\n\n[Psychopathological Observations:]{.underline}\n\nPatient appears well-groomed, responsive and clear-minded, talkative and\nforthright. Aware of location, date, and identity. Adequate focus,\nrecall, and concentration. Mental organization is orderly. No evidence\nof delusional beliefs or identity disturbances. No compulsions, mentions\nfear of expansive spaces and fear of water. Emotional responsiveness\nintact, heightened psychomotor activity. Mood swings between despondent\nand irritable, lowered motivation. Diminished appetite, issues with\nsleep initiation and maintenance. Firm and believable denial of\nimmediate suicidal thoughts, patient appears cooperative. No current\nsigns of self-harm or threat to others.\n\n[Handling the Condition, Strengths:]{.underline}\n\nCurrently, her coping strategy seems to be proactive with some restless\nelements. Ms. S. says she remains \\\"optimistic\\\" and is well-backed by\nher communal links. Notably, she shares a close bond with her\n80-year-old aunt. Her other social bonds primarily arise from her\nassociation with a hockey enthusiasts club. Hockey has been a crucial\nsupport for her from a young age.\n\n[Evaluation Diagnoses:]{.underline}\n\nAdjustment disorder: anxiety and depressive reaction mixed\n\nAgoraphobia\n\nAcrophobia\n\n[Interventions, approaches:]{.underline}\n\nAn evaluative and assistive discussion was conducted. The patient has a\ndependable therapeutic community for post-hospitalization. Additionally,\nshe was provided the contact of the psychological support outpatient\ncenter. She mentioned finding the therapeutic conversation comforting,\nprompting an arranged check-in the subsequent week. We also suggest\nguidance in self-initiated physical activities to aid her recovery and\ntemper restlessness.\n\n**NC: Consultation of 01/15/2017**\n\n[Examination findings:]{.underline}\n\nPatient alert, fully oriented. Articulate and spontaneous speech.\nCranial nerve evaluation normal. No evident sensorimotor abnormalities.\nBDK with voiding challenges. Sphincter response diminished, but fecal\ncontrol maintained. KPPS at 85%. Wound site clean and non-irritated,\nexcept for the lower central portion.\n\n[Procedure:]{.underline}\n\nNeurosurgical intervention not required; no reassessment of the lower\nwound needed. Advise return if neurological symptoms intensify.\n\nThe patient, diagnosed with relapsing-remitting multiple sclerosis that\ninitially manifested aggressively, has been relapse-free on fingolimod\nsince 2009 and was generally well, barring a slight imbalance when\nwalking due to minor weakness in her left leg. She later experienced\nnumbness and weakness in her legs, reaching up to the hip, persisting\nfor several days and then faced challenges with urination and bowel\nmovements approximately 7 weeks prior. During a home examination, a\nlesion was identified in the T10 which was surgically addressed by our\nin-house neurosurgery team. Histology identified it as a DLBCL, leading\nto a chemotherapy plan inclusive of Rituximab. Post-surgery, her\nsymptoms have subsided somewhat, but the patient still has BDK and\nrelies on a wheelchair.\n\nOn clinical neurological assessment, a mild paraparesis was noted in her\nleft leg, accompanied by heightened reflex response and sporadic left\nfoot spasms, which were intense but temporary.\n\nTo conclude, the new neurological manifestations are not a recurrence of\nthe formerly stable multiple sclerosis. As Rituximab is also an\neffective third-phase drug for MS treatment and is essential,\ndiscontinuing fingolimod (second phase) was discussed with the patient.\nAfter a span of approximately 4-5 months following the last Rituximab\ntreatment, a radiological (cMRI) and clinical review is suggested. Based\non results, either resuming fingolimod or, if no adverse effects\npresent, potentially continuing Rituximab treatment is recommended (for\nthis, reach our neuroimmunology outpatient department). The primary\nneurologist was unavailable for comments.\n\n**Boards**\n\nOncology tumor board as of 01/22/2017\n\n6 cycles of R-Pola-CHP\n\n[Pathology]{.underline}\n\nPathology. Findings from 01/05/2017\n\n[Clinical information/question:]{.underline}\n\nTumor cuff T10. dignity? Entity? Macroscopy:\n\n1st lamina T10: fixed. some assembled 0.7 x 0.5 x 0.2 cm calcareous\ntissue fragments. Complete embedding. Decalcify in EDTA. 2nd ligament:\nFix. some assembled 0.9 x 0.7 x 0.2 cm, coarse, partly also calcareous\ntissue fragments. Complete embedding. Decalcify overnight in EDTA.\n\n3\\. epidural tumor: Numerous beige-colored tissue fragments, 3.8 x 2.8 x\n0.6 cm. Embedding of exemplary sections after lamellation.\n\n[Processing]{.underline}: 1 block, HE. Microscopy:\n\n1\\. and 2. (lamina T10 and ligament) are still being decalcified.\n\n3rd epidural tumor: Paravertebral soft tissue with infiltrates of a\npartly lymphoid, partly blastic neoplasia. The tumor cells are diffuse,\nsometimes nodular in the tissue and have hyperchromatic nuclei with\ncoarse-grained chromatin and a narrow cytoplasmic border. There are also\nblastic cells with enlarged nuclei, vesicular chromatin, and sometimes\nprominent nucleoli. The stroma is loose and vacuolated. Clearly\npronounced crush artifacts.\n\nPreliminary report of critical findings:\n\n3\\. epidural tumor: paravertebral soft tissue with infiltrates of\nlymphoid and blastic cells compatible with hematologic neoplasia.\n\nAdditional immunohistochemical staining is being performed to further\ncharacterize the tumor. In addition, material 1 (lamina T10) and\nmaterial 2 (ligament) are still undergoing decalcification. A follow-up\nreport will be provided.\n\nProcessing: 2 blocks, decalcification, HE, Giemsa, IHC: CD20, PAX5,\nBcl2, Bcl6, CD5, CD3, CD23, CD21, Kappa, Lambda, CD10, c-Myc, CyclinD1,\nCD30, MIB1, EBV/EBER.\n\nMolecular pathology: testing for B-cell clonal expansion and IgH/Bcl2\ntranslocation.\n\n[Microscopy]{.underline}:\n\n1\\. Ligament: Scarred connective tissue and fragmented bone tissue\nwithout evidence of the tumor described in the preliminary findings\nunder 3.\n\n2\\. Lamina T10: Bone tissue without evidence of the tumor described in\nthe preliminary findings under 3.\n\n3\\. Epidural tumor: Immunohistochemically, blastic tumor cells show a\npositive reaction after incubation with antibodies against CD20, PAX5\nand BCL2. Partially positive reaction against Bcl-6 (\\<20%). Some\nisolated blastic cells staining positive for CD30. Lymphoid cells\npositive for CD3 and CD5. Some residual germinal centers with positive\nreaction to CD23 and CD21. Predominantly weak positive reaction of\nblasts and lymphoid cells to CD10. Some solitary cells with positive\nreaction to kappa, rather unspecific, flat reaction to lambda. No\noverexpression of c-Myc or cyclinD1. No\n\nNo reaction to EBV/EBER. The Ki-67 proliferation index is 40%, related\nto blastic tumor cells \\> 90%.\n\nSignificantly limited evaluability of immunohistochemical staining due\nto severe squeezing artifacts of the material.\n\n[Molecular pathology report:]{.underline}\n\nExamination for clonal B-cell expansion and t(14;18) translocation\nMethodology:\n\nDNA was isolated from the sent tissues and used in duplicate in specific\nPCRs (B-cell clonality analysis with Biomed-2 primer sets: IGHG1 gene:\nscaffold 2 and 3). The size distribution of the PCR products was further\nanalyzed by fragment analysis.\n\nTo detect a BCL2/IgH fusion corresponding to a t(14;18) translocation,\nDNA was inserted into a specific PCR (according to Stetler-Stevenson et\nal. Blood. 1998;72:1822-25).\n\nResults:\n\nAmplification of isolated DNA: good. B cell clonality analyses\n\nIGHG1 fragment 2: polyclonal signal pattern.\n\nIGHG1 frame 3: reproducible clonal signal at approximately 115/116 bp.\nt(14;18) translocation: negative.\n\n[Molecular pathology report:]{.underline}\n\nMolecular pathologic evidence of clonal B-cell expansion. No evidence of\nt(14;18) translocation in test material with normal control reactions.\n\nPreliminary critical findings report:\n\n1\\. Lamina TH 10: tumor-free bone tissue.\n\n2\\. Ligament: Tumor-free, scarred connective tissue and fragmented bone\ntissue.\n\n3\\. Epidural tumor: aggressive B non-Hodgkin\\'s lymphoma.\n\nFindings (continued)\n\nAdditional findings from 01/06/2017\n\nImmunohistochemical processing: MUM1, ALK1, CD68, TdT. Microscopy:\n\n3\\. Immunohistochemically, blastic tumor cells are positive for MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\nCritical findings report:\n\n1\\. Lamina T10: Tumor-free bone tissue. 2: Tumor free, scarred connective\ntissue and fragmented bone tissue.\n\n3\\. epidural tumor: aggressive B-non-Hodgkin lymphoma, morphologically\nand immunohistochemically most compatible with diffuse large B-cell\nlymphoma (DLBCL, NOS) of germinal center type according to Hans\nclassifier (GCB).\n\n**Path. Findings from 01/05/2017**\n\nClinical Findings\n\nClinical data:\n\nInitial diagnosis of DLBCL with spinal involvement.\n\nPuncture Site(s): 1\n\nCollection date: 01/04/2017\n\nArrival at cytology lab: 01/04/2017, 8 PM. Material:\n\n1 Liquid Material: 2 mL colorless, clear Processing:\n\nMGG staining Microscopic:\n\nZTA:\n\nLiquid precipitate Erythrocytes\n\n(+) Lymphocytes (+) Granulocytes\n\nEosinophils Histiocytes Siderophages\n\n\\+ Monocytes\n\nOthers: Isolated evidence of fewer monocytes. No evidence of atypical\ncells. Critical report of findings:\n\nCSF sediment without evidence of inflammation or malignancy. Diagnostic\nGrading:\n\nNegative\n\nTherapy and course\n\nMrs. S was admitted from the neurosurgical department for chemotherapy\n(R-POLA-CHP) of suspected DLBCL with spinal/vertebral manifestations.\n\nAfter exclusion of clinical and laboratory contraindications,\nantineoplastic therapy was started on 01/08/2017. This was well\ntolerated under the usual supportive measures. There were no acute\ncomplications.\n\nDuring her hospitalization, Ms. S reported numbness in both vascular\nhemispheres. A neurosurgical and neurological presentation was made\nwithout acute need for action. In consultation with the neurology\ndepartment, the existing therapy with fingolimod should be discontinued\ndue to the concomitant use of rituximab and the associated risk of PML.\nIf necessary, re-exposure to fingolimod may be considered after\ncompletion of oncologic therapy.\n\nOn 01/07/2017, a port placement was performed by our vascular surgery\ndepartment without complications.\n\nOn 01/19/2017, a single administration of Pegfilgrastim 6 mg s.c. was\nperformed. With a latency of 10 days, G-CSF should not be repeated in\nthe meantime.\n\nWe are able to transfer Mrs. S to the Mountain Hospital Center\n(Neurological Initial Therapy & Recovery) on 02/01/2017. We thank you\nfor accommodating the patient and are available for any additional\ninquiries.\n\n**Medications at Discharge**\n\n**Aspirin (Aspirin®)** - 100mg, 1 tablet in the morning\n\n**Atorvastatin - 40mg -** 1 tablet at bedtime\n\n**Sertraline - 50mg** - 2 tablets in the morning\n\n**Lorazepam (Tavor®)** - 1mg, as needed\n\n**Fingolimod** - 0.5mg, 1 capsule at bedtime, Note: Take a break as\ndirected\n\n**Hydromorphone hydrochloride** - 2mg (extended-release), 2 capsules in\nthe morning and 2 capsules at bedtime\n\n**Melatonin -** 2mg (sustained-release), 1 tablet at bedtime\n\n**Baclofen (Lioresal®) -** 10mg, 1 tablet three times a day\n\n**Pregabalin -** 75mg, 1 capsule in the morning and 1 capsule at bedtime\n\n**MoviCOL® (Macrogol, Sodium chloride, Potassium chloride) -** 1 packet\nthree times a day, mixed with water for oral intake\n\n**Pantoprazole -** 40mg, 1 tablet in the morning\n\n**Colecalciferol (Vitamin D3) -** 20000 I.U., 1 capsule on Monday and\nThursday\n\n**Co-trimoxazole -** 960mg, 1 tablet on Monday, Wednesday, and Friday\n\n**Valaciclovir -** 500mg, 1 tablet in the morning and 1 tablet at\nbedtime\n\n**Prednisolone -** 50mg, 2 tablets in the morning, Continue through\n02/19/2017\n\n**Enoxaparin sodium (Clexane®) -** 40mg (4000 I.U.), 1 injection at\nbedtime, Note: Continue in case of immobility\n\n**Dimenhydrinate (Vomex A®)** - 150mg (sustained-release), as needed for\nnausea, up to 2 capsules daily.\n\n**Procedure**\n\n**Oncology board decision: 6 cycles of R-Pola-CHP.**\n\n- Fingolimod pause, re-evaluation in 4-5 months.\n\n- Continuation of therapy near residence in the clinic as of\n 02/28/2017\n\n- Bi-Weekly laboratory tests (electrolytes, blood count, kidney and\n liver function tests)\n\n- In case of fever \\>38.3 °C please report immediately to our\n emergency room\n\n- Immediate gynecological examination for nodular mass in the left\n breast\n\nDates:\n\n- From 03/01/2017 third cycle of R-Pola-CHP in the clinic. The patient\n will be informed of the date by telephone.\n\nIf symptoms persist or exacerbate, we advocate for an urgent revisit.\nOutside standard working hours, emergencies can also be addressed at the\nemergency hub.\n\nDuring discharge management, the patient was extensively educated and\nassisted, and equipped with required appliances, medication scripts, and\nabsence from work notices.\n\nAll observations were thoroughly deliberated upon. Multiple alternate\ntherapy notions were considered before making a treatment proposition.\nThe opportunity for a second viewpoint and recommendation to our\nfacility was also emphasized.\n\n**Lab values at discharge: **\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 136 mEq/L 135 - 145 mEq/L\n Potassium 3.9 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.2 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 19 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 138 U/L 40 - 129 U/L\n Total Bilirubin 0.3 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 82 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 42 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 34 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 366 U/L \\< 244 U/L\n Uric Acid 4.1 mg/dL 3 - 7 mg/dL\n Calcium 9.0 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>60 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 64 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 2.5 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 103% 70 - 120%\n INR 1.0 N/A\n aPTT 25 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- ---------------- ---------------------\n WBC 12.71 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 2.9 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.1 g/dL 14 - 18 g/dL\n Hematocrit 24.7% 40 - 48%\n MCH 28 pg 27 - 32 pg\n MCV 86 fL 82 - 92 fL\n MCHC 32.8 g/dL 32 - 36 g/dL\n Platelets 257 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 77% 40 - 70%\n Lymphocytes 4% 25 - 40%\n Monocytes 18% 4 - 10%\n Eosinophils 0% 2 - 4%\n Basophils 0% 0 - 1%\n\n\n\n### text_1\n**Dear colleague, **\n\nI am writing to provide a follow-up report on our mutual patient, Mrs.\nAnna Sample, born on January 1st, 1970, post her recent visit to our\nclinic on October 9th, 2017.\n\nUpon assessment, Mrs. Sample reported experiencing a moderate\nimprovement in symptoms since the initiation of the R-Pola-CHP regimen.\nThe discomfort in her dorsal calf and thoracic spine has notably\nreduced, and her arm strength has seen gradual improvement, though she\noccasionally still encounters difficulty in grasping objects.\n\nShe has been undergoing physiotherapy to aid in the recovery of her arm\nstrength.\n\n**Physical Examination:** No palpable lymphadenopathy. Her neurological\nexamination was stable with no new deficits.\n\n**Laboratory Findings:** Most recent blood counts and biochemistry\npanels showed a trend towards normalization, with liver enzymes within\nthe reference range.\n\n**Imaging:**\n\n-Ultrasound of the abdomen was conducted.\n\n-A follow-up MRI conducted showed a reduction in the size of the\npreviously noted metastatic masses. There\\'s a decreased impingement on\nthe myelon at the levels of T10-L1. The lesions in L2, L3, and L4 also\nshowed signs of regression.\n\n-PET scan was performed: Favourable response. Increased FDG avidity in\nthe liver: Liver MRI recommended.\n\n-Liver MRI: No pathology of the liver.\n\n**Senological Examination:** The nodule-like deposit in the right breast\nwas found to be benign.\n\n**Medication on admission:** Aspirin (Aspirin®) - 100mg, 1 tablet in the\nmorning Atorvastatin - 40mg - 1 tablet at bedtime Sertraline - 50mg - 2\ntablets in the morning Lorazepam (Tavor®) - 1mg, as needed Fingolimod -\n0.5mg, 1 capsule at bedtime, Note: Take a break as directed\nHydromorphone hydrochloride - 2mg (extended-release), 2 capsules in the\nmorning and 2 capsules at bedtime Melatonin - 2mg (sustained-release), 1\ntablet at bedtime Baclofen (Lioresal®) - 10mg, 1 tablet three times a\nday Pregabalin - 75mg, 1 capsule in the morning and 1 capsule at bedtime\nMoviCOL® (Macrogol, Sodium chloride, Potassium chloride) - 1 packet\nthree times a day, mixed with water for oral intake Pantoprazole - 40mg,\n1 tablet in the morning Colecalciferol (Vitamin D3) - 20000 I.U., 1\ncapsule on Monday and Thursday Co-trimoxazole - 960mg, 1 tablet on\nMonday, Wednesday, and Friday Valaciclovir - 500mg, 1 tablet in the\nmorning and 1 tablet at bedtime Prednisolone - 50mg, 2 tablets in the\nmorning, Continue through 02/19/2017 Enoxaparin sodium (Clexane®) - 40mg\n(4000 I.U.), 1 injection at bedtime, Note: Continue in case of\nimmobility Dimenhydrinate (Vomex A®) - 150mg (sustained-release), as\nneeded for nausea, up to 2 capsules daily.\n\n**Physician\\'s report for ultrasound on 10/05/2017:**\n\nLiver: The liver is large with 18.1 cm in the MCL, 18.5 cm in the CCD\nand 20.2 cm in the AL. The internal structure is not compacted. Focal\nchanges are not seen. Orthograde flow in the portal vein (vmax 16 cm/s).\nGallbladder: the gallbladder is 9.0 x 2.9 cm, the lumen is free of\nstones.\n\nBiliary tract: The intra- and extrahepatic bile ducts are not\nobstructed, DHC 5 mm, DC 3 mm.\n\nPancreas: The pancreas is approximately 3.2/1.5/3.0 cm in size, the\ninternal structure is moderately echo-rich.\n\nSpleen: The spleen is 28.0 x 9.6 cm, the parenchyma is homogeneous.\n\nKidneys: The right kidney is 9.8/2.0 cm, the pelvis is not congested.\nThe left kidney is 12.4/1.2 cm, the pelvis is not congested. Vessels\nretroperitoneal: the aorta is normal in width in the partially visible\narea.\n\nStomach/intestine: The gastric corpus wall is up to 14 mm thick. No\nevidence of free fluid in the abdominal cavity.\n\nBladder/genitals: The prostate is orientationally about 3.8 x 4.8 x 3.1\ncm, the urinary bladder is moderately full.\n\n**MR Spine plain + post-contrast from 10/06/2017**\n\n**Study:** Magnetic Resonance Imaging (MRI) of the thoracolumbar spine\n\n**Clinical Information:** Follow-up MRI post treatment for previously\nnoted metastatic masses.\n\n**Technique:** Standard T1-weighted, T2-weighted, and post-contrast\nenhanced sequences of the thoracolumbar spine were obtained in sagittal\nand axial planes.\n\n**Findings:** There is a reduction in the size of the previously noted\nmetastatic masses when compared to prior MRI studies. A reduced mass\neffect is observed at the levels of T10-L1. Notably, there is decreased\nimpingement on the myelon at these levels. This indicates a significant\nimprovement, suggesting a positive response to the recent therapy. The\nlesion noted in the previous study at the level of L2 has shown signs of\nregression in both size and intensity. Similar regression is noted for\nthe lesion at the L3 level. The lesion at the L4 level has also\ndecreased in size as compared to previous imaging. The intervertebral\ndiscs show preserved hydration. No significant disc protrusions or\nherniations are observed. The vertebral bodies do not show any\nsignificant collapse or deformity. Bone marrow signal is otherwise\nnormal, apart from the aforementioned lesions. The spinal canal\nmaintains a normal caliber throughout, and there is no significant canal\nstenosis. The conus medullaris and cauda equina nerve roots appear\nunremarkable without evidence of displacement or compression.\n\n**Impression:** Reduction in the size of previously noted metastatic\nmasses, indicating a positive therapeutic response. Decreased\nimpingement on the myelon at the levels of T10-L1, suggesting\nsignificant regression of the previously observed mass effect.\nRegression of lesions at L2, L3, and L4 levels, further indicating the\npositive response to treatment.\n\n**Positron Emission Tomography (PET)/CT from 10/09/2017:**\n\n**Indication:** Follow-up evaluation of Diffuse large B-cell lymphoma of\ngerminal center type diagnosed in 01/2017.\n\n**Technique:** Whole-body FDG-PET/CT was performed from the base of the\nskull to the mid-thighs.\n\n**Findings:** Liver: There is increased FDG uptake in the liver,\npredominantly in the anterolateral segment. The size of the liver is\nconsistent with the previous ultrasound report, measuring 18.1 cm in the\nMCL, 18.5 cm in the CCD, and 20.2 cm in the AL. The SUV max is 5.5.\nLymph Nodes: There is no pathological FDG uptake in the previously noted\nleft axillary lymph node, suggesting a therapeutic response. Lungs:\nPreviously noted deposit in the ventral left upper lobe now demonstrates\nreduced FDG avidity. No other FDG-avid nodules or masses. Bone: There\\'s\nno FDG uptake in the spine, including the previously described\nmetastatic lesion, indicating a positive response to treatment.\n\n**Impression:** Overall, the findings demonstrate a marked metabolic\nimprovement in the sites of lymphoma previously noted, particularly in\nthe left axillary lymph node and the vertebral bone lesions. The liver,\nhowever, presents with increased FDG avidity, especially in the\nanterolateral segment. This uptake might represent active lymphomatous\ninvolvement or could be due to an inflammatory process. Given the\ndifferential, and to ascertain the etiology, further diagnostic\nevaluation, such as a liver MRI or biopsy, is recommended.\n\n**Liver MRI from 10/11/2017:**\n\n**Clinical Indication:** Evaluation of increased FDG uptake in the liver\nas noted on the recent PET scan. Concern for active lymphomatous\ninvolvement or an inflammatory process.\n\n**Technique:** MRI of the liver was performed using a 3T scanner.\nSequences included T1-weighted (in-phase and out-of-phase), T2-weighted,\ndiffusion-weighted imaging (DWI), and post-contrast dynamic imaging\nafter the administration of gadolinium-based contrast agent.\n\n**Detailed Findings:** The liver demonstrates enlargement with\nmeasurements consistent with the recent ultrasound: 18.1 cm in the\nmid-clavicular line (MCL), 18.5 cm in the maximum cranial-caudal\ndiameter (CCD), and 20.2 cm along the anterior line (AL).\n\nThe liver parenchyma is mostly homogenous. However, there is a region in\nthe anterolateral segment demonstrating T2 hyperintensity and\nhypointensity on T1-weighted images. The aforementioned region in the\nanterolateral segment demonstrates restricted diffusion, suggestive of\nincreased cellular density. After gadolinium administration, there is\nperipheral enhancement of the lesion in the arterial phase, followed by\nprogressive central filling in portal venous and delayed phases. This\npattern is suggestive of a focal nodular hyperplasia (FNH) or atypical\nhemangioma. The intrahepatic and extrahepatic bile ducts are not\ndilated. No evidence of any obstructing lesion. The hepatic arteries,\nportal vein, and hepatic veins appear patent with no evidence of\nthrombosis or stenosis. The gallbladder, pancreas, spleen, and adjacent\nsegments of the bowel appear normal. No lymphadenopathy is noted in the\nporta hepatis or celiac axis.\n\n**Impression:** Enlarged liver with a suspicious lesion in the\nanterolateral segment demonstrating characteristics that might be\nconsistent with focal nodular hyperplasia or atypical hemangioma. No\nindication of lymphomatous involvement of the liver.\n\n**Discussion: **\n\nGiven her positive response to the treatment so far, we intend to\ncontinue with the current regimen, with careful monitoring of her side\neffects and symptomatology.\n\nWe deeply appreciate your continued involvement in Mrs. Sample\\'s\nhealthcare journey. Collaborative care is paramount, especially in cases\nas complex as hers. Should you have any recommendations, insights, or if\nyou require additional information, please do not hesitate to reach out.\n\n**Medication at discharge: **\n\nAspirin 100mg: Take 1 tablet in the morning; Atorvastatin 40mg: Take 1\ntablet at bedtime; Sertraline 50mg: Take 2 tablets in the morning;\nLorazepam 1mg: Take as needed; Melatonin (sustained-release) 2mg: Take 1\ntablet at bedtime; Fingolimod 0.5mg: Take 1 capsule at bedtime/take a\nbreak as directed; Hydromorphone hydrochloride (extended-release) 2mg:\nTake 2 capsules in the morning and 2 capsules at bedtime; Pregabalin\n75mg: Take 1 capsule in the morning and 1 capsule at bedtime; Baclofen\n10mg: Take 1 tablet three times a day; MoviCOL®: Mix 1 packet with water\nand take orally three times a day; Pantoprazole 40mg: Take 1 tablet in\nthe morning; Colecalciferol (Vitamin D3) 20000 I.U.: Take 1 capsule on\nMonday and Thursday; Dimenhydrinate (sustained-release) 150mg: Take as\nneeded for nausea, up to 2 capsules daily.\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 135 - 145 mEq/L\n Potassium 4.1 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 17 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 124 U/L 40 - 129 U/L\n Total Bilirubin 0.4 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 75 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 39 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 36 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 342 U/L \\< 244 U/L\n Uric Acid 3.8 mg/dL 3 - 7 mg/dL\n Calcium 9.12 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>62 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 67 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 1.8 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 105% 70 - 120%\n INR 0.98 N/A\n aPTT 28 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- --------------- ---------------------\n WBC 11.9 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 3.1 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.4 g/dL 14 - 18 g/dL\n Hematocrit 26% 40 - 48%\n MCH 27.8 pg 27 - 32 pg\n MCV 84 fL 82 - 92 fL\n MCHC 33 g/dL 32 - 36 g/dL\n Platelets 263 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 73% 40 - 70%\n Lymphocytes 7% 25 - 40%\n Monocytes 16% 4 - 10%\n Eosinophils 1% 2 - 4%\n Basophils 0.5% 0 - 1%\n\n\n\n\nHere is the query:\nBased on the Immunohistochemical processing results from 01/06/2017, which of the following is true for Mrs. Sample? \n\nChoose the correct answer from the following options:\nA. Blastic tumor cells showed a negative reaction to MUM1.\nB. There was a positive reaction to both ALK1 and TdT.\nC. CD68-positive macrophages were absent in the sample.\nD. The epidural tumor was identified as a non-aggressive form of lymphoma.\nE. The blastic tumor cells were positive for MUM1.\n\n\nYour response:\n", "role": "user" }, { "content": "The blastic tumor cells were positive for MUM1.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Anna Sample, born on\n01.01.1970. She was admitted to our clinic from 01/01/2017 to\n01/02/2017.\n\n**Diagnosis:** Diffuse large B-cell lymphoma of germinal center type; ID\n01/2017\n\n- Ann-Arbor: Stage IV\n\n- R-IPI: 2 (LDH, stage)\n\n- CNS-IPI: 2\n\n- Histology: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\n translocation. Ki-67 at 40%. Positive reaction to MUM1, numerous\n CD68-positive macrophages. Negative reaction to ALK1 and TdT.\n\n- cMRI: Chronic inflammatory lesions suggestive of Multiple Sclerosis (MS)\n\n- CSF: no evidence of malignancy\n\n- Bone marrow aspiration: no infiltration from the pre-existing\n lymphoma.\n\n**Current treatment: **\n\nInitiated R-Pola-CHP regimen q21\n\n- Polatuzumab vedotin: 1.8mg/kg on Day 1.\n\n- Rituximab: 375mg/m² on Day 0.\n\n- Cyclophosphamide: 750mg/m² on Day 1.\n\n- Doxorubicin: 50mg/m on Day 1.\n\n- Prednisone: 100mg orally from Day 1-5.\n\n**Previous therapy and course**\n\nFrom 12/01/2016: Discomfort in the dorsal calf and thoracic spine,\nweakness in the arms with limited ability to lift and grasp, occasional\ndizziness.\n\n12/19/2016 cMRI: chronic inflammatory marks indicative of MS. \n\n12/20/2016 MRI: thoracic/lumbar spinal cord: Indication of a\nmetastatic mass starting from the left pedicle T1 with a significant\nextraosseous tumor element and full spinal narrowing at the level of\nT10-L1 with pressure on the myelon and growth into the neuroforamen\nT11/T12 on the right and T12/L1 left. More lesions suggestive for\nmetastasis are L2, L3, and L4, once more with extraosseous tumor element\nand invasion of the left pedicle.\n\n12/21/2016 Fixed dorsal support T8-9 to L3-4. Decompression via\nlaminectomy T10 and partial laminectomy lumbar vertebra 3.\n\n12/24/2016 CT chest/abdomen/pelvis: Magnified left axillary lymph node.\nIn the ventral left upper lobe, indication of a round, loose, cloudy\ndeposit, i.e., of inflammatory origin, follow-up in 5-7 weeks.\nNodule-like deposit in the upper inner quadrant of the right breast,\nsenological examination suggested.\n\n**Pathology**: Aggressive B-NHL (DLBCL, NOS); no evidence of t(14;18)\ntranslocation. Ki-67 staining was at 40%. Positive reaction to MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\n**Other diagnoses**\n\n- Primary progressive type of multiple sclerosis (ID 03/02) \n\n- Mood disorder.\n\n- 2-vessel CHD\n\n**Medical History**\n\nMrs. Sample was transferred inpatient from DC for the initiation of\nchemotherapy (R-Pola-CHP) for her DLBCL. In the context of her\npre-existing ALS, she presented on 12/19/2016 with acute pains and\nrestricted mobility in her upper limbs. After her admission to HK\nFlowermoon, an MRI was performed which revealed a thoracic neoplastic\ngrowth especially at the level of T10-L1, but also affecting lumbar\nvertebra 3, L4 and L6. Surgical intervention on 12/21/2016 at DC\nresulted in symptom relief. Presently, her complaints are restricted to\npost-operative spine discomfort, shoulder hypoesthesia, and intermittent\nhand numbness. She reported a weight loss of 5 kg during her\nhospitalization. She denied having respiratory symptoms, infections,\nsystemic symptoms, or gastrointestinal complaints. Mrs. Sample currently\nhas a urinary catheter in place.\n\n**Physical examination on admission**\n\nGeneral: The patient has a satisfactory nutritional status, normal\nweight, and is dependent on a walker. Her functional status is evaluated\nas ECOG 2. Cardiovascular: Regular heart rhythm at a normal rate. Heart\nsounds are clear with no detected murmurs. Respiratory: Normal alveolar\nbreath sounds. No wheezing, stridor, or other abnormal sounds.\nAbdominal: The abdomen is soft, non-tender, and non-distended with\nnormal bowel sounds in all quadrants. There is no palpable enlargement\nof the liver or spleen, and the kidneys are not palpable.\nMusculoskeletal: Tenderness noted in the cervical and thoracic spine\narea, but no other remarkable findings. This is consistent with her\npost-operative status. Lymphatic: No enlargement detected in the\ntemporal, occipital, cubital, or popliteal lymph nodes. Oral: The oral\nmucosa is moist and well-perfused. The oropharynx is unremarkable, and\nthe tongue appears normal. Peripheral Vascular: Pulses in the hands are\nstrong and regular. No edema observed. Neurological: Cranial nerves are\nintact. There is numbness in both hands and mild hypoesthesia in the\nshoulders. Motor strength is 3/5 in the right arm, attributed to her\nknown ALS diagnosis. No other motor or sensory deficits noted.\nOccasional bladder incontinence and intermittent gastrointestinal\ndisturbances are reported.\n\n**Medications on admission**\n\nAcetylsalicylic acid (Aspirin®) 100 mg: Take 1 tablet in the morning.\nAtorvastatin (Lipitor®) 40 mg: Take 1 tablet in the evening. Fingolimod\n(Gilenya®) 0.5 mg: Take 1 capsule in the evening. Sertraline (Zoloft®)\n50 mg: Take 2 tablets in the morning. Hydromorphone (Dilaudid® or\nExalgo® for extended-release) 2 mg: Take 1 capsule in the morning and 1\nin the evening. Lorazepam (Ativan®) 1 mg: 1 tablet as needed.\n\n**Radiology/Nuclear Medicine**\n\n**MR Head 3D unenhanced + contrast from 12/19/2016 10:30 AM**\n\n**Technique:** Sequences obtained include 3D FLAIR, 3D DIR, 3D T2, SWI,\nDTI/DWI, plain MPRAGE, and post-contrast MPRAGE. All images are of good\nquality. Imaging area: Brain.\n\nThere are 20 FLAIR hyperintense lesions in the brain parenchyma,\nspecifically located periventricularly and in the cortical/juxtacortical\nregions (right and left frontal, left temporal, and right and left\ninsular). No contrast-enhancing lesions are identified. There are also\nsubcortical/nonspecific lesions present, with some lesions appearing\nconfluent. The spinal cord is visualized up to the C4 level. No spinal\nlesions are noted.\n\n[Incidental findings:]{.underline}\n\n- Brain volume assessment: no indication of reduced brain volume.\n\n- CSF space: age-appropriate usual wide, moderate, and symmetric CSF\n spacing with no signs of CSF flow abnormalities.\n\n- Cortical-Subcortical Differentiation: Clear cortical-subcortical\n distinction.\n\n- RML-characteristic alterations: none detected.\n\n- Eye socket: appears normal.\n\n- Nasal cavities: Symmetric mucosal thickening with a focus on the\n right ethmoidal sinus.\n\n- Pituitary and peri-auricular region: no abnormalities.\n\n- Subcutaneous lesion measuring 14.4 x 21.3 mm, right parietal likely\n representing an inflamed cyst or abscess, differential includes soft\n tissue growth.\n\n[Evaluation]{.underline}\n\nDissemination: MRI standards for spatial distribution are satisfied. MRI\ncriteria for temporal distribution are unfulfilled. Comprehensive\nneurological review: The findings are consistent with a chronic\ninflammatory CNS disease in the sense of Multiple Sclerosis.\n\n**MR Spine plain + post-contrast from 12/20/2016 10:00 AM**\n\n**Technique:** GE 3T MRI Scanner\n\nMRI was conducted under anesthesia due to claustrophobia.\n\n**Sequences**: Holospinal T2 Dixon sagittal, T1 pre-contrast, T1 fs\npost-contrast. The spine is visualized from the craniocervical junction\nto S2.\n\n**Thoracic spine: **\n\nOn T2-STIR and T2, there is a hyperintense signal of vertebral bodies T5\nand T6 with inconsistent delineation of the vertebral endplates,\nindicative of age-related changes. There is a reduction in the height of\nthe disc spaces T4/5 and T5/6 with subligamentous disc protrusion\nleading to a spongy appearance of the spinal cord at this location.\nMyelon atrophy is noted at T5/6, along with a T2 bright lesion\nsuggestive of MS at the level of T3 and also T4/5. Spine: A large\nintraspinal mass extends from T10-L1, causing an anterior spongy\nappearance of the spinal cord and resulting in complete spinal canal\nstenosis at this level. On fat-only imaging, there is almost total\nreplacement of the marrow space of vertebral body T11 with external\ntumor extension and infiltration into the lateral structures (more on\nthe left than the right) and neural foramen T11 on both sides. There is\nmild disc herniation at T8/9 with slight sponginess of the spinal cord.\nMS-characteristic spinal cord lesions are noted at segments T5 and T8/9.\n\n**Lumbar spine: **\n\nT2-DIXON shows bright signal intensity of the anterior part of lumbar\nvertebra 1, a patchy appearance of lumbar vertebra 2, and lumbar\nvertebra 4. Almost the entire marrow space is replaced in the fat-only\nimaging. There is an external tumor mass posterior to lumbar vertebra 4\nwithout significant spinal canal stenosis, which involves the left\nlateral structure and a pronounced appearance of the cauda equina at\nlumbar vertebra 1. A call to communicate the results was made at 11:15\na.m. to the on-duty orthopedic surgeon and to colleagues in neurology.\nEvaluation Evidence of a metastatic lesion originating from the left\npedicle of T10 with a significant extramedullary tumor mass and full\nspinal canal narrowing at the level of T10 with compression of the\nspinal cord and extension into the neural foramen T11-T12 on the right,\nand T12-L1 on the left. Additional sites suggestive of metastasis\ninclude L2, L3, and L4, again with extramedullary tumor components and\ninvasion of the left lateral structure. Contrast enhancement of the\ndistal cord is noted. There are MS-characteristic spinal cord lesions at\nthe levels of T3, T4-5, T5, and T8-9. The conus medullaris is not\nvisualized due to spinal cord displacement.\n\n\n**CT Thoracic Spine from 01/03/2017**\n\n[Clinical Findings]{.underline}\n\nLateral and medial alignment is stable. No sign of vertebral column\ndamage. Multiple segment degenerative alterations in the spine. No\nindications of mineralization in the recognized space at the level of\nT10/L2. Invasion of T10 and L4 with composite osteolytic-osteoblastic\ndefects starting from the left pedicle into the vertebral column. More\ncortical inconsistency with enhanced sclerosis at the endplate of L2.\nReview with prior MRI indicative of a different composite defect. Defect\npit at the endplate of lumbar vertebra 2.\n\nMinor pericardial effusion with nearby superior ventilation. Intubation\ntube placed. Mild cardiomediastinum. Splenomegaly. Standard display of\nthe tissue organs of the mid-abdomen, as naturally observed. Normal\nspleen. Thin adrenals. Tightly raised kidney bowls and leading ureter\nfrom both aspects, e.g., upon entry during the exhalation period after\ngadolinium inclusion in the earlier MRI. No bowel obstruction.\nIntestinal stasis. No sign of abnormally magnified lymphatic vessels.\nRemaining pin holes in the femoral head on both sides.\n\n[Evaluation]{.underline}\n\nComposite osteolytic-osteoblastic defects starting from the left pedicle\nin T10 and lumbar vertebra 4, and at the endplate of lumbar vertebra 2.\n\n**CT Thoracic Spine from 01/04/2017 **\n\nIntraoperative CT imaging for enhanced guidance.\n\nTwo intraoperative CT scans were undertaken in total.\n\nOn the concluding CT scan, recently implanted non-radiopaque pedicle\nscrews T8-9 to L2-L3 at tumor band T10. Regular screw placement. No\nevident sign of material breakage.\n\nApart from this, no notable alteration in findings from CT of\n01/03/2017.\n\nEvaluation Intraoperative CT imaging for better guidance. Recently\ninserted pedicle screws T8/T9 and L2/L3 in tumor indication T10,\nultimate standard screw positioning done transpedicular.\n\n**CT Chest/Abdomen/Pelvis + Contrast from 01/09/2017**\n\nResults: After uneventful intravenous administration of Omnipaque 320, a\nmulti-slice helical CT of the chest, abdomen, and pelvis was performed\nduring the venous phase of contrast enhancement. Additional oral\ncontrast was given using Gastrografin (diluted 1:35). Thin slice\nreconstructions were obtained, along with secondary coronal and sagittal\nreconstructions.\n\n[Thorax]{.underline}:\n\nUniform presentation of the apical thoracic sections when included. No \nevidence of subclavian lymphadenopathy. Uniform visualization of the pectoral \ntissues. No evidence of mediastinal lymphadenopathy. The anterior segment \nof the left upper lobe (series 205, image 88 of 389) shows a subpleural \nground-glass opaque solid consolidation. There is an enlarged lymph node \nin the left hilar region measuring approximately 1.2 cm laterally. Otherwise, \nthere are no signs of suspicious intrapulmonary markings, no new inflammatory \ninfiltrates, no pneumothorax, no pericardial effusion. In the upper inner \nquadrant of the right breast there is an oval mass, DD cystadenoma, \nDD glandular cluster (measuring 1.2 cm).\n\n[Abdomen/pelvis: ]{.underline}\n\nDominant display of the gastrocolic junction; absence of oral contrast\nin this zone prevents more detailed analysis. Uniformly displayed\nhepatic tissue with no signs of focal, density-varied lesions. Portal\nand liver veins are well filled. Liver with minor auxiliary liver.\nAdrenal nodes thin on both sides. Natural kidneys on both sides. Urinary\nsac with placed transurethral tube and intravesical gas pockets.\nGallbladder typical. Paravertebral and within vertebral and in the\ndomain of the superior hepatic artery multiple pronounced lymph nodes,\nthese up to a maximum of 8 mm. Typical representation of the organs in\nthe pelvic region.\n\n[Skeleton: ]{.underline}\n\nCondition post dorsal reinforcement (T8-T9-L2-L3). After surgery,\nepidermal air pockets and bloated tissue inflammation in the access path\nzone. Signs of a resin in a pre-spinal vessel anterior to T8 and T9.\nKnown mixed osteoblastic/osteolytic bony metastasis of lumbar vertebra 4\nand the cap plate of lumbar vertebra 2. State post-cutting of the\npedicle of T10. L5 also with slightly multiple solidified core\nosteolytic defects.\n\n[Evaluation:]{.underline}\n\n- No sign of primary malignancy in the previously mentioned mixed\n osteoblastic/osteolytic lesions in the vertebra (to be deemed\n suspicious in coordination with the MR review of 12/20/2016).\n\n- A magnified lymph node exists in the left hilar territory. In the\n anterior left upper lobe, evidence of a solid cloudy consolidation,\n i.e., of inflammatory origin, revisitation in 5-7 weeks recommended.\n\n- Rounded consolidation in the upper inner quadrant of the right\n breast, further breast examination advised.\n\n**Functional Diagnostics**\n\nExtended Respiratory Function (Diffusion) from 01/15/2017\n\n[Evaluation]{.underline}\n\nPatient cooperation: satisfactory. No detectable obstructive ventilation\nissue. No pulmonary over-expansion after RV/TLC. No identified\nrestrictive ventilation impairment. Standard O2 diffusion ability. No\nevidence of low oxygen levels, no blockage.\n\n[Consultations / Therapy Reports]{.underline}\n\nPsychological Support Consultation from 01/22/2017\n\n[Current Situation/History:]{.underline}\n\nThe patient initially discussed \\\"night episodes\\\" in the calves, which\nover time manifested during the day and were coupled with discomfort in\nthe cervical region. Prior, she had visited the Riverside Medical Center\nmultiple times before an MRI was executed. A \\\"mass in the neck\\\" was\nidentified. Since she suffers from fear of heights and fear of crowds,\nthe MRI could only be done under mild sedation. The phobias emerged\nabruptly in 2011 with no apparent cause, leading to multiple hospital\nvisits. She is now in outpatient care. Additionally, she battles with\nMS, with the most recent flare-up in 2012. She declined a procedure,\nwhich was set for the MRI is day, because \\\"two sedatives in one day\nfelt excessive.\\\" She anticipates avoiding a repeated procedure.\nCurrently, however, she still experiences spasms in her right hand and a\nnumbing sensation in her fingers. She still encounters discomfort (NRS\n5/10). She was previously informed that relief might be gradual, but she\nis \\\"historically been restless\\\". Therefore, \\\"resting and inactivity\\\"\nnegatively impact her spirits and rest.\n\n[Medical background:]{.underline}\n\nSeveral in-patient and day clinic admissions since 2011.\n\nNow, from 2015, continuous outpatient psychological counseling (CBT),\nsomatic therapy, particular sessions for driving anxieties. Also\nundergoing outpatient psychiatric care (fluoxetine 90mg).\n\n[Psychopathological Observations:]{.underline}\n\nPatient appears well-groomed, responsive and clear-minded, talkative and\nforthright. Aware of location, date, and identity. Adequate focus,\nrecall, and concentration. Mental organization is orderly. No evidence\nof delusional beliefs or identity disturbances. No compulsions, mentions\nfear of expansive spaces and fear of water. Emotional responsiveness\nintact, heightened psychomotor activity. Mood swings between despondent\nand irritable, lowered motivation. Diminished appetite, issues with\nsleep initiation and maintenance. Firm and believable denial of\nimmediate suicidal thoughts, patient appears cooperative. No current\nsigns of self-harm or threat to others.\n\n[Handling the Condition, Strengths:]{.underline}\n\nCurrently, her coping strategy seems to be proactive with some restless\nelements. Ms. S. says she remains \\\"optimistic\\\" and is well-backed by\nher communal links. Notably, she shares a close bond with her\n80-year-old aunt. Her other social bonds primarily arise from her\nassociation with a hockey enthusiasts club. Hockey has been a crucial\nsupport for her from a young age.\n\n[Evaluation Diagnoses:]{.underline}\n\nAdjustment disorder: anxiety and depressive reaction mixed\n\nAgoraphobia\n\nAcrophobia\n\n[Interventions, approaches:]{.underline}\n\nAn evaluative and assistive discussion was conducted. The patient has a\ndependable therapeutic community for post-hospitalization. Additionally,\nshe was provided the contact of the psychological support outpatient\ncenter. She mentioned finding the therapeutic conversation comforting,\nprompting an arranged check-in the subsequent week. We also suggest\nguidance in self-initiated physical activities to aid her recovery and\ntemper restlessness.\n\n**NC: Consultation of 01/15/2017**\n\n[Examination findings:]{.underline}\n\nPatient alert, fully oriented. Articulate and spontaneous speech.\nCranial nerve evaluation normal. No evident sensorimotor abnormalities.\nBDK with voiding challenges. Sphincter response diminished, but fecal\ncontrol maintained. KPPS at 85%. Wound site clean and non-irritated,\nexcept for the lower central portion.\n\n[Procedure:]{.underline}\n\nNeurosurgical intervention not required; no reassessment of the lower\nwound needed. Advise return if neurological symptoms intensify.\n\nThe patient, diagnosed with relapsing-remitting multiple sclerosis that\ninitially manifested aggressively, has been relapse-free on fingolimod\nsince 2009 and was generally well, barring a slight imbalance when\nwalking due to minor weakness in her left leg. She later experienced\nnumbness and weakness in her legs, reaching up to the hip, persisting\nfor several days and then faced challenges with urination and bowel\nmovements approximately 7 weeks prior. During a home examination, a\nlesion was identified in the T10 which was surgically addressed by our\nin-house neurosurgery team. Histology identified it as a DLBCL, leading\nto a chemotherapy plan inclusive of Rituximab. Post-surgery, her\nsymptoms have subsided somewhat, but the patient still has BDK and\nrelies on a wheelchair.\n\nOn clinical neurological assessment, a mild paraparesis was noted in her\nleft leg, accompanied by heightened reflex response and sporadic left\nfoot spasms, which were intense but temporary.\n\nTo conclude, the new neurological manifestations are not a recurrence of\nthe formerly stable multiple sclerosis. As Rituximab is also an\neffective third-phase drug for MS treatment and is essential,\ndiscontinuing fingolimod (second phase) was discussed with the patient.\nAfter a span of approximately 4-5 months following the last Rituximab\ntreatment, a radiological (cMRI) and clinical review is suggested. Based\non results, either resuming fingolimod or, if no adverse effects\npresent, potentially continuing Rituximab treatment is recommended (for\nthis, reach our neuroimmunology outpatient department). The primary\nneurologist was unavailable for comments.\n\n**Boards**\n\nOncology tumor board as of 01/22/2017\n\n6 cycles of R-Pola-CHP\n\n[Pathology]{.underline}\n\nPathology. Findings from 01/05/2017\n\n[Clinical information/question:]{.underline}\n\nTumor cuff T10. dignity? Entity? Macroscopy:\n\n1st lamina T10: fixed. some assembled 0.7 x 0.5 x 0.2 cm calcareous\ntissue fragments. Complete embedding. Decalcify in EDTA. 2nd ligament:\nFix. some assembled 0.9 x 0.7 x 0.2 cm, coarse, partly also calcareous\ntissue fragments. Complete embedding. Decalcify overnight in EDTA.\n\n3\\. epidural tumor: Numerous beige-colored tissue fragments, 3.8 x 2.8 x\n0.6 cm. Embedding of exemplary sections after lamellation.\n\n[Processing]{.underline}: 1 block, HE. Microscopy:\n\n1\\. and 2. (lamina T10 and ligament) are still being decalcified.\n\n3rd epidural tumor: Paravertebral soft tissue with infiltrates of a\npartly lymphoid, partly blastic neoplasia. The tumor cells are diffuse,\nsometimes nodular in the tissue and have hyperchromatic nuclei with\ncoarse-grained chromatin and a narrow cytoplasmic border. There are also\nblastic cells with enlarged nuclei, vesicular chromatin, and sometimes\nprominent nucleoli. The stroma is loose and vacuolated. Clearly\npronounced crush artifacts.\n\nPreliminary report of critical findings:\n\n3\\. epidural tumor: paravertebral soft tissue with infiltrates of\nlymphoid and blastic cells compatible with hematologic neoplasia.\n\nAdditional immunohistochemical staining is being performed to further\ncharacterize the tumor. In addition, material 1 (lamina T10) and\nmaterial 2 (ligament) are still undergoing decalcification. A follow-up\nreport will be provided.\n\nProcessing: 2 blocks, decalcification, HE, Giemsa, IHC: CD20, PAX5,\nBcl2, Bcl6, CD5, CD3, CD23, CD21, Kappa, Lambda, CD10, c-Myc, CyclinD1,\nCD30, MIB1, EBV/EBER.\n\nMolecular pathology: testing for B-cell clonal expansion and IgH/Bcl2\ntranslocation.\n\n[Microscopy]{.underline}:\n\n1\\. Ligament: Scarred connective tissue and fragmented bone tissue\nwithout evidence of the tumor described in the preliminary findings\nunder 3.\n\n2\\. Lamina T10: Bone tissue without evidence of the tumor described in\nthe preliminary findings under 3.\n\n3\\. Epidural tumor: Immunohistochemically, blastic tumor cells show a\npositive reaction after incubation with antibodies against CD20, PAX5\nand BCL2. Partially positive reaction against Bcl-6 (\\<20%). Some\nisolated blastic cells staining positive for CD30. Lymphoid cells\npositive for CD3 and CD5. Some residual germinal centers with positive\nreaction to CD23 and CD21. Predominantly weak positive reaction of\nblasts and lymphoid cells to CD10. Some solitary cells with positive\nreaction to kappa, rather unspecific, flat reaction to lambda. No\noverexpression of c-Myc or cyclinD1. No\n\nNo reaction to EBV/EBER. The Ki-67 proliferation index is 40%, related\nto blastic tumor cells \\> 90%.\n\nSignificantly limited evaluability of immunohistochemical staining due\nto severe squeezing artifacts of the material.\n\n[Molecular pathology report:]{.underline}\n\nExamination for clonal B-cell expansion and t(14;18) translocation\nMethodology:\n\nDNA was isolated from the sent tissues and used in duplicate in specific\nPCRs (B-cell clonality analysis with Biomed-2 primer sets: IGHG1 gene:\nscaffold 2 and 3). The size distribution of the PCR products was further\nanalyzed by fragment analysis.\n\nTo detect a BCL2/IgH fusion corresponding to a t(14;18) translocation,\nDNA was inserted into a specific PCR (according to Stetler-Stevenson et\nal. Blood. 1998;72:1822-25).\n\nResults:\n\nAmplification of isolated DNA: good. B cell clonality analyses\n\nIGHG1 fragment 2: polyclonal signal pattern.\n\nIGHG1 frame 3: reproducible clonal signal at approximately 115/116 bp.\nt(14;18) translocation: negative.\n\n[Molecular pathology report:]{.underline}\n\nMolecular pathologic evidence of clonal B-cell expansion. No evidence of\nt(14;18) translocation in test material with normal control reactions.\n\nPreliminary critical findings report:\n\n1\\. Lamina TH 10: tumor-free bone tissue.\n\n2\\. Ligament: Tumor-free, scarred connective tissue and fragmented bone\ntissue.\n\n3\\. Epidural tumor: aggressive B non-Hodgkin\\'s lymphoma.\n\nFindings (continued)\n\nAdditional findings from 01/06/2017\n\nImmunohistochemical processing: MUM1, ALK1, CD68, TdT. Microscopy:\n\n3\\. Immunohistochemically, blastic tumor cells are positive for MUM1.\nNumerous CD68-positive macrophages. No reaction to ALK1 and TdT.\n\nCritical findings report:\n\n1\\. Lamina T10: Tumor-free bone tissue. 2: Tumor free, scarred connective\ntissue and fragmented bone tissue.\n\n3\\. epidural tumor: aggressive B-non-Hodgkin lymphoma, morphologically\nand immunohistochemically most compatible with diffuse large B-cell\nlymphoma (DLBCL, NOS) of germinal center type according to Hans\nclassifier (GCB).\n\n**Path. Findings from 01/05/2017**\n\nClinical Findings\n\nClinical data:\n\nInitial diagnosis of DLBCL with spinal involvement.\n\nPuncture Site(s): 1\n\nCollection date: 01/04/2017\n\nArrival at cytology lab: 01/04/2017, 8 PM. Material:\n\n1 Liquid Material: 2 mL colorless, clear Processing:\n\nMGG staining Microscopic:\n\nZTA:\n\nLiquid precipitate Erythrocytes\n\n(+) Lymphocytes (+) Granulocytes\n\nEosinophils Histiocytes Siderophages\n\n\\+ Monocytes\n\nOthers: Isolated evidence of fewer monocytes. No evidence of atypical\ncells. Critical report of findings:\n\nCSF sediment without evidence of inflammation or malignancy. Diagnostic\nGrading:\n\nNegative\n\nTherapy and course\n\nMrs. S was admitted from the neurosurgical department for chemotherapy\n(R-POLA-CHP) of suspected DLBCL with spinal/vertebral manifestations.\n\nAfter exclusion of clinical and laboratory contraindications,\nantineoplastic therapy was started on 01/08/2017. This was well\ntolerated under the usual supportive measures. There were no acute\ncomplications.\n\nDuring her hospitalization, Ms. S reported numbness in both vascular\nhemispheres. A neurosurgical and neurological presentation was made\nwithout acute need for action. In consultation with the neurology\ndepartment, the existing therapy with fingolimod should be discontinued\ndue to the concomitant use of rituximab and the associated risk of PML.\nIf necessary, re-exposure to fingolimod may be considered after\ncompletion of oncologic therapy.\n\nOn 01/07/2017, a port placement was performed by our vascular surgery\ndepartment without complications.\n\nOn 01/19/2017, a single administration of Pegfilgrastim 6 mg s.c. was\nperformed. With a latency of 10 days, G-CSF should not be repeated in\nthe meantime.\n\nWe are able to transfer Mrs. S to the Mountain Hospital Center\n(Neurological Initial Therapy & Recovery) on 02/01/2017. We thank you\nfor accommodating the patient and are available for any additional\ninquiries.\n\n**Medications at Discharge**\n\n**Aspirin (Aspirin®)** - 100mg, 1 tablet in the morning\n\n**Atorvastatin - 40mg -** 1 tablet at bedtime\n\n**Sertraline - 50mg** - 2 tablets in the morning\n\n**Lorazepam (Tavor®)** - 1mg, as needed\n\n**Fingolimod** - 0.5mg, 1 capsule at bedtime, Note: Take a break as\ndirected\n\n**Hydromorphone hydrochloride** - 2mg (extended-release), 2 capsules in\nthe morning and 2 capsules at bedtime\n\n**Melatonin -** 2mg (sustained-release), 1 tablet at bedtime\n\n**Baclofen (Lioresal®) -** 10mg, 1 tablet three times a day\n\n**Pregabalin -** 75mg, 1 capsule in the morning and 1 capsule at bedtime\n\n**MoviCOL® (Macrogol, Sodium chloride, Potassium chloride) -** 1 packet\nthree times a day, mixed with water for oral intake\n\n**Pantoprazole -** 40mg, 1 tablet in the morning\n\n**Colecalciferol (Vitamin D3) -** 20000 I.U., 1 capsule on Monday and\nThursday\n\n**Co-trimoxazole -** 960mg, 1 tablet on Monday, Wednesday, and Friday\n\n**Valaciclovir -** 500mg, 1 tablet in the morning and 1 tablet at\nbedtime\n\n**Prednisolone -** 50mg, 2 tablets in the morning, Continue through\n02/19/2017\n\n**Enoxaparin sodium (Clexane®) -** 40mg (4000 I.U.), 1 injection at\nbedtime, Note: Continue in case of immobility\n\n**Dimenhydrinate (Vomex A®)** - 150mg (sustained-release), as needed for\nnausea, up to 2 capsules daily.\n\n**Procedure**\n\n**Oncology board decision: 6 cycles of R-Pola-CHP.**\n\n- Fingolimod pause, re-evaluation in 4-5 months.\n\n- Continuation of therapy near residence in the clinic as of\n 02/28/2017\n\n- Bi-Weekly laboratory tests (electrolytes, blood count, kidney and\n liver function tests)\n\n- In case of fever \\>38.3 °C please report immediately to our\n emergency room\n\n- Immediate gynecological examination for nodular mass in the left\n breast\n\nDates:\n\n- From 03/01/2017 third cycle of R-Pola-CHP in the clinic. The patient\n will be informed of the date by telephone.\n\nIf symptoms persist or exacerbate, we advocate for an urgent revisit.\nOutside standard working hours, emergencies can also be addressed at the\nemergency hub.\n\nDuring discharge management, the patient was extensively educated and\nassisted, and equipped with required appliances, medication scripts, and\nabsence from work notices.\n\nAll observations were thoroughly deliberated upon. Multiple alternate\ntherapy notions were considered before making a treatment proposition.\nThe opportunity for a second viewpoint and recommendation to our\nfacility was also emphasized.\n\n**Lab values at discharge: **\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 136 mEq/L 135 - 145 mEq/L\n Potassium 3.9 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.2 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 19 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 138 U/L 40 - 129 U/L\n Total Bilirubin 0.3 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 82 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 42 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 34 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 366 U/L \\< 244 U/L\n Uric Acid 4.1 mg/dL 3 - 7 mg/dL\n Calcium 9.0 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>60 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 64 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 2.5 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 103% 70 - 120%\n INR 1.0 N/A\n aPTT 25 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- ---------------- ---------------------\n WBC 12.71 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 2.9 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.1 g/dL 14 - 18 g/dL\n Hematocrit 24.7% 40 - 48%\n MCH 28 pg 27 - 32 pg\n MCV 86 fL 82 - 92 fL\n MCHC 32.8 g/dL 32 - 36 g/dL\n Platelets 257 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 77% 40 - 70%\n Lymphocytes 4% 25 - 40%\n Monocytes 18% 4 - 10%\n Eosinophils 0% 2 - 4%\n Basophils 0% 0 - 1%\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nI am writing to provide a follow-up report on our mutual patient, Mrs.\nAnna Sample, born on January 1st, 1970, post her recent visit to our\nclinic on October 9th, 2017.\n\nUpon assessment, Mrs. Sample reported experiencing a moderate\nimprovement in symptoms since the initiation of the R-Pola-CHP regimen.\nThe discomfort in her dorsal calf and thoracic spine has notably\nreduced, and her arm strength has seen gradual improvement, though she\noccasionally still encounters difficulty in grasping objects.\n\nShe has been undergoing physiotherapy to aid in the recovery of her arm\nstrength.\n\n**Physical Examination:** No palpable lymphadenopathy. Her neurological\nexamination was stable with no new deficits.\n\n**Laboratory Findings:** Most recent blood counts and biochemistry\npanels showed a trend towards normalization, with liver enzymes within\nthe reference range.\n\n**Imaging:**\n\n-Ultrasound of the abdomen was conducted.\n\n-A follow-up MRI conducted showed a reduction in the size of the\npreviously noted metastatic masses. There\\'s a decreased impingement on\nthe myelon at the levels of T10-L1. The lesions in L2, L3, and L4 also\nshowed signs of regression.\n\n-PET scan was performed: Favourable response. Increased FDG avidity in\nthe liver: Liver MRI recommended.\n\n-Liver MRI: No pathology of the liver.\n\n**Senological Examination:** The nodule-like deposit in the right breast\nwas found to be benign.\n\n**Medication on admission:** Aspirin (Aspirin®) - 100mg, 1 tablet in the\nmorning Atorvastatin - 40mg - 1 tablet at bedtime Sertraline - 50mg - 2\ntablets in the morning Lorazepam (Tavor®) - 1mg, as needed Fingolimod -\n0.5mg, 1 capsule at bedtime, Note: Take a break as directed\nHydromorphone hydrochloride - 2mg (extended-release), 2 capsules in the\nmorning and 2 capsules at bedtime Melatonin - 2mg (sustained-release), 1\ntablet at bedtime Baclofen (Lioresal®) - 10mg, 1 tablet three times a\nday Pregabalin - 75mg, 1 capsule in the morning and 1 capsule at bedtime\nMoviCOL® (Macrogol, Sodium chloride, Potassium chloride) - 1 packet\nthree times a day, mixed with water for oral intake Pantoprazole - 40mg,\n1 tablet in the morning Colecalciferol (Vitamin D3) - 20000 I.U., 1\ncapsule on Monday and Thursday Co-trimoxazole - 960mg, 1 tablet on\nMonday, Wednesday, and Friday Valaciclovir - 500mg, 1 tablet in the\nmorning and 1 tablet at bedtime Prednisolone - 50mg, 2 tablets in the\nmorning, Continue through 02/19/2017 Enoxaparin sodium (Clexane®) - 40mg\n(4000 I.U.), 1 injection at bedtime, Note: Continue in case of\nimmobility Dimenhydrinate (Vomex A®) - 150mg (sustained-release), as\nneeded for nausea, up to 2 capsules daily.\n\n**Physician\\'s report for ultrasound on 10/05/2017:**\n\nLiver: The liver is large with 18.1 cm in the MCL, 18.5 cm in the CCD\nand 20.2 cm in the AL. The internal structure is not compacted. Focal\nchanges are not seen. Orthograde flow in the portal vein (vmax 16 cm/s).\nGallbladder: the gallbladder is 9.0 x 2.9 cm, the lumen is free of\nstones.\n\nBiliary tract: The intra- and extrahepatic bile ducts are not\nobstructed, DHC 5 mm, DC 3 mm.\n\nPancreas: The pancreas is approximately 3.2/1.5/3.0 cm in size, the\ninternal structure is moderately echo-rich.\n\nSpleen: The spleen is 28.0 x 9.6 cm, the parenchyma is homogeneous.\n\nKidneys: The right kidney is 9.8/2.0 cm, the pelvis is not congested.\nThe left kidney is 12.4/1.2 cm, the pelvis is not congested. Vessels\nretroperitoneal: the aorta is normal in width in the partially visible\narea.\n\nStomach/intestine: The gastric corpus wall is up to 14 mm thick. No\nevidence of free fluid in the abdominal cavity.\n\nBladder/genitals: The prostate is orientationally about 3.8 x 4.8 x 3.1\ncm, the urinary bladder is moderately full.\n\n**MR Spine plain + post-contrast from 10/06/2017**\n\n**Study:** Magnetic Resonance Imaging (MRI) of the thoracolumbar spine\n\n**Clinical Information:** Follow-up MRI post treatment for previously\nnoted metastatic masses.\n\n**Technique:** Standard T1-weighted, T2-weighted, and post-contrast\nenhanced sequences of the thoracolumbar spine were obtained in sagittal\nand axial planes.\n\n**Findings:** There is a reduction in the size of the previously noted\nmetastatic masses when compared to prior MRI studies. A reduced mass\neffect is observed at the levels of T10-L1. Notably, there is decreased\nimpingement on the myelon at these levels. This indicates a significant\nimprovement, suggesting a positive response to the recent therapy. The\nlesion noted in the previous study at the level of L2 has shown signs of\nregression in both size and intensity. Similar regression is noted for\nthe lesion at the L3 level. The lesion at the L4 level has also\ndecreased in size as compared to previous imaging. The intervertebral\ndiscs show preserved hydration. No significant disc protrusions or\nherniations are observed. The vertebral bodies do not show any\nsignificant collapse or deformity. Bone marrow signal is otherwise\nnormal, apart from the aforementioned lesions. The spinal canal\nmaintains a normal caliber throughout, and there is no significant canal\nstenosis. The conus medullaris and cauda equina nerve roots appear\nunremarkable without evidence of displacement or compression.\n\n**Impression:** Reduction in the size of previously noted metastatic\nmasses, indicating a positive therapeutic response. Decreased\nimpingement on the myelon at the levels of T10-L1, suggesting\nsignificant regression of the previously observed mass effect.\nRegression of lesions at L2, L3, and L4 levels, further indicating the\npositive response to treatment.\n\n**Positron Emission Tomography (PET)/CT from 10/09/2017:**\n\n**Indication:** Follow-up evaluation of Diffuse large B-cell lymphoma of\ngerminal center type diagnosed in 01/2017.\n\n**Technique:** Whole-body FDG-PET/CT was performed from the base of the\nskull to the mid-thighs.\n\n**Findings:** Liver: There is increased FDG uptake in the liver,\npredominantly in the anterolateral segment. The size of the liver is\nconsistent with the previous ultrasound report, measuring 18.1 cm in the\nMCL, 18.5 cm in the CCD, and 20.2 cm in the AL. The SUV max is 5.5.\nLymph Nodes: There is no pathological FDG uptake in the previously noted\nleft axillary lymph node, suggesting a therapeutic response. Lungs:\nPreviously noted deposit in the ventral left upper lobe now demonstrates\nreduced FDG avidity. No other FDG-avid nodules or masses. Bone: There\\'s\nno FDG uptake in the spine, including the previously described\nmetastatic lesion, indicating a positive response to treatment.\n\n**Impression:** Overall, the findings demonstrate a marked metabolic\nimprovement in the sites of lymphoma previously noted, particularly in\nthe left axillary lymph node and the vertebral bone lesions. The liver,\nhowever, presents with increased FDG avidity, especially in the\nanterolateral segment. This uptake might represent active lymphomatous\ninvolvement or could be due to an inflammatory process. Given the\ndifferential, and to ascertain the etiology, further diagnostic\nevaluation, such as a liver MRI or biopsy, is recommended.\n\n**Liver MRI from 10/11/2017:**\n\n**Clinical Indication:** Evaluation of increased FDG uptake in the liver\nas noted on the recent PET scan. Concern for active lymphomatous\ninvolvement or an inflammatory process.\n\n**Technique:** MRI of the liver was performed using a 3T scanner.\nSequences included T1-weighted (in-phase and out-of-phase), T2-weighted,\ndiffusion-weighted imaging (DWI), and post-contrast dynamic imaging\nafter the administration of gadolinium-based contrast agent.\n\n**Detailed Findings:** The liver demonstrates enlargement with\nmeasurements consistent with the recent ultrasound: 18.1 cm in the\nmid-clavicular line (MCL), 18.5 cm in the maximum cranial-caudal\ndiameter (CCD), and 20.2 cm along the anterior line (AL).\n\nThe liver parenchyma is mostly homogenous. However, there is a region in\nthe anterolateral segment demonstrating T2 hyperintensity and\nhypointensity on T1-weighted images. The aforementioned region in the\nanterolateral segment demonstrates restricted diffusion, suggestive of\nincreased cellular density. After gadolinium administration, there is\nperipheral enhancement of the lesion in the arterial phase, followed by\nprogressive central filling in portal venous and delayed phases. This\npattern is suggestive of a focal nodular hyperplasia (FNH) or atypical\nhemangioma. The intrahepatic and extrahepatic bile ducts are not\ndilated. No evidence of any obstructing lesion. The hepatic arteries,\nportal vein, and hepatic veins appear patent with no evidence of\nthrombosis or stenosis. The gallbladder, pancreas, spleen, and adjacent\nsegments of the bowel appear normal. No lymphadenopathy is noted in the\nporta hepatis or celiac axis.\n\n**Impression:** Enlarged liver with a suspicious lesion in the\nanterolateral segment demonstrating characteristics that might be\nconsistent with focal nodular hyperplasia or atypical hemangioma. No\nindication of lymphomatous involvement of the liver.\n\n**Discussion: **\n\nGiven her positive response to the treatment so far, we intend to\ncontinue with the current regimen, with careful monitoring of her side\neffects and symptomatology.\n\nWe deeply appreciate your continued involvement in Mrs. Sample\\'s\nhealthcare journey. Collaborative care is paramount, especially in cases\nas complex as hers. Should you have any recommendations, insights, or if\nyou require additional information, please do not hesitate to reach out.\n\n**Medication at discharge: **\n\nAspirin 100mg: Take 1 tablet in the morning; Atorvastatin 40mg: Take 1\ntablet at bedtime; Sertraline 50mg: Take 2 tablets in the morning;\nLorazepam 1mg: Take as needed; Melatonin (sustained-release) 2mg: Take 1\ntablet at bedtime; Fingolimod 0.5mg: Take 1 capsule at bedtime/take a\nbreak as directed; Hydromorphone hydrochloride (extended-release) 2mg:\nTake 2 capsules in the morning and 2 capsules at bedtime; Pregabalin\n75mg: Take 1 capsule in the morning and 1 capsule at bedtime; Baclofen\n10mg: Take 1 tablet three times a day; MoviCOL®: Mix 1 packet with water\nand take orally three times a day; Pantoprazole 40mg: Take 1 tablet in\nthe morning; Colecalciferol (Vitamin D3) 20000 I.U.: Take 1 capsule on\nMonday and Thursday; Dimenhydrinate (sustained-release) 150mg: Take as\nneeded for nausea, up to 2 capsules daily.\n\n**Metabolic Panel**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 135 - 145 mEq/L\n Potassium 4.1 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n BUN (Blood Urea Nitrogen) 17 mg/dL 7 - 18 mg/dL\n Alkaline Phosphatase 124 U/L 40 - 129 U/L\n Total Bilirubin 0.4 mg/dL \\< 1.2 mg/dL\n GGT (Gamma-Glutamyl Transferase) 75 U/L \\< 66 U/L\n ALT (Alanine Aminotransferase) 39 U/L 10 - 50 U/L\n AST (Aspartate Aminotransferase) 36 U/L 10 - 50 U/L\n LDH (Lactate Dehydrogenase) 342 U/L \\< 244 U/L\n Uric Acid 3.8 mg/dL 3 - 7 mg/dL\n Calcium 9.12 mg/dL 8.8 - 10.6 mg/dL\n\n**Kidney Function**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------- ------------- ---------------------\n GFR (MDRD) \\>62 mL/min \\> 60 mL/min\n GFR (CKD-EPI with Creatinine) 67 mL/min \\> 90 mL/min\n\n**Inflammatory Markers**\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n CRP (C-Reactive Protein) 1.8 mg/dL \\< 0.5 mg/dL\n\n**Coagulation Panel**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n PT Percentage 105% 70 - 120%\n INR 0.98 N/A\n aPTT 28 sec 26 - 37 sec\n\n**Complete Blood Count**\n\n **Parameter** **Results** **Reference Range**\n --------------- --------------- ---------------------\n WBC 11.9 x10\\^9/L 4.0 - 9.0 x10\\^9/L\n RBC 3.1 x10\\^12/L 4.5 - 6.0 x10\\^12/L\n Hemoglobin 8.4 g/dL 14 - 18 g/dL\n Hematocrit 26% 40 - 48%\n MCH 27.8 pg 27 - 32 pg\n MCV 84 fL 82 - 92 fL\n MCHC 33 g/dL 32 - 36 g/dL\n Platelets 263 x10\\^9/L 150 - 450 x10\\^9/L\n\n**Differential**\n\n **Parameter** **Results** **Reference Range**\n --------------- ------------- ---------------------\n Neutrophils 73% 40 - 70%\n Lymphocytes 7% 25 - 40%\n Monocytes 16% 4 - 10%\n Eosinophils 1% 2 - 4%\n Basophils 0.5% 0 - 1%\n", "title": "text_1" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n\n\n\n\nHere is the query:\nAs of 01/02/20, which of the following was last detected in Mr. Hurley's sputum?\n\nChoose the correct answer from the following options:\nA. Acid-fast bacilli\nB. Mycobacterium tuberculosis\nC. Nontuberculous mycobacteria\nD. Fungal pathogens\nE. Staphylococcus aureus\n\n\nYour response:\n", "role": "user" }, { "content": "Mycobacterium tuberculosis", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_3\n**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n\nHere is the query:\nHow is Mr. Davies' galactosemia primarily managed?\n\nChoose the correct answer from the following options:\nA. Enzyme replacement therapy\nB. Gene therapy\nC. Dietetically\nD. Regular liver function tests\nE. Regular bone density measurements\n\n\nYour response:\n", "role": "user" }, { "content": "Dietetically", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n\n\n\n\nHere is the query:\nWhich sedative was Mr. Chapman on during the weaning process?\n\nChoose the correct answer from the following options:\nA. Midazolam\nB. Propofol\nC. Clonidine\nD. Lorazepam\nE. Dexmedetomidine\n\n\nYour response:\n", "role": "user" }, { "content": "Clonidine", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953. He was under our inpatient care from 04/19/2009 to\n04/28/2009.\n\n**Diagnoses:**\n\n- Progressive deterioration of renal transplant function (creeping\n creatinine) without evidence of biopsy-proven rejection\n\n- Isovolumetric tubular epithelial vacuolization\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Mr. Fisher was admitted for a renal transplant\nbiopsy due to progressive deterioration of transplant function (creeping\ncreatinine). His recent creatinine values had increased to around 1.4 --\n1.6 mg/dL, while they had previously been around 1.1 mg/dL.\n\n**Therapy and Progression:** Following appropriate preparation and\ninformed consent, a complication-free transplant puncture was performed.\nThe biopsy showed isometric tubular epithelial vacuolization without\nsignificant findings. This was followed by adjustment of Cyclosporin-A\nlevels and the addition of a lymphocyte proliferation inhibitor to the\nexisting immunosuppressive dual therapy. There was a significant\nincrease in Cyclosporin-A levels at one point due to accidental double\ndosing by the patient, but levels returned to the target range. This\nmight explain the current rise in creatinine. Another explanation could\nbe recurrent hypotensive blood pressure dysregulations, leading to the\ndiscontinuation of Minoxidile medication. For chronic atrial\nfibrillation, anticoagulation therapy with Marcumar was restarted during\nhospitalization and should be continued as an outpatient according to\nthe target INR. Low molecular weight heparin administration could be\ndiscontinued.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No dyspnea. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable.\n\nLungs: Normal chest shape, moderately mobile, resonant percussion sound,\nvesicular breath sounds bilaterally, no wheezing or crackles heard.\n\nHeart: Irregular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, markedly obese, no tenderness, no palpable\nmasses, liver and spleen not palpable due to limited access, non-tender\nkidneys. Large reducible incisional hernia on the right side following\nnephrectomy.\n\nExtremities: Occluded fistula on the right forearm. Normal peripheral\npulses; joints freely movable. Strength, motor function, and sensation\nare unremarkable.\n\n**Kidney Biopsy on 04/19/2009:** Complication-free biopsy of the\ntransplant kidney.\n\nFindings: Erythematous macules.\n\nRecommendation: Follow-up in 3 months.\n\n**Ultrasound of Transplant Kidney on 04/20/2009:** Transplant kidney\nwell visualized, located in the left iliac fossa, measurable,\noval-shaped. Parenchymal echogenicity normal, normal corticomedullary\ndifferentiation. No evidence of arteriovenous fistula or hematoma after\nkidney biopsy.\n\n**Pathological-anatomical assessment on 04/19/2009:**\n\n**Macroscopic Findings:** Singular Nodule Identified: Dimensions\nmeasuring 8 mm.\n\n**Microscopic Examination:**\n\nSampled Tissue: Renal cortex\n\nIdentified Components:\n\n- Glomeruli: Nine observed\n\n- Interlobular Artery: One segment present\n\n- Absence of medullary tissue\n\n**Diagnostic Observations:** There were no signs of inflammation or\nscarring in the renal cortex. The glomeruli appeared normocellular, and\nno signs of inflammation or pathological changes were observed in them.\nThe peritubular capillaries were free of inflammation, and the specific\ntest for C4d staining yielded negative results. The arterioles within\nthe tissue had thin walls, and there was no evidence of inflammation in\nthis vascular component.\n\nThe interlobular artery was also thin-walled and showed no evidence of\ninflammation.\n\nA notable finding was extensive damage to the tubular epithelium. The\ndamage was characterized by isometric microvesicular cytoplasmic\ntransformation, which exceeded 80%. Importantly, there was no evidence\nof cell necrosis and only minimal flattening of cells was observed. In\naddition, no pathological imprints, microcalcifications, or nuclear\ninclusion bodies were observed in the tubular epithelium.\n\n**Summary:** The predominant pathological finding in this case is\nsubstantial tubular damage. Consequently, it is highly advisable to\nclosely monitor immunosuppression levels in the patient\\'s management.\nFurther comprehensive evaluation is strongly recommended to determine\nthe underlying cause of the observed tubular damage and to address the\nclinical question concerning the presence of Chronic Allograft\nNephropathy or the potential involvement of an infection in the clinical\npresentation.\n\n**Chest X-ray (2 views) on 04/22/2009:**\n\n[Findings]{.underline}: No pneumothorax, no effusion. No evidence of\npneumonia. No focal findings. Left-biased heart without decompensation.\nMediastinum centrally positioned, not widened. Unremarkable depiction of\ncentral hilar structures. Thoracic hyperkyphosis.\n\n**Current Recommenations:** We request regular outpatient monitoring of\nretention parameters (initially every 2-3 weeks) and are available for\nfurther questions at the provided telephone number.\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 144 mEq/L 134-145 mEq/L\n Potassium 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium 9.48 mg/dL 8.6-10.6 mg/dL\n Chloride 106 mEq/L 95-112 mEq/L\n Phosphorus 2.88 mg/dL 2.5-4.5 mg/dL\n Transferrin Saturation 20 % 16-45 %\n Magnesium 1.9 mg/dL 1.8-2.6 mg/dL\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n Glomerular Filtration Rate 36 mL/min \\>90 mL/min\n BUN (Blood Urea Nitrogen) 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n C-Reactive Protein 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 ng/mL 30-300 ng/mL\n ALT (Alanine Aminotransferase) 17 U/L \\<45 U/L\n AST (Aspartate Aminotransferase) 20 U/L \\<50 U/L\n Alkaline Phosphatase 119 U/L 40-129 U/L\n GGT (Gamma-Glutamyltransferase) 94 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n TSH (Thyroid-Stimulating Hormone) 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43% 40-52%\n Red Blood Cells 4.60 M/uL 4.6-6.2 M/uL\n White Blood Cells 8.78 K/uL 4.5-11.0 K/uL\n Platelets 205 K/uL 150-400 K/uL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/uL 1.8-7.7 K/uL\n Lymphocytes 2.37 K/uL 1.4-3.7 K/uL\n Monocytes 0.93 K/uL 0.2-1.0 K/uL\n Eosinophils 1.67 K/uL \\<0.7 K/uL\n Basophils 0.09 K/uL 0.01-0.10 K/uL\n Nucleated Red Blood Cells Negative \\<0.01 K/uL\n APTT (Activated Partial Thromboplastin Time) 45.1 sec 26-40 sec\n Antithrombin Activity 85 % 80-120 %\n\n**Medication upon discharge**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Cyclosporine (Neoral) 1 mg 1-0-1\n Mycophenolic Acid (Myfortic) 180 mg 1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0\n Aspirin 81 mg 1-0-0\n Candesartan (Atacand) 16 mg 0-0-1\n Metoprolol (Lopressor) 50 mg 1-1-1-1\n Isosorbide Dinitrate (Isordil) 60 mg 1-0-0\n Torsemide (Demadex) 10 mg As directed\n Ranitidine (Zantac) 300 mg 0-0-1\n Fluvastatin (Lescol) 20 mg 0-0-1\n Allopurinol (Zyloprim) 100 mg 0-1-0\n Tamsulosin (Flomax) 0.4 mg 1-0-0\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide an update on our patient, Mr. Alan Fisher,\nborn on 12/09/1953.\n\nHe was under our inpatient care from 10/02/2018 to 10/03/2018.\n\n**Diagnoses:**\n\n- Urosepsis\n\n- Acute postrenal kidney failure\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Previous Surgeries:** Previous prostate vesiculectomy with regional\nlymphadenectomy\n\n**Planned procedure:** Urethro-cystoscopy with catheter placement for\nurethral stricture\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by the outpatient urologist due to suspicion of\na urethral stricture. Mr. Fisher reports a worsening urinary retention\nfor approximately 6 months. Despite multiple unsuccessful attempts at\ncatheter placement, ureterocystoscopy with catheter insertion was\nperformed. Intraoperatively, purulent cystitis and a bladder outlet\nobstruction were observed.\n\nMr. Fisher regularly attends follow-up examinations for his history of\nkidney transplantation in 1995 and previous prostate vesiculectomy with\nregional lymphadenectomy in 01/2018.\n\n**Physical Examination:** Neurology: RASS 0, alert, CAM-ICU negative, no\nnew focal neurology\n\nLungs: Bilateral air entry, no rales or wheezing, sufficient gas\nexchange on 2L/O2 Cardiovascular: Normal sinus rhythm, normotensive on\n0.01 µg/kg/min NA\n\nAbdomen: Soft, no guarding, sparse peristalsis, advanced oral diet,\nregular bowel movements\n\nDiuresis: Normal urine output, retention values within normal range,\ngoal: balanced fluid status\n\nSkin/Wounds: Non-irritated, no peripheral edema\n\n**Therapy and Progression**: We received Mr. Fisher, who was awake and\nspontaneously breathing under a 2L O2 mask via nasal cannula, to our\nintensive care unit due to urosepsis. To maintain an adequate\ncirculation, low-dose catecholamine therapy was required but could be\ndiscontinued on the first postoperative day. Pulmonary function remained\nstable with intensive non-invasive ventilation and breathing training.\n\nGiven his immunosuppression, we escalated the intraoperatively initiated\nanti-infective therapy from Ceftriaxone to Piperacillin/Tazobactam.\nPneumococcal and Legionella rapid tests were negative. Following\nappropriate volume resuscitation and diuretic therapy with Furosemide,\ndiuresis became sufficient. Oral diet progression occurred without\ncomplications. Anticoagulation was initially in prophylactic dosing with\nHeparin and later switched to therapeutic dosing with Enoxaparin.\n\n**Current Recommendations:**\n\n- Switch unfractionated Heparin to Fragmin\n\n- baseline Crea 2mg/dL, target CyA level: 50-60ng/mL, Myfortic\n continued.\n\n- Urological care of the stricture in progress, leave catheter until\n then.\n\n- Mobilization\n\n**Medication upon Discharge:**\n\n **Medication (Brand)** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Torsemide (Demadex) 10 mg 1-1-0-0\n Prednisone (Deltasone) 5 mg 1-1-0-0\n Pantoprazole (Protonix) 20 mg 1-1-0-0\n Mycophenolate Mofetil (CellCept) 360 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 100 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Candesartan (Atacand) 16 mg 0-0.5-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Allopurinol (Zyloprim) 100 mg 1-0-0-0\n Aspirin 81 mg 1-0-0-0\n Paracetamol (Tylenol) 500 mg As needed\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. Alan Fisher, born on\n12/09/1953.\n\nHe was under our inpatient care from 11/04/2018 to 11/12/2018.\n\n**Current Symptoms:** Decreased diuresis, rising creatinine, frustrating\ncatheterization.\n\n**Diagnoses:**\n\n- Acute on chronic graft failure\n\n<!-- -->\n\n- Creatinine increased from 1.56 mg/dL to a maximum of 2.35 mg/dL.\n\n- Likely postrenal origin due to urethral stricture; sonographically,\n Grade II urinary stasis with urinary retention and residual urine\n formation.\n\n- Frustrating catheterization due to urethral stricture\n\n- Urethro-cystoscopy with bougie and catheter placement\n\n- Parainfectious component in purulent cystitis with urosepsis\n\n- Discharged with indwelling catheter\n\n- Inpatient readmission to the colleagues in Urology for internal\n urethrotomy\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by an outpatient urologist due to suspected\nurethral stricture. Mr. Fisher reports increasing difficulty urinating\nfor approximately 6 months. He has to \\\"squeeze out\\\" his bladder\ncompletely. Frustrating catheterization was performed due to urinary\nretention. Intraoperatively, purulent cystitis and bladder outlet\nstenosis were observed. Mr. Fisher regularly undergoes follow-up\nexaminations for a history of kidney transplantation in 1995 and a\nprostate vesiculectomy with regional lymphadenectomy in 01/2018.\n\n**Vegetative Findings:** The patient had a bowel movement 4 days ago,\nindwelling catheter irritation (3L of diuresis the previous day), no\nnausea/vomiting, no fever or night sweats, weight loss of 30kg from\nFebruary to April 2020.\n\n**Physical Capacity:** Limited, can still climb 2 stairs but needs to\ntake a break due to shortness of breath.\n\n**Physical Examination:** Temperature 37.4°C, Blood pressure 128/72\nmmHg; Pulse 72/min; Respiratory rate 15/min, O2 saturation under 2L O2:\n96%\n\nAwake, alert, cooperative, oriented to time, place, person, and\nsituation.\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; Clear paranasal\nsinuses; moist and pink mucous membranes; unremarkable dentition; moist\nand glossy tongue; non-palpable thyroid enlargement.\n\n[Chest]{.underline}: Normal configuration; Non-tender spine; free renal\nbeds bilaterally.\n\n[Heart]{.underline}: Rhythmic, clear heart sounds, normal rate, no\nsplitting; non-distended jugular veins. [Lungs]{.underline}: Vesicular\nbreath sounds; Resonant percussion note; no adventitious sounds; no\nstridor; normal chest expansion.\n\n[Abdomen]{.underline}: Protuberant, known incisional hernia, normal\nperistalsis in all quadrants; soft; no pathological resistance; no\ntenderness; liver palpable below the costal margin; spleen not palpable.\n\n[Lymph nodes:]{.underline} No pathologically enlarged cervical nodes\npalpable; axillary and inguinal nodes not palpable.\n\nSkin: No pathological skin findings.\n\n[Extremities:]{.underline} Warm; mild bilateral ankle edema.\n\n[Pulse status (right/left):]{.underline} A. carotis +/+, A. radialis\n+/+, A. femoralis +/+, A. tibialis post. +/+, A. dorsalis ped. +/+\n\n[Neurological]{.underline}: Oriented and unremarkable.\n\n**Therapy and Progression:** The patient was admitted through our\nemergency department upon referral by an outpatient urologist due to\nsuspected urethral stricture, which had been causing increasingly\ndifficult urination for approximately 6 months. Sonography showed Grade\nII urinary stasis with urinary retention and residual urine. Frustrating\ncatheterization was performed, followed by ureterocystoscopy with bougie\nand catheter placement. Intraoperatively, purulent cystitis and bladder\noutlet stenosis were observed. Laboratory tests revealed acute kidney\ntransplant failure, with creatinine increasing from 1.56 mg/dL to 2.35\nmg/dL, along with significantly elevated infection parameters: CRP up to\n186 mg/dL, PCT 12.82 µg/L, and leukocytosis of 21.6/nL. After obtaining\nblood cultures, empirical antibiotic therapy with Ceftriaxone was\ninitiated. Upon detecting Pseudomonas aeruginosa, therapy was switched\nto Piperacillin/Tazobactam on 12/06/20 and continued until 12/13/20.\nUnder this treatment, infection parameters significantly improved, and\nMr. Fisher remained afebrile. Kidney retention parameters also decreased\nto a discharge creatinine of 2.05 mg/dL. Regarding the urethral\nstricture, he was initially discharged with an indwelling catheter. A\nfollow-up appointment for internal urethrotomy and potentially Allium\nstent placement was scheduled for 4 weeks later. During the hospital\nstay, ciclosporin levels remained within the target range. Following\nprostate vesiculectomy earlier in the year, anticoagulation was switched\nfrom Enoxaparin to Apixaban 2.5 mg twice daily, and Aspirin therapy was\ndiscontinued.\n\n**Recommendations**: We recommend regular monitoring of kidney retention\nparameters and infection parameters. Regarding the urethral stricture,\nthe patient will be discharged with an indwelling catheter. We scheduled\na follow-up with colleagues in Urology for internal urethrotomy and\npotentially Allium stent placement. Pause oral anticoagulation with\nApixaban one day before inpatient admission.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Candesartan (Atacand) 8 mg 0-1-0-0\n Torsemide (Demadex) 10 mg 1-1-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU Pause\n Magnesium Oxide 400 mg 1-0-0-0\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under outpatient care on 07/01/2019.\n\n**Current Symptoms:** Pain on the left side at rib level**,** Dyspnea\n\n**Diagnoses:**\n\n- Infection of unclear origin\n\n - CT Thorax and Abdomen showed no focus\n\n - Urine dipstick and cultures were bland\n\n - Antibiotics: Meropenem from 06/11/2019 to 06/19/2019\n\n- Acute Transplant Dysfunction\n\n - Serum Creatinine: 2.4 -\\> 4.5 -\\> 2.6 mg/dl\n\n - Renal ultrasound: 123 x 54 x 24 mm, not dilated, some areas of\n increased echogenicity, no twinkling, no acoustic shadowing, no\n signs of urolithiasis.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Initial presentation was at the local emergency\ndepartment on referral from the primary care physician for suspected\nacute coronary syndrome. Mr. Fisher described left-sided rib pain, which\nwas related to breathing and pressure, as well as dyspnea for a few\ndays. Laboratory tests showed acute-on-chronic kidney failure and\nelevated infection parameters. A urine dipstick test was negative for\nnitrites and leukocytes. Chest CT ruled out pulmonary pathology, and\nacute coronary syndrome was also excluded. Mr. Fisher reported a urinary\ntract infection about 4 weeks ago, which was treated with antibiotics as\nan outpatient.\n\n**Physical Examination:** Alert, oriented, cooperative, and responsive\nto time, place, person, and situation\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; clear nasal\nsinuses; moist pink mucous membranes; unremarkable dental status; moist\ntongue\n\n[Chest]{.underline}: Normal configuration; no tenderness in the spine;\nboth renal beds free\n\n[Heart]{.underline}: Arrhythmic heart sounds, pure, tachycardic, not\nsplit\n\n[Lungs]{.underline}: Vesicular breath sounds; somewhat decreased breath\nsounds bilaterally; no adventitious sounds; no stridor\n\n[Abdomen]{.underline}: Regular peristalsis in all quadrants; soft; right\nlower abdomen notably distended with increased vascular markings, liver\nand spleen not palpable, transplant kidney non-tender\n\n[Lymph Nodes:]{.underline} No pathologically enlarged cervical lymph\nnodes palpable\n\n[Skin]{.underline}: No pathological skin findings\n\n[Extremities:]{.underline} Warm; no edema; cyanosis of toes bilaterally\nafter prolonged leg dependency\n\n- Pulse status (right/left): Carotid artery +/+, Radial artery +/+,\n Posterior tibial artery +/+\n\n- Neurology: Normal cranial nerves; round, moderately dilated pupils;\n prompt bilateral pupillary light reflex; no sensory or motor\n deficits; ubiquitous muscle strength 5/5\n\n**Therapy and Progression:** We admitted the patient for further\ndiagnosis and treatment. Initially suspected acute coronary syndrome was\nruled out. Laboratory results showed elevated retention and infection\nparameters. With volume substitution, we achieved baseline creatinine\nlevels again. The transplant kidney appeared non-dilated and\nwell-perfused. For the infection, the patient received the mentioned\nimaging studies, which did not reveal any definitive findings. Our urine\nanalyses and cultures also showed bland results. It should be noted that\nprior outpatient treatment for suspected urinary tract infection was\nlikely with cotrimoxazole. Ultimately, considering the recent\nantibiograms, we decided on a calculated antibiotic therapy with\nMeropenem. This led to a significant improvement in infection\nparameters. The last measured Ciclosporin level was slightly\nsubtherapeutic, so we adjusted the dosage accordingly. We recommend\nfollow-up with the primary care physician.\n\n**Chest CT on 06/10/2019:**\n\n[Clinical Information, Question, Justification]{.underline}: Patient\nwith a history of kidney transplantation. Bursting pain on both sides at\nthe ribcage. Cough. Elevated inflammatory markers. Question about\ninfiltrates, pleural effusion, congestion.\n\n[Technique]{.underline}: Digital overview radiographs. Plain 80-line CT\nof the chest. MPR (Multiplanar reconstruction). DLP (Dose-Length\nProduct) 120.6 mGy\\*cm.\n\n[Findings]{.underline}: No previous images available for comparison.\nSymmetric thyroid. Minimal pericardial effusion, accentuated at the\nbase, measuring up to 8 mm in width (Series 5, Image 293). Coronary\natherosclerosis. No pathologically enlarged lymph nodes in the\nmediastinum, axilla, or hilum on plain images. Multisegmental calcified\n(micro)nodules. No suspicious pulmonary nodules indicative of\nmalignancy. No pneumonic infiltrates. No pleural effusions. No\npneumothorax. No pulmonary venous congestion. Delicate scar tissue at\nthe bases bilaterally. Small axial hiatal hernia. Rounded soft tissue\nstructure in the right adrenal space (Series 5, measuring 411 x 10 mm).\nIncidentally captured at the image margins is a shrunken left kidney.\nSpondylosis deformans of the thoracic spine. Interpretation: No\npneumonic infiltrates. No pleural effusions. No pulmonary venous\ncongestion. Minimal pericardial effusion. Multisegmental calcified\n(micro)nodules, likely post-inflammatory.\n\n**Abdomen/Pelvis CT on 06/14/2019:**\n\n[Clinical Information, Question, Justification:]{.underline} Acute\nkidney failure. Question regarding kidney or ureteral stones.\n\n[Technique]{.underline}: Plain 80-line CT of the abdomen. MPR. DLP 947\nmGy\\*cm. Findings and [Interpretation:]{.underline}\n\nThe left transplant kidney shows pelvic dilation with an expanded renal\npelvis and ureter (hydronephrosis grade II) but no evidence of stones.\nStatus post-right nephrectomy. Shrunken left kidney. Known large,\nbroad-based right-sided abdominal wall weakness with prolapsed\nintestinal loops and mesenteric fat tissue without evidence of\nincarceration. No ileus. Diverticulosis of the sigmoid colon. Small\naxial hiatal hernia. No free or encapsulated fluid or free air in the\nabdomen with the right diaphragmatic dome not fully visualized.\n\nCholecystolithiasis. No cholestasis. Vascular sclerosis. No\nlymphadenopathy. Bilaterally aerated lung bases captured without change.\nUnchanged irregularly thickened and coarsely structured right iliac\nbone, consistent with Paget\\'s disease.\n\n**Recommendations:**\n\nCiclosporin level monitoring\n\n**Medication upon discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Candesartan Cilexetil (Atacand) 8 mg 0-1-0-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU 1 x/week\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 70-0-70-0\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under our inpatient care from 02/19/2020 to\n03/01/2020.\n\n**Current Symptoms:** Decreased general condition, weakness,\ndecompensation\n\n**Diagnosis**: Acute episode of recurrent urinary tract infection with\ndetection of E. faecalis, E. faecium, and Enterobacter cloacae in urine\n(blood cultures sterile).\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our internal\nmedicine emergency department. He presented with worsening general\ncondition and increasing weakness, following the recommendation of our\nlocal nephrological telemedicine. He particularly noticed the increasing\nweakness when getting up, describing his legs as feeling like rubber. He\nalso experienced shortness of breath. His walking distance was greater\nthan 100 meters. There was no fever, chills, nausea, vomiting, dysuria,\nor changes in bowel movements. Before the outpatient visit, the patient\nhad collected urine for 24 hours, totaling 1700 ml, with a fluid intake\nof approximately 2 liters. His blood pressure at home was approximately\n120/60 mmHg. In the emergency department, he had negative urinary\ndipstick results and a non-specific chest X-ray. Blood and urine\ncultures were obtained, and he was subsequently transferred to our\ngeneral ward. No angina pectoris symptoms. The patient had normal bowel\nmovements, specifically no melena, and no blood-tinged stools. Urine was\ndescribed as clear and light.\n\n**Physical Examination:** Alert, oriented, cooperative, oriented to\ntime, place, person, and situation. Height 179 cm; Weight 114 kg\n\n[Head/neck:]{.underline} No tender nerve exit points; Clear nasal\nsinuses; No tenderness over the skull; Mucous membranes pink and moist;\nDental status is rehabilitated; Tongue moist and glossy\n[Thorax]{.underline}: Normally shaped; Spine without tenderness; Renal\nregions free of tenderness\n\n[Heart]{.underline}: Heart sounds are faint, arrhythmic, clear, regular\nrate, no splitting of heart sounds; Jugular veins are not distended\n\n[Lungs]{.underline}: Faint vesicular breath sounds; Resonant percussion\nnote; Dullness on the left, no added sounds; No stridor; Normal breath\nexcursion\n\n[Abdomen]{.underline}: Large right abdominal wall hernia, normal\nperistalsis in all quadrants; Soft; No pathological resistances; No\ntenderness (especially not over the left lower abdomen)\n\n[Skin status:]{.underline} No pathological skin findings\n\nExtremities: Warm; Mild edema.\n\n[Neurology:]{.underline} Alert. No focal deficits\n\n**Treatment and Progression:** The patient was admitted through our\nemergency department due to a decrease in general condition and\nweakness, accompanied by significantly elevated laboratory infection\nparameters and slightly worsened retention parameters (Creatinine max\n3.4 mg/dL compared to the current baseline of 3 mg/dL). Upon admission,\napart from a known and persistent leukocyturia since 2020, there were no\nindications of any other infectious focus. We were able to detect\nEnterobacter cloacae and Enterococcus faecalis in the urine, and we\ninitially treated the patient with intravenous Tazobactam. Blood\ncultures remained sterile. The patient\\'s general condition improved\nwithin a few days, along with a regression of infection parameters.\n\nFor further investigation of recurrent urinary tract infections (UTIs)\nand in the context of a history of urethral stricture treatment in\nFebruary 2021 with bougienage of the urethra one year ago, a urological\nconsultation was arranged. During this consultation, there was suspicion\nof a recurrence of the urethral stricture due to a significant residual\nurine volume of 175 ml. A scheduled readmission for repeat surgical\nmanagement was set for May 16, 2022. Due to the lack of normalization of\nelevated infection parameters and significant residual urine, a urinary\ncatheter was inserted. Subsequently, Enterococcus faecium was detected,\nand we continued treatment with oral Linezolid after the completion of\nintravenous antibiotic therapy.\n\nThe antibiotic treatment was planned to continue on an outpatient basis\nfor a total of 10 days. We kindly request an outpatient follow-up to\nmonitor infection parameters next week. The urinary catheter will be\nmaintained until the urological follow-up appointment, and the patient\nhas been provided with a prescription for medication.\n\nFurthermore, the patient exhibited atrial tachyarrhythmia. We reduced\nthe heart rate using Digoxin, as the patient was already on maximum\nbeta-blocker therapy. The atrial tachyarrhythmia significantly improved\nunder this treatment.\n\nAdditionally, there was a non-puncture-worthy pleural effusion and a\nchronic pericardial effusion, which was not hemodynamically relevant.\nThere were no clinical indications of pericarditis.\n\n**Current Recommendations:**\n\n1. Inpatient admission to Urology Department.\n\n2. Outpatient laboratory monitoring and referral issuance by the\n primary care physician.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on mutual patient, Mr. Alan Fisher, born on 12/09/1953,\nwho was under our inpatient care from 03/14/2020 to 03/15/2020.\n\n**Diagnoses**: Anastomotic stricture following history of prostatectomy\nand history of urethrotomy interna.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Procedure**:\n\n- Urethrotomy interna according to Sachse\n\n- Calculated intravenous antibiotic therapy with Meropenem starting on\n 03/14/2020\n\n- Extension of therapy to include antifungal treatment with\n Fluconazole on 03/15/2020\n\n**Medical History:** The patient presents with a recurrence of\nsymptomatic urethral stricture at the anastomosis site following\nprostatectomy. The main symptoms are frequent urination, dysuria, and\nresidual urine formation up to 175 ml. In January 2019, urethrotomy\ninterna was already performed. Since the last hospitalization due to a\nurinary tract infection, the patient has had a continuous\ncatheterization.\n\n**Physical Examination:** Patient in a reduced general condition and\nobese nutritional status. The abdomen is soft, without signs of\nresistance or pain. Kidney beds on both sides are indolent.\n\n**Urine Diagnostics**: Urine dipstick: Leukocytes 500, Nitrite negative,\nErythrocytes 50\n\n**Microbiology**: Candida in urine, collected by the general\npractitioner on 03/11/2020.\n\n**Chest X-ray in two planes on 02/19/2020:**\n\n[Clinical Information, Question, Justification for the\nExamination]{.underline}: Deterioration of general condition. History of\nrecurrent sepsis. History of lung transplantation. Infiltrates?\n\n**Findings**: The heart is shifted to the left and has a mitral\nconfiguration. No signs of acute congestion. The mediastinum shows no\nsigns of emphysema, is centrally located, and of normal width. No active\npneumonia in the ventilated lung regions. Progressive costophrenic angle\neffusion on the left. No pleural effusion on the right, as far as can be\nassessed. No pneumothorax. Degenerative changes in the spine.\nHyperkyphosis of the thoracic spine.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complication. Scar tissue at the level of the bladder sphincter\nwas incised. The postoperative course was uneventful. The transurethral\nindwelling catheter was removed on the 19th postoperative day. At the\ntime of discharge, the patient could urinate without residual urine with\na good urinary stream. We discharged the patient on 03/19/2020 for\nfurther outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------------- ------------------- ------------------\n Magnesium Oxide 400 mg 1-0-0-0\n Atorvastatin (Lipitor) 43.3 mg 0-0-1-0\n Candesartan Cilexetil (Atacand) 16 mg 1-1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol, oily) 20,000 IU 1x every 2 weeks\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 385 mg 1-0-1-0\n Pantoprazole (Protonix) 22.6 mg 1-0-0-0\n Piperacillin/Tazobactam (Zosyn) 4.17 g and 0.54 g 1-1-1-0\n Cyclosporine, microemulsified (Neoral) 10 mg 1-0-1-0\n Cyclosporine, microemulsified (Neoral) 50 mg 1-0-1-0\n Torsemide (Demadex) 10 mg 2-1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------------ ---------------------\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 3.02 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 19 mL/min/1.73m² \\-\n Total Bilirubin 0.73 mg/dL \\< 1.20 mg/dL\n Direct Bilirubin 0.41 mg/dL \\< 0.30 mg/dL\n C-reactive Protein 78.3 mg/dL \\< 5.0 mg/dL\n Alanine Aminotransferase 35 U/L \\< 41 U/L\n Aspartate Aminotransferase 33 U/L \\< 50 U/L\n Alkaline Phosphatase 273 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 184 U/L 8-61 U/L\n Lipase 102 U/L 13-60 U/L\n Hemoglobin 12.3 g/dL 12.5-17.2 g/dL\n Hematocrit 39.0% 37.0-49.0%\n Red Blood Cells 4.2 M/uL 4.0-5.6 M/uL\n White Blood Cells 10.41 K/uL 3.90-10.50 K/uL\n Platelets 488 K/uL 150-370 K/uL\n Mean Corpuscular Volume 92.4 fL 80.0-101.0 fL\n Mean Corpuscular Hemoglobin 29.1 pg 27.0-34.0 pg\n Mean Corpuscular Hemoglobin Concentration 31.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.3 fL 7.0-12.0 fL\n Red Cell Distribution Width 13.5% 11.5-15.0%\n\n\n\n\nHere is the query:\nWhat was the outcome of the histological examination after Mr. Fisher's right laparoscopic nephrectomy?\n\nChoose the correct answer from the following options:\nA. Confirmed renal cell carcinoma\nB. Chronic pyelonephritis identified\nC. No evidence of malignancy\nD. Nephrolithiasis confirmed\nE. Secondary hyperparathyroidism diagnosis\n\n\nYour response:\n", "role": "user" }, { "content": "No evidence of malignancy", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953. He was under our inpatient care from 04/19/2009 to\n04/28/2009.\n\n**Diagnoses:**\n\n- Progressive deterioration of renal transplant function (creeping\n creatinine) without evidence of biopsy-proven rejection\n\n- Isovolumetric tubular epithelial vacuolization\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Mr. Fisher was admitted for a renal transplant\nbiopsy due to progressive deterioration of transplant function (creeping\ncreatinine). His recent creatinine values had increased to around 1.4 --\n1.6 mg/dL, while they had previously been around 1.1 mg/dL.\n\n**Therapy and Progression:** Following appropriate preparation and\ninformed consent, a complication-free transplant puncture was performed.\nThe biopsy showed isometric tubular epithelial vacuolization without\nsignificant findings. This was followed by adjustment of Cyclosporin-A\nlevels and the addition of a lymphocyte proliferation inhibitor to the\nexisting immunosuppressive dual therapy. There was a significant\nincrease in Cyclosporin-A levels at one point due to accidental double\ndosing by the patient, but levels returned to the target range. This\nmight explain the current rise in creatinine. Another explanation could\nbe recurrent hypotensive blood pressure dysregulations, leading to the\ndiscontinuation of Minoxidile medication. For chronic atrial\nfibrillation, anticoagulation therapy with Marcumar was restarted during\nhospitalization and should be continued as an outpatient according to\nthe target INR. Low molecular weight heparin administration could be\ndiscontinued.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No dyspnea. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable.\n\nLungs: Normal chest shape, moderately mobile, resonant percussion sound,\nvesicular breath sounds bilaterally, no wheezing or crackles heard.\n\nHeart: Irregular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, markedly obese, no tenderness, no palpable\nmasses, liver and spleen not palpable due to limited access, non-tender\nkidneys. Large reducible incisional hernia on the right side following\nnephrectomy.\n\nExtremities: Occluded fistula on the right forearm. Normal peripheral\npulses; joints freely movable. Strength, motor function, and sensation\nare unremarkable.\n\n**Kidney Biopsy on 04/19/2009:** Complication-free biopsy of the\ntransplant kidney.\n\nFindings: Erythematous macules.\n\nRecommendation: Follow-up in 3 months.\n\n**Ultrasound of Transplant Kidney on 04/20/2009:** Transplant kidney\nwell visualized, located in the left iliac fossa, measurable,\noval-shaped. Parenchymal echogenicity normal, normal corticomedullary\ndifferentiation. No evidence of arteriovenous fistula or hematoma after\nkidney biopsy.\n\n**Pathological-anatomical assessment on 04/19/2009:**\n\n**Macroscopic Findings:** Singular Nodule Identified: Dimensions\nmeasuring 8 mm.\n\n**Microscopic Examination:**\n\nSampled Tissue: Renal cortex\n\nIdentified Components:\n\n- Glomeruli: Nine observed\n\n- Interlobular Artery: One segment present\n\n- Absence of medullary tissue\n\n**Diagnostic Observations:** There were no signs of inflammation or\nscarring in the renal cortex. The glomeruli appeared normocellular, and\nno signs of inflammation or pathological changes were observed in them.\nThe peritubular capillaries were free of inflammation, and the specific\ntest for C4d staining yielded negative results. The arterioles within\nthe tissue had thin walls, and there was no evidence of inflammation in\nthis vascular component.\n\nThe interlobular artery was also thin-walled and showed no evidence of\ninflammation.\n\nA notable finding was extensive damage to the tubular epithelium. The\ndamage was characterized by isometric microvesicular cytoplasmic\ntransformation, which exceeded 80%. Importantly, there was no evidence\nof cell necrosis and only minimal flattening of cells was observed. In\naddition, no pathological imprints, microcalcifications, or nuclear\ninclusion bodies were observed in the tubular epithelium.\n\n**Summary:** The predominant pathological finding in this case is\nsubstantial tubular damage. Consequently, it is highly advisable to\nclosely monitor immunosuppression levels in the patient\\'s management.\nFurther comprehensive evaluation is strongly recommended to determine\nthe underlying cause of the observed tubular damage and to address the\nclinical question concerning the presence of Chronic Allograft\nNephropathy or the potential involvement of an infection in the clinical\npresentation.\n\n**Chest X-ray (2 views) on 04/22/2009:**\n\n[Findings]{.underline}: No pneumothorax, no effusion. No evidence of\npneumonia. No focal findings. Left-biased heart without decompensation.\nMediastinum centrally positioned, not widened. Unremarkable depiction of\ncentral hilar structures. Thoracic hyperkyphosis.\n\n**Current Recommenations:** We request regular outpatient monitoring of\nretention parameters (initially every 2-3 weeks) and are available for\nfurther questions at the provided telephone number.\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 144 mEq/L 134-145 mEq/L\n Potassium 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium 9.48 mg/dL 8.6-10.6 mg/dL\n Chloride 106 mEq/L 95-112 mEq/L\n Phosphorus 2.88 mg/dL 2.5-4.5 mg/dL\n Transferrin Saturation 20 % 16-45 %\n Magnesium 1.9 mg/dL 1.8-2.6 mg/dL\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n Glomerular Filtration Rate 36 mL/min \\>90 mL/min\n BUN (Blood Urea Nitrogen) 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n C-Reactive Protein 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 ng/mL 30-300 ng/mL\n ALT (Alanine Aminotransferase) 17 U/L \\<45 U/L\n AST (Aspartate Aminotransferase) 20 U/L \\<50 U/L\n Alkaline Phosphatase 119 U/L 40-129 U/L\n GGT (Gamma-Glutamyltransferase) 94 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n TSH (Thyroid-Stimulating Hormone) 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43% 40-52%\n Red Blood Cells 4.60 M/uL 4.6-6.2 M/uL\n White Blood Cells 8.78 K/uL 4.5-11.0 K/uL\n Platelets 205 K/uL 150-400 K/uL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/uL 1.8-7.7 K/uL\n Lymphocytes 2.37 K/uL 1.4-3.7 K/uL\n Monocytes 0.93 K/uL 0.2-1.0 K/uL\n Eosinophils 1.67 K/uL \\<0.7 K/uL\n Basophils 0.09 K/uL 0.01-0.10 K/uL\n Nucleated Red Blood Cells Negative \\<0.01 K/uL\n APTT (Activated Partial Thromboplastin Time) 45.1 sec 26-40 sec\n Antithrombin Activity 85 % 80-120 %\n\n**Medication upon discharge**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Cyclosporine (Neoral) 1 mg 1-0-1\n Mycophenolic Acid (Myfortic) 180 mg 1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0\n Aspirin 81 mg 1-0-0\n Candesartan (Atacand) 16 mg 0-0-1\n Metoprolol (Lopressor) 50 mg 1-1-1-1\n Isosorbide Dinitrate (Isordil) 60 mg 1-0-0\n Torsemide (Demadex) 10 mg As directed\n Ranitidine (Zantac) 300 mg 0-0-1\n Fluvastatin (Lescol) 20 mg 0-0-1\n Allopurinol (Zyloprim) 100 mg 0-1-0\n Tamsulosin (Flomax) 0.4 mg 1-0-0\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient, Mr. Alan Fisher,\nborn on 12/09/1953.\n\nHe was under our inpatient care from 10/02/2018 to 10/03/2018.\n\n**Diagnoses:**\n\n- Urosepsis\n\n- Acute postrenal kidney failure\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Previous Surgeries:** Previous prostate vesiculectomy with regional\nlymphadenectomy\n\n**Planned procedure:** Urethro-cystoscopy with catheter placement for\nurethral stricture\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by the outpatient urologist due to suspicion of\na urethral stricture. Mr. Fisher reports a worsening urinary retention\nfor approximately 6 months. Despite multiple unsuccessful attempts at\ncatheter placement, ureterocystoscopy with catheter insertion was\nperformed. Intraoperatively, purulent cystitis and a bladder outlet\nobstruction were observed.\n\nMr. Fisher regularly attends follow-up examinations for his history of\nkidney transplantation in 1995 and previous prostate vesiculectomy with\nregional lymphadenectomy in 01/2018.\n\n**Physical Examination:** Neurology: RASS 0, alert, CAM-ICU negative, no\nnew focal neurology\n\nLungs: Bilateral air entry, no rales or wheezing, sufficient gas\nexchange on 2L/O2 Cardiovascular: Normal sinus rhythm, normotensive on\n0.01 µg/kg/min NA\n\nAbdomen: Soft, no guarding, sparse peristalsis, advanced oral diet,\nregular bowel movements\n\nDiuresis: Normal urine output, retention values within normal range,\ngoal: balanced fluid status\n\nSkin/Wounds: Non-irritated, no peripheral edema\n\n**Therapy and Progression**: We received Mr. Fisher, who was awake and\nspontaneously breathing under a 2L O2 mask via nasal cannula, to our\nintensive care unit due to urosepsis. To maintain an adequate\ncirculation, low-dose catecholamine therapy was required but could be\ndiscontinued on the first postoperative day. Pulmonary function remained\nstable with intensive non-invasive ventilation and breathing training.\n\nGiven his immunosuppression, we escalated the intraoperatively initiated\nanti-infective therapy from Ceftriaxone to Piperacillin/Tazobactam.\nPneumococcal and Legionella rapid tests were negative. Following\nappropriate volume resuscitation and diuretic therapy with Furosemide,\ndiuresis became sufficient. Oral diet progression occurred without\ncomplications. Anticoagulation was initially in prophylactic dosing with\nHeparin and later switched to therapeutic dosing with Enoxaparin.\n\n**Current Recommendations:**\n\n- Switch unfractionated Heparin to Fragmin\n\n- baseline Crea 2mg/dL, target CyA level: 50-60ng/mL, Myfortic\n continued.\n\n- Urological care of the stricture in progress, leave catheter until\n then.\n\n- Mobilization\n\n**Medication upon Discharge:**\n\n **Medication (Brand)** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Torsemide (Demadex) 10 mg 1-1-0-0\n Prednisone (Deltasone) 5 mg 1-1-0-0\n Pantoprazole (Protonix) 20 mg 1-1-0-0\n Mycophenolate Mofetil (CellCept) 360 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 100 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Candesartan (Atacand) 16 mg 0-0.5-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Allopurinol (Zyloprim) 100 mg 1-0-0-0\n Aspirin 81 mg 1-0-0-0\n Paracetamol (Tylenol) 500 mg As needed\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. Alan Fisher, born on\n12/09/1953.\n\nHe was under our inpatient care from 11/04/2018 to 11/12/2018.\n\n**Current Symptoms:** Decreased diuresis, rising creatinine, frustrating\ncatheterization.\n\n**Diagnoses:**\n\n- Acute on chronic graft failure\n\n<!-- -->\n\n- Creatinine increased from 1.56 mg/dL to a maximum of 2.35 mg/dL.\n\n- Likely postrenal origin due to urethral stricture; sonographically,\n Grade II urinary stasis with urinary retention and residual urine\n formation.\n\n- Frustrating catheterization due to urethral stricture\n\n- Urethro-cystoscopy with bougie and catheter placement\n\n- Parainfectious component in purulent cystitis with urosepsis\n\n- Discharged with indwelling catheter\n\n- Inpatient readmission to the colleagues in Urology for internal\n urethrotomy\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by an outpatient urologist due to suspected\nurethral stricture. Mr. Fisher reports increasing difficulty urinating\nfor approximately 6 months. He has to \\\"squeeze out\\\" his bladder\ncompletely. Frustrating catheterization was performed due to urinary\nretention. Intraoperatively, purulent cystitis and bladder outlet\nstenosis were observed. Mr. Fisher regularly undergoes follow-up\nexaminations for a history of kidney transplantation in 1995 and a\nprostate vesiculectomy with regional lymphadenectomy in 01/2018.\n\n**Vegetative Findings:** The patient had a bowel movement 4 days ago,\nindwelling catheter irritation (3L of diuresis the previous day), no\nnausea/vomiting, no fever or night sweats, weight loss of 30kg from\nFebruary to April 2020.\n\n**Physical Capacity:** Limited, can still climb 2 stairs but needs to\ntake a break due to shortness of breath.\n\n**Physical Examination:** Temperature 37.4°C, Blood pressure 128/72\nmmHg; Pulse 72/min; Respiratory rate 15/min, O2 saturation under 2L O2:\n96%\n\nAwake, alert, cooperative, oriented to time, place, person, and\nsituation.\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; Clear paranasal\nsinuses; moist and pink mucous membranes; unremarkable dentition; moist\nand glossy tongue; non-palpable thyroid enlargement.\n\n[Chest]{.underline}: Normal configuration; Non-tender spine; free renal\nbeds bilaterally.\n\n[Heart]{.underline}: Rhythmic, clear heart sounds, normal rate, no\nsplitting; non-distended jugular veins. [Lungs]{.underline}: Vesicular\nbreath sounds; Resonant percussion note; no adventitious sounds; no\nstridor; normal chest expansion.\n\n[Abdomen]{.underline}: Protuberant, known incisional hernia, normal\nperistalsis in all quadrants; soft; no pathological resistance; no\ntenderness; liver palpable below the costal margin; spleen not palpable.\n\n[Lymph nodes:]{.underline} No pathologically enlarged cervical nodes\npalpable; axillary and inguinal nodes not palpable.\n\nSkin: No pathological skin findings.\n\n[Extremities:]{.underline} Warm; mild bilateral ankle edema.\n\n[Pulse status (right/left):]{.underline} A. carotis +/+, A. radialis\n+/+, A. femoralis +/+, A. tibialis post. +/+, A. dorsalis ped. +/+\n\n[Neurological]{.underline}: Oriented and unremarkable.\n\n**Therapy and Progression:** The patient was admitted through our\nemergency department upon referral by an outpatient urologist due to\nsuspected urethral stricture, which had been causing increasingly\ndifficult urination for approximately 6 months. Sonography showed Grade\nII urinary stasis with urinary retention and residual urine. Frustrating\ncatheterization was performed, followed by ureterocystoscopy with bougie\nand catheter placement. Intraoperatively, purulent cystitis and bladder\noutlet stenosis were observed. Laboratory tests revealed acute kidney\ntransplant failure, with creatinine increasing from 1.56 mg/dL to 2.35\nmg/dL, along with significantly elevated infection parameters: CRP up to\n186 mg/dL, PCT 12.82 µg/L, and leukocytosis of 21.6/nL. After obtaining\nblood cultures, empirical antibiotic therapy with Ceftriaxone was\ninitiated. Upon detecting Pseudomonas aeruginosa, therapy was switched\nto Piperacillin/Tazobactam on 12/06/20 and continued until 12/13/20.\nUnder this treatment, infection parameters significantly improved, and\nMr. Fisher remained afebrile. Kidney retention parameters also decreased\nto a discharge creatinine of 2.05 mg/dL. Regarding the urethral\nstricture, he was initially discharged with an indwelling catheter. A\nfollow-up appointment for internal urethrotomy and potentially Allium\nstent placement was scheduled for 4 weeks later. During the hospital\nstay, ciclosporin levels remained within the target range. Following\nprostate vesiculectomy earlier in the year, anticoagulation was switched\nfrom Enoxaparin to Apixaban 2.5 mg twice daily, and Aspirin therapy was\ndiscontinued.\n\n**Recommendations**: We recommend regular monitoring of kidney retention\nparameters and infection parameters. Regarding the urethral stricture,\nthe patient will be discharged with an indwelling catheter. We scheduled\na follow-up with colleagues in Urology for internal urethrotomy and\npotentially Allium stent placement. Pause oral anticoagulation with\nApixaban one day before inpatient admission.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Candesartan (Atacand) 8 mg 0-1-0-0\n Torsemide (Demadex) 10 mg 1-1-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU Pause\n Magnesium Oxide 400 mg 1-0-0-0\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under outpatient care on 07/01/2019.\n\n**Current Symptoms:** Pain on the left side at rib level**,** Dyspnea\n\n**Diagnoses:**\n\n- Infection of unclear origin\n\n - CT Thorax and Abdomen showed no focus\n\n - Urine dipstick and cultures were bland\n\n - Antibiotics: Meropenem from 06/11/2019 to 06/19/2019\n\n- Acute Transplant Dysfunction\n\n - Serum Creatinine: 2.4 -\\> 4.5 -\\> 2.6 mg/dl\n\n - Renal ultrasound: 123 x 54 x 24 mm, not dilated, some areas of\n increased echogenicity, no twinkling, no acoustic shadowing, no\n signs of urolithiasis.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Initial presentation was at the local emergency\ndepartment on referral from the primary care physician for suspected\nacute coronary syndrome. Mr. Fisher described left-sided rib pain, which\nwas related to breathing and pressure, as well as dyspnea for a few\ndays. Laboratory tests showed acute-on-chronic kidney failure and\nelevated infection parameters. A urine dipstick test was negative for\nnitrites and leukocytes. Chest CT ruled out pulmonary pathology, and\nacute coronary syndrome was also excluded. Mr. Fisher reported a urinary\ntract infection about 4 weeks ago, which was treated with antibiotics as\nan outpatient.\n\n**Physical Examination:** Alert, oriented, cooperative, and responsive\nto time, place, person, and situation\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; clear nasal\nsinuses; moist pink mucous membranes; unremarkable dental status; moist\ntongue\n\n[Chest]{.underline}: Normal configuration; no tenderness in the spine;\nboth renal beds free\n\n[Heart]{.underline}: Arrhythmic heart sounds, pure, tachycardic, not\nsplit\n\n[Lungs]{.underline}: Vesicular breath sounds; somewhat decreased breath\nsounds bilaterally; no adventitious sounds; no stridor\n\n[Abdomen]{.underline}: Regular peristalsis in all quadrants; soft; right\nlower abdomen notably distended with increased vascular markings, liver\nand spleen not palpable, transplant kidney non-tender\n\n[Lymph Nodes:]{.underline} No pathologically enlarged cervical lymph\nnodes palpable\n\n[Skin]{.underline}: No pathological skin findings\n\n[Extremities:]{.underline} Warm; no edema; cyanosis of toes bilaterally\nafter prolonged leg dependency\n\n- Pulse status (right/left): Carotid artery +/+, Radial artery +/+,\n Posterior tibial artery +/+\n\n- Neurology: Normal cranial nerves; round, moderately dilated pupils;\n prompt bilateral pupillary light reflex; no sensory or motor\n deficits; ubiquitous muscle strength 5/5\n\n**Therapy and Progression:** We admitted the patient for further\ndiagnosis and treatment. Initially suspected acute coronary syndrome was\nruled out. Laboratory results showed elevated retention and infection\nparameters. With volume substitution, we achieved baseline creatinine\nlevels again. The transplant kidney appeared non-dilated and\nwell-perfused. For the infection, the patient received the mentioned\nimaging studies, which did not reveal any definitive findings. Our urine\nanalyses and cultures also showed bland results. It should be noted that\nprior outpatient treatment for suspected urinary tract infection was\nlikely with cotrimoxazole. Ultimately, considering the recent\nantibiograms, we decided on a calculated antibiotic therapy with\nMeropenem. This led to a significant improvement in infection\nparameters. The last measured Ciclosporin level was slightly\nsubtherapeutic, so we adjusted the dosage accordingly. We recommend\nfollow-up with the primary care physician.\n\n**Chest CT on 06/10/2019:**\n\n[Clinical Information, Question, Justification]{.underline}: Patient\nwith a history of kidney transplantation. Bursting pain on both sides at\nthe ribcage. Cough. Elevated inflammatory markers. Question about\ninfiltrates, pleural effusion, congestion.\n\n[Technique]{.underline}: Digital overview radiographs. Plain 80-line CT\nof the chest. MPR (Multiplanar reconstruction). DLP (Dose-Length\nProduct) 120.6 mGy\\*cm.\n\n[Findings]{.underline}: No previous images available for comparison.\nSymmetric thyroid. Minimal pericardial effusion, accentuated at the\nbase, measuring up to 8 mm in width (Series 5, Image 293). Coronary\natherosclerosis. No pathologically enlarged lymph nodes in the\nmediastinum, axilla, or hilum on plain images. Multisegmental calcified\n(micro)nodules. No suspicious pulmonary nodules indicative of\nmalignancy. No pneumonic infiltrates. No pleural effusions. No\npneumothorax. No pulmonary venous congestion. Delicate scar tissue at\nthe bases bilaterally. Small axial hiatal hernia. Rounded soft tissue\nstructure in the right adrenal space (Series 5, measuring 411 x 10 mm).\nIncidentally captured at the image margins is a shrunken left kidney.\nSpondylosis deformans of the thoracic spine. Interpretation: No\npneumonic infiltrates. No pleural effusions. No pulmonary venous\ncongestion. Minimal pericardial effusion. Multisegmental calcified\n(micro)nodules, likely post-inflammatory.\n\n**Abdomen/Pelvis CT on 06/14/2019:**\n\n[Clinical Information, Question, Justification:]{.underline} Acute\nkidney failure. Question regarding kidney or ureteral stones.\n\n[Technique]{.underline}: Plain 80-line CT of the abdomen. MPR. DLP 947\nmGy\\*cm. Findings and [Interpretation:]{.underline}\n\nThe left transplant kidney shows pelvic dilation with an expanded renal\npelvis and ureter (hydronephrosis grade II) but no evidence of stones.\nStatus post-right nephrectomy. Shrunken left kidney. Known large,\nbroad-based right-sided abdominal wall weakness with prolapsed\nintestinal loops and mesenteric fat tissue without evidence of\nincarceration. No ileus. Diverticulosis of the sigmoid colon. Small\naxial hiatal hernia. No free or encapsulated fluid or free air in the\nabdomen with the right diaphragmatic dome not fully visualized.\n\nCholecystolithiasis. No cholestasis. Vascular sclerosis. No\nlymphadenopathy. Bilaterally aerated lung bases captured without change.\nUnchanged irregularly thickened and coarsely structured right iliac\nbone, consistent with Paget\\'s disease.\n\n**Recommendations:**\n\nCiclosporin level monitoring\n\n**Medication upon discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Candesartan Cilexetil (Atacand) 8 mg 0-1-0-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU 1 x/week\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 70-0-70-0\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under our inpatient care from 02/19/2020 to\n03/01/2020.\n\n**Current Symptoms:** Decreased general condition, weakness,\ndecompensation\n\n**Diagnosis**: Acute episode of recurrent urinary tract infection with\ndetection of E. faecalis, E. faecium, and Enterobacter cloacae in urine\n(blood cultures sterile).\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our internal\nmedicine emergency department. He presented with worsening general\ncondition and increasing weakness, following the recommendation of our\nlocal nephrological telemedicine. He particularly noticed the increasing\nweakness when getting up, describing his legs as feeling like rubber. He\nalso experienced shortness of breath. His walking distance was greater\nthan 100 meters. There was no fever, chills, nausea, vomiting, dysuria,\nor changes in bowel movements. Before the outpatient visit, the patient\nhad collected urine for 24 hours, totaling 1700 ml, with a fluid intake\nof approximately 2 liters. His blood pressure at home was approximately\n120/60 mmHg. In the emergency department, he had negative urinary\ndipstick results and a non-specific chest X-ray. Blood and urine\ncultures were obtained, and he was subsequently transferred to our\ngeneral ward. No angina pectoris symptoms. The patient had normal bowel\nmovements, specifically no melena, and no blood-tinged stools. Urine was\ndescribed as clear and light.\n\n**Physical Examination:** Alert, oriented, cooperative, oriented to\ntime, place, person, and situation. Height 179 cm; Weight 114 kg\n\n[Head/neck:]{.underline} No tender nerve exit points; Clear nasal\nsinuses; No tenderness over the skull; Mucous membranes pink and moist;\nDental status is rehabilitated; Tongue moist and glossy\n[Thorax]{.underline}: Normally shaped; Spine without tenderness; Renal\nregions free of tenderness\n\n[Heart]{.underline}: Heart sounds are faint, arrhythmic, clear, regular\nrate, no splitting of heart sounds; Jugular veins are not distended\n\n[Lungs]{.underline}: Faint vesicular breath sounds; Resonant percussion\nnote; Dullness on the left, no added sounds; No stridor; Normal breath\nexcursion\n\n[Abdomen]{.underline}: Large right abdominal wall hernia, normal\nperistalsis in all quadrants; Soft; No pathological resistances; No\ntenderness (especially not over the left lower abdomen)\n\n[Skin status:]{.underline} No pathological skin findings\n\nExtremities: Warm; Mild edema.\n\n[Neurology:]{.underline} Alert. No focal deficits\n\n**Treatment and Progression:** The patient was admitted through our\nemergency department due to a decrease in general condition and\nweakness, accompanied by significantly elevated laboratory infection\nparameters and slightly worsened retention parameters (Creatinine max\n3.4 mg/dL compared to the current baseline of 3 mg/dL). Upon admission,\napart from a known and persistent leukocyturia since 2020, there were no\nindications of any other infectious focus. We were able to detect\nEnterobacter cloacae and Enterococcus faecalis in the urine, and we\ninitially treated the patient with intravenous Tazobactam. Blood\ncultures remained sterile. The patient\\'s general condition improved\nwithin a few days, along with a regression of infection parameters.\n\nFor further investigation of recurrent urinary tract infections (UTIs)\nand in the context of a history of urethral stricture treatment in\nFebruary 2021 with bougienage of the urethra one year ago, a urological\nconsultation was arranged. During this consultation, there was suspicion\nof a recurrence of the urethral stricture due to a significant residual\nurine volume of 175 ml. A scheduled readmission for repeat surgical\nmanagement was set for May 16, 2022. Due to the lack of normalization of\nelevated infection parameters and significant residual urine, a urinary\ncatheter was inserted. Subsequently, Enterococcus faecium was detected,\nand we continued treatment with oral Linezolid after the completion of\nintravenous antibiotic therapy.\n\nThe antibiotic treatment was planned to continue on an outpatient basis\nfor a total of 10 days. We kindly request an outpatient follow-up to\nmonitor infection parameters next week. The urinary catheter will be\nmaintained until the urological follow-up appointment, and the patient\nhas been provided with a prescription for medication.\n\nFurthermore, the patient exhibited atrial tachyarrhythmia. We reduced\nthe heart rate using Digoxin, as the patient was already on maximum\nbeta-blocker therapy. The atrial tachyarrhythmia significantly improved\nunder this treatment.\n\nAdditionally, there was a non-puncture-worthy pleural effusion and a\nchronic pericardial effusion, which was not hemodynamically relevant.\nThere were no clinical indications of pericarditis.\n\n**Current Recommendations:**\n\n1. Inpatient admission to Urology Department.\n\n2. Outpatient laboratory monitoring and referral issuance by the\n primary care physician.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on mutual patient, Mr. Alan Fisher, born on 12/09/1953,\nwho was under our inpatient care from 03/14/2020 to 03/15/2020.\n\n**Diagnoses**: Anastomotic stricture following history of prostatectomy\nand history of urethrotomy interna.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Procedure**:\n\n- Urethrotomy interna according to Sachse\n\n- Calculated intravenous antibiotic therapy with Meropenem starting on\n 03/14/2020\n\n- Extension of therapy to include antifungal treatment with\n Fluconazole on 03/15/2020\n\n**Medical History:** The patient presents with a recurrence of\nsymptomatic urethral stricture at the anastomosis site following\nprostatectomy. The main symptoms are frequent urination, dysuria, and\nresidual urine formation up to 175 ml. In January 2019, urethrotomy\ninterna was already performed. Since the last hospitalization due to a\nurinary tract infection, the patient has had a continuous\ncatheterization.\n\n**Physical Examination:** Patient in a reduced general condition and\nobese nutritional status. The abdomen is soft, without signs of\nresistance or pain. Kidney beds on both sides are indolent.\n\n**Urine Diagnostics**: Urine dipstick: Leukocytes 500, Nitrite negative,\nErythrocytes 50\n\n**Microbiology**: Candida in urine, collected by the general\npractitioner on 03/11/2020.\n\n**Chest X-ray in two planes on 02/19/2020:**\n\n[Clinical Information, Question, Justification for the\nExamination]{.underline}: Deterioration of general condition. History of\nrecurrent sepsis. History of lung transplantation. Infiltrates?\n\n**Findings**: The heart is shifted to the left and has a mitral\nconfiguration. No signs of acute congestion. The mediastinum shows no\nsigns of emphysema, is centrally located, and of normal width. No active\npneumonia in the ventilated lung regions. Progressive costophrenic angle\neffusion on the left. No pleural effusion on the right, as far as can be\nassessed. No pneumothorax. Degenerative changes in the spine.\nHyperkyphosis of the thoracic spine.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complication. Scar tissue at the level of the bladder sphincter\nwas incised. The postoperative course was uneventful. The transurethral\nindwelling catheter was removed on the 19th postoperative day. At the\ntime of discharge, the patient could urinate without residual urine with\na good urinary stream. We discharged the patient on 03/19/2020 for\nfurther outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------------- ------------------- ------------------\n Magnesium Oxide 400 mg 1-0-0-0\n Atorvastatin (Lipitor) 43.3 mg 0-0-1-0\n Candesartan Cilexetil (Atacand) 16 mg 1-1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol, oily) 20,000 IU 1x every 2 weeks\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 385 mg 1-0-1-0\n Pantoprazole (Protonix) 22.6 mg 1-0-0-0\n Piperacillin/Tazobactam (Zosyn) 4.17 g and 0.54 g 1-1-1-0\n Cyclosporine, microemulsified (Neoral) 10 mg 1-0-1-0\n Cyclosporine, microemulsified (Neoral) 50 mg 1-0-1-0\n Torsemide (Demadex) 10 mg 2-1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------------ ---------------------\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 3.02 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 19 mL/min/1.73m² \\-\n Total Bilirubin 0.73 mg/dL \\< 1.20 mg/dL\n Direct Bilirubin 0.41 mg/dL \\< 0.30 mg/dL\n C-reactive Protein 78.3 mg/dL \\< 5.0 mg/dL\n Alanine Aminotransferase 35 U/L \\< 41 U/L\n Aspartate Aminotransferase 33 U/L \\< 50 U/L\n Alkaline Phosphatase 273 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 184 U/L 8-61 U/L\n Lipase 102 U/L 13-60 U/L\n Hemoglobin 12.3 g/dL 12.5-17.2 g/dL\n Hematocrit 39.0% 37.0-49.0%\n Red Blood Cells 4.2 M/uL 4.0-5.6 M/uL\n White Blood Cells 10.41 K/uL 3.90-10.50 K/uL\n Platelets 488 K/uL 150-370 K/uL\n Mean Corpuscular Volume 92.4 fL 80.0-101.0 fL\n Mean Corpuscular Hemoglobin 29.1 pg 27.0-34.0 pg\n Mean Corpuscular Hemoglobin Concentration 31.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.3 fL 7.0-12.0 fL\n Red Cell Distribution Width 13.5% 11.5-15.0%\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\n\nWe are writing to report on the outpatient treatment of Mrs. Laura\nMiller, born on 04/03/1967, on 05/22/2020.\n\n**Diagnosis**: Osteoporotic vertebral body sintering (lumbar vertebra 2\nand thoracic vertebra 8).\n\n**Medical History**: Mrs. Miller presents with pain in her back, legs\nradiating, after fall on the back 6 weeks ago. The complaints were\nprogressive with intermittent paresthesia in both legs.\n\n**Other Diagnoses** (not fully collectible):\n\n- Status post apoplexy\n\n**Current Medication (**not ascertainable):\n\n- Blood pressure medication\n\n- Osteoporosis medication\n\n- No anticoagulation.\n\n**Physical Examination: Lumbar spine:** Skin without pathological\nfindings. No redness, no evidence of infection.\n\nTapping pain over thoracic spine/lumbar spine, no compression pain, no\ntorsion pain, no pressure pain over spinous process.\n\nRadiation of pain into the right and left leg, paravertebral muscle\nhardness.\n\nNo paresthesias in the genital area, no breech anesthesia, no peripheral\nneurologic deficits, No bladder or rectal dysfunction.\n\nPeripheral Circulation/Motor function/Sensitivity intact.\n\nStrength grade on all sides: Hip Flex/Ex: 5/5, Knee Flex/Ex: 5/5,\n\nFoot extensor muscles of the lower leg/flexor muscles of the lower leg:\n3/5.\n\nBig toe extensor muscles of the lower leg/big toe flexor muscles of the\nlower leg: 2/5.\n\n**Thoracic Spine 2 levels from 05/22/2020, Lumbar spine in 2 planes from\n05/22/2020:**\n\nClinical indication: Status post fall\n\nQuestion: new fracture?\n\nPreliminary images: none comparable\n\n**Findings**\n\n1\\) [Thoracic Spine]{.underline}: Multiple thoracic vertebral bodies\nexhibit decreased height, most notably at the central region where a\nmeasurement of approximately 17 mm suggests significant height loss and\npotential acute fracture. Additionally, there are endplate impressions\nin individual vertebrae of the lower thoracic spine. Aortic sclerosis is\npresent, along with degenerative changes throughout the thoracic\nvertebrae. The osseous structure presents osteoporotic features. A\nsuspected hemangioma is identified in a vertebral body of the lower\nthoracic spine.\n\n2\\) [Lumbar Spine]{.underline}: In a presumed five-segment lumbar spine,\nthe L1 vertebra shows a subtle reduction in height with a questionable\nendplate impression. Osteoporotic features are evident in the bony\nstructure.\n\n**Assessment:** Multiple fractures are evident in both thoracic\nvertebrae and the first lumbar vertebra, some of which may be acute. MRI\nis recommended for further evaluation. Osseous structure displays\npronounced osteoporotic features.\n\nGrade III esophageal varices present without definitive high-risk\nstigmata. Varices also noted at the gastroesophageal junction,\nclassified as GOV 1 according to Sarin\\'s classification. Band ligation\nof the varices is not performed, as no unambiguous source of bleeding is\nidentifiable and a significant portion of the stomach remains outside\nthe field of view.\n\n**Recommendation**: Terlipressin, monitor surveillance, Erythromycin\n\n**Computed Tomography Thoracic spine from 05/22/2020:**\n\nFracture at the base plate of lumbar vertebra 2 with involvement of the\nposterior margin. Left lateral, no significant reduction in height of\nthe vertebral body. No tension of the spine.\n\nSuspicion of new small fracture also at the cover plate at thoracic\nvertebra 8.\n\nMultiple, older, osteoporotic compression fractures at the thoracic\nspine and\n\nupper lumbar spine.\n\n**Additional Finding:**\n\nLiver cirrhosis with multiple nodules, low ascites, and portal vein\ncongestion. Splenomegaly. If not already known, further workup of liver\nlesions is recommended. Hydrops of the gallbladder.\n\n**Current Recommendations**: There is a general indication for admission\nof the patient and further diagnostics before surgical treatment of the\nfractures. Mrs. Miller is generally opposed to surgical care. She was\nthoroughly informed about the risks (progression, cross-section, death).\n\nRe-presentation with current bone densitometry and update of\nosteoporosis medication, as well as current holospinal MRI. In the\nmeantime, analgesia as needed using Acetaminophen 500mg 1-1-1 under\ngastric protection.\n\n**Esophagogastroduodenoscopy from 05/22/2020:**\n\n[Esophagus]{.underline}: Unobstructed intubation of the esophageal\nopening was achieved under direct visualization. In the upper third of\nthe esophagus, multiple prominent varices protrude into the lumen,\nunaltered by air insufflation. In the middle third, there are areas with\nwhitish overlying material that do not resemble the typical white nipple\nsign. Despite meticulous inspection, no active bleeding sites were\nidentified. The Z-line reveals isolated minor erosions. Cardiac\nsphincter closure is complete.\n\n[Stomach]{.underline}: Full distension of the gastric lumen was\naccomplished with air insufflation. The major curvature of the stomach\ncontained food mixed with hematin. The mucosal surface was similarly\ncoated with hematin, but no active bleeding was discernible in the\nvisualized areas. Peristaltic movement was widespread. Upon\nretroflexion, pronounced varices were noted near the cardiac region on\nthe lesser curvature. The pylorus was unremarkable and easily\ntraversable.\n\n[Duodenum]{.underline}: Adequate distension of the duodenal bulb was\nachieved, providing a clear view up to the descending part of the\nduodenum. Overall, the mucosa appeared normal with minor remnants of\nhematin, and no source of bleeding was identified.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about Mrs. Laura Miller, born on 04/03/1967, who was in\nour inpatient treatment from 05/27/2020 to 06/22/2020.\n\n**Diagnoses**: Initial diagnosis of hepatocellular carcinoma.\n\n- MRI liver: disseminated HCC foci in all segments, the largest foci\n is localized in segments 5 / 7 / 8\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: sophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: Residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Physical Examination:** Patient in mildly reduced general and normal\nnutritional status (BMI 20.3).\n\n- Lungs: Vesicular breath sound, no pathological secondary sounds.\n SpO2 96%.\n\n- Heart: Pure, rhythmic. Systolic with maximum at Erb\\'s point and\n continuation into the carotids. HR: 87/min. BP: 124/54mmHg\n\n- Abdomen: Lively bowel sounds, no tenderness, no guarding, no\n resistance, no peritonism. Soft abdomen. Liver not enlarged,\n palpable. Renal bed not palpable.\n\n- Extremities: Edema of the lower extremities on both sides, foot\n pulses bilaterally well palpable.\n\n- Spine: No tap pain.\n\n- Orienting neurological examination: Right leg weakness, known\n paresis of the extensor muscles of the lower leg/flexor muscles of\n the lower leg.\n\n**Therapy and Progression:** Mrs. Miller was taken over for suspected\nupper GI bleeding. Initially, the patient had presented with increasing\nback pain since approximately 6 weeks at status post fall in the Park\nClinic on 04/26/2020. The patient was known there for her stroke in\n2016. On the day of admission to the Park Clinic, normochromic\nnormocytic anemia (Hemoglobin 3 g/dL) was noticed, which is why the\ntransfer to our clinic was made.\n\nOn inpatient admission, the patient presented in slightly reduced\ngeneral condition. She reported having black stools once. In addition,\nMs. Miller had coffee ground-like emesis once. Dyspnea, angina pectoris\ncomplaints, and B symptoms were denied. There were no problems with\nmicturition. Recently, there were no abnormalities in bowel movements.\nSo far, no colonoscopy has been performed. There were no known\nintestinal diseases in the family.\n\n[Noxae]{.underline}: Ex-nicotine use (since 1996, previously cumulative\nca. 3 PY), occasional alcohol consumption (probably abstinent for about\n5 years).\n\nLaboratory results showed that the patient had elevated infectious\nparameters. The\n\nurinalysis was unremarkable. X-ray chest showed no clear picture of\npneumonia. In a first emergency esophagogastroduodenoscopy on\n05/28/2020, esophageal varices °III were found without clear signs of\nrisk. Furthermore, varices in the area of the cardia (GOV 1 after Sarin)\nwere seen. When the source of bleeding was inconclusive, it was referred\nto a banding initially waived. In a renewed esophagogastroduodenoscopy\nin the morning of 05/30/2020, 2 ampoules of Histoacryl were applied to\nthe cardia varices. In addition, the picture of an incipient\nportal-hypertensive gastropathy. Antibiotic intravenous therapy with\nceftriaxone was initiated. At 06/13/2020, a\nre-esophagogastroduodenoscopy took place, during which a renewed twofold\nbanding of the esophageal varices was performed with injection of 0.5 ml\nHistoacryl. Abdominal ultrasound showed a picture of liver cirrhosis\nwith splenomegaly and perihepatic ascites. In addition, the liver showed\nmultiple echo-poor nodes in the right lobe and a suspicious\n2.4x3.6x4.4cm echo-poor area with a halo in SII. This was followed by an\nMRI of the liver, in which the HCC in segment II was confirmed by\nimaging.\n\nMultiple additional arterial hypervascularized areas/round foci in all\nliver lobes without definite washout. There is no evidence of suspicious\nnodular changes on CT chest/abdomen/pelvis. At an in-house liver\nconference, systemic therapy (Lenvatinib or Sorafenib in Child B7) was\nrecommended.\n\nDue to the back pain, a holospinal MRI was performed, which showed a\nsubacute cover plate compression fracture in the thoracic vertebra 8 as\nwell as multiple older compression fractures of the thoracic spine and\nupper lumbar spine. The colleagues of neurosurgery were consulted, who\ngave the indication for surgery. On 06/14/2020, the planned surgery with\nkyphoplasty thoracic vertebra 8 under C-arm fluoroscopy could be\nperformed without complications. Postoperatively, the patient remained\ncirculatory stable.\n\nDue to auscultatory suspicion of aortic valve stenosis, further\nclarification was performed by cardiac echography, showing no\nhigher-grade valvular vitiation.\n\nWe are transferring Mrs. Miller in improved general condition to the\nSenior Citizens\\' Residence Seaview. If you have any questions, please\ndo not hesitate to contact us.\n\n**Addition:**\n\n**Ultrasound of the upper abdomen on 05/27/2020:**\n\nLimited assessable due to meteorism.\n\n**Liver**: Liver dimensions are within normal limits, measuring 15.9 cm\nin the craniocaudal axis. Echotexture demonstrates inhomogeneous\ngranularity. There is hepatic margin convexity and nodular surface\nappearance. Rarification of hepatic veins. Segment III reveals two\nhypoechoic lesions measuring 3 cm and 1 cm in diameter. Portal vein\ndemonstrates orthograde flow with a maximum velocity of 17 cm/s.\n\n**Gallbladder:** Gallbladder is partially contracted; its wall appears\nunremarkable without sonographic evidence of cholecystitis. No\ntenderness elicited upon sonographic examination.\n\n**Biliary Tract**: Intrahepatic bile ducts are patent. Common hepatic\nduct measures 6 mm in diameter. Common bile duct appears transiently\ndilated up to 9 mm and is otherwise unremarkable as far as can be\nvisualized prepapillary.\n\n**Pancreas**: Limited visualization of the pancreas; however, the\nvisible parenchyma appears homogeneously echoic.\n\n**Spleen**: Spleen is enlarged, measuring 13 x 4 cm, with homogeneous\nparenchyma.\n\n**Kidneys**: Kidneys are morphologically unremarkable, without evidence\nof pelvicalyceal system dilation.\n\n**Abdominal Vessels**: Aorta is partially visualized and appears within\nnormal calibers.\n\nIntestinal/Peritoneal Cavity: No evidence of free intraperitoneal fluid.\n\nUrinary Bladder/Genitalia: Urinary bladder is adequately distended,\nappearing unremarkable upon limited assessment. Uterus is not\nvisualized.\n\n**Virology from 05/28/2020:**\n\n- SARS CoV-2 PCR PCR negative Geq/ml\n\n- Findings: No detection of SARS-CoV-2 by PCR in the submitted\n material.\n\n**Chest X-ray a.p. from 05/28/2020:**\n\nLimited assessability in supine position, malrotation. The diaphragmatic\ncrests are smooth. The marginal sinuses are free of effusions and\ncalluses. Heart and mediastinum lie cryptically. The aorta is sclerosed.\nCranialization of the vessels as well as slightly elevated vascular\nmarkings in the supine position, especially in the right upper field.\nDystelectasis on the right. Sharply defined vertical shadowing in the\nleft upper field. The upper mediastinum is narrow, the trachea is in the\nmidline and is not constricted. Degenerative changes in the cervical\nspine. Overlying foreign material.\n\n**Assessment**: Sharply defined vertical shadowing in the left upper\nfield. Dystelectasis on the right side. Conventional radiographic\nexamination No evidence of a mass. No effusion.\n\n**Esophagogastroduodenoscopy of 05/28/2020:**\n\n**Esophagus**: Successful intubation of the esophageal orifice under\ndirect visualization. Multiple intraluminal protrusions noted in the\nupper third of the esophagus. Non-collapsible variceal strands observed\nupon air insufflation, beginning from the middle third. Whitish\nproliferations seen at multiple sites, not consistent with typical white\nnipple signs. No evidence of active bleeding on close inspection. Z-line\nobserved with isolated minor erosions. Cardiac sphincter fully\ncompetent.\n\n**Stomach**: Gastric lumen fully distended under air insufflation.\nCorpus predominantly contains hematin-laden food remnants. Mucosal\nsurface also stained with hematin but without visible active bleeding.\nPeristalsis noted throughout. Distinct coronary vasculature observed on\nthe lesser curvature. Pylorus unremarkable, offering no resistance to\npassage.\n\n**Duodenum**: Bulbus duodeni well-formed. Pars descendens duodeni\nvisualized clearly. Overall mucosa appears unremarkable, with scattered\nhematin remnants observed without an identifiable bleeding source.\n\n**Assessment**: Esophageal varices graded as °III, with no definitive\nhigh-risk stigmata. Varices also noted in the cardia, classified as GOV\n1 according to Sarin\\'s classification. Ligation of varices was not\nperformed due to the absence of an identifiable bleeding source and\nincomplete visualization of the gastric lumen.\n\n**Ultrasound of the abdomen on 05/29/2020:**\n\n**Quality of Exam**: Limited due to patient non-cooperation and\nmeteorism.\n\n**Liver**: Liver size is paradoxically reported both as normal at 15.9\ncm and enlarged at 18.7 cm. Margins are rounded. Echotexture is markedly\ninhomogeneous with nodular surface. Multiple hypoechoic nodules are\npresent in the right lobe, along with a suspicious hypoechoic area\nmeasuring 2.4 x 3.6 x 4.4 cm with peripheral halo in segment II. Hepatic\nveins are rarified. Portal vein shows orthograde flow with a vmax of 28\ncm/s.\n\n**Gallbladder**: Morphologically unremarkable with no wall thickening.\nCholelithiasis noted with concretions measuring at least 2 to 1.6 cm.\n\n**Biliary Tract:** Intrahepatic bile ducts are not dilated; Common\nhepatic duct measures up to 8.5 mm and common bile duct measures 6.6 mm\nin diameter.\n\n**Pancreas**: Partially visualized; adequacy of assessment is\ncompromised.\n\n**Spleen**: Enlarged with homogeneous internal echotexture.\n\n**Kidneys**: Morphologically unremarkable; no evidence of\nhydronephrosis.\n\n**Abdominal Vessels:** Aorta is not dilated.\n\n**Gastrointestinal**: Perihepatic ascites noted. Both small and large\nintestines appear unremarkable upon limited assessment.\n\n**Urinary Bladder/Genitalia:** Bladder is moderately filled and\nunremarkable in shape and size.\n\n**Assessment**: Limited study due to patient non-cooperation and\nmeteorism. Findings are suggestive of liver cirrhosis and grade I\nascites. Additional findings include suspected hepatic space-occupying\nlesions, splenomegaly, and cholelithiasis. Mild dilation of DHC and DC\nobserved without signs of intrahepatic cholestasis.\n\n**Virology from 06/01/2020:**\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HAV IgG 0.73 negative\n Anti HAV IgM \\<0.1 negative\n\n**Interpretation:** Serologically no evidence of fresh or expired\ninfection with\n\nHepatitis A virus, no immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n HBs antigen 0.21 negative\n Anti HBs \\<0.1 negative\n Anti HBc 0.1 negative\n\n**Interpretation:** Serologically no evidence of acute, chronic or\nexpired Hepatitis B virus infection. No immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HCV 0.06 negative\n\n**Interpretation:** Serologically no evidence of hepatitis C virus\ninfection. At possible fresh infection resubmission in 2-4 weeks and HCV\nPCR recommended.\n\n**MRI total spine plain from 06/04/2020:**\n\n**Technique**: T2 Dixon Sagittal and T2 Axial MRI Sequences. Coverage\nextends from the craniocervical junction to the sacrum.\n\n**Findings:**\n\n**General Spine:** Full extent from craniocervical junction to sacrum\nvisualized. Conus medullaris appropriately located at T12-L1 level.\nMyelon demonstrates uniform width and homogeneous signal. Evaluation of\nthoracolumbar transition and lumbar spine is compromised by artifact\nsuperimposition from ascites.\n\n**Cervical Spine:** Irregular alignment of the posterior vertebral body\nmargins noted, with evidence of disc protrusions and ligamentum flavum\nhypertrophy. Focal T2 hyperintensity observed at C5 level. No evidence\nof prevertebral soft tissue proliferation.\n\n**Thoracic Spine**: Maintained alignment of the posterior vertebral body\nmargins. Multiple anterior endplate compression fractures noted at T5,\nT8, T9, T11, T12 levels. Focal T2 hyperintensity near the anterior\nendplate of T8 involving the posterior margin, indicative of a\nnon-displaced fracture without spinal canal compromise. Hypertrophic\nfacet joint arthrosis at T10-T11 levels resulting in relative spinal\nnarrowing. Bilateral pleural effusions noted, more pronounced on the\nright, with a maximum width of approximately 2 cm. No evidence of\nsignificant neuroforaminal stenosis.\n\n**Lumbar Spine:** Maintained alignment of posterior vertebral body\nmargins. Known anterior endplate compression fractures at L1 and\nbaseplate compression fracture at L2. No evidence of pathological T2\nedema within the vertebral bodies, although assessment is limited due to\nsuperimposed artifacts from ascites. Spinal canal dimensions appear\nadequate throughout. Moderate fatty degeneration of sacral bone noted.\n\n**Assessment**: Evaluation limited due to ascites-related artifacts.\nSubacute anterior endplate compression fracture at T8, along with\nseveral other likely older compression fractures in the thoracic and\nupper lumbar spine. Bilateral pleural effusions observed. Multiple\nneuroforaminal narrowings as detailed above.\n\n**MR Liver plain + contast agent from 06/06/2020**\n\n**Findings:**\n\n1) [Lesion 1]{.underline}\n\n- Size of the lesion 41 mm\n\n- Segment 2\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: yes\n\n- Pseudocapsule: yes\n\n- Behavior delayed leaching: yes\n\n- pseudocapsule macrovascular invasion: no\n\n2) [Lesion 2]{.underline}\n\n- Size of the lesion 104 mm\n\n- Segment 5 / 7 / 8\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: no\n\n- Pseudocapsule: no\n\n- Behavior delayed washing out: no\n\n- Pseudocapsule: no\n\n- Macrovascular invasion: yes\n\n**Comments:**\n\n- MRI with Gadovist intravenous.\n\n- Multiple other satellite foci in all liver segments.\n\n- Signs of liver cirrhosis with nodular liver parenchyma and\n hypertrophy of the left lobe.\n\n- Cholecystolithiasis and gallbladder hydrops. No cholestasis.\n\n- Varices of the esophagus and fundus. Splenomegaly. Ascites. Pleural\n effusions on both sides.\n\n- Lymph node (approximately 8 mm) between the small curvature of the\n Stomach and S1 of the liver.\n\n- Axial hernia.\n\n**Assessment:** Milan fulfilled**.** Dissiminated HCC foci in all\nsegments, the largest foci being in segments 5 / 7 / 8 localized. Portal\nhypertension with bypass circulation and splenomegaly. Ascites and\npleural effusions.\n\n**Microbiology from 06/09/2020:**\n\n[Material]{.underline}: Ascites in blood culture bottles\n\n[Microscopic]{.underline}: No cells, no germs\n\n- Anaerobic culture negative after 48 hours\n\n- So far, no growth in the anaerobic cultures. The cultures are\n incubated for a total of 5 days. In case of growth of anaerobes we\n will send you a follow-up report.\n\n- No growth after 48 hours\n\n**Esophagogastroduodenoscopy of 06/11/2020:**\n\n**Esophagus**: In the distal esophagus, multiple band-like ulcerations\nas well as residual varices with risk signs that may not completely pass\nair insufflation. Z-line without erosions.\n\n**Stomach**: Mosaic-like occupancy of the gastric mucosa. With inversion\nthe\n\nknown small-curved lateral cardiavarii, which is hard on palpation with\nclosed forceps after histoacryl injection. Directly next to it, another\ncardiavarice can now be seen, which has not yet been injected with\nhistoacryl and is soft on palpation.\n\n**Duodenum**: Endoscopic therapy: Injection of 0.5 mL Histoacryl (+0.5\nmL Lipoidol) in the new cardiavarice. Application of 3 rubber band\nligatures to the residual varices in the esophagus.\n\n**Assessment:** Residual varices in the esophagus, application of 3\nrubber band ligations; portal hypertensive gastropathy\n\n**Spine-whole: 2 planes from 06/13/2020**\n\nThe perpendicular of C7 protrudes about 15 mm laterally to the left of\nsacral vertebra 1 in the anterior-posterior image and about 9.3 cm in\nfront of sacral vertebra 1 in the lateral ray path. Slight left convex\nscoliosis thoracolumbally with thoracic counter-swing (Cobb angle \\< 10°\nin each case). The lungs are unremarkable as far as technically\nassessable.\n\n**Assessment**: decompensated positive sagittal spinal imbalance. There\nis no relevant lateral trunk overhang.\n\n**Critical Findings Report:**\n\nA conspicuous single cell population of cells with partial signet ring\ncell character is detected in the smears. A cell block is prepared from\nthe remaining liquid material for further typing of these cells. A\nfollow-up report will follow.\n\n**Thoracic spine in 2 planes from 06/15/2020:**\n\n**Findings**: Thoracic vertebra 8: Post-kyphoplasty status with notable\nimprovement in vertebral height, now measuring 21 mm compared to a\npreoperative height of 13 mm. Mild straightening of the vertebral column\nobserved at this level.\n\nThoracic vertebra 9: Known older anterior endplate collapse.\n\nThoracolumbar spine: Multisegmental height reduction in vertebral bodies\nconsistent with osteoporotic changes. No signs of contrast\nextravasation.\n\nAdditional Finding: Pre-existing calcified structure projecting onto the\nleft upper abdomen; likely unrelated to current surgical site.\n\n**Assessment**: Unremarkable postoperative imaging following kyphoplasty\nof T8. No evidence of postoperative sintering or newly identifiable\nfractures. Overall, the surgical intervention appears successful in\nincreasing vertebral height and stabilizing the fracture site.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 06/18/2020:**\n\n**Technique**: Multislice spiral CT of the chest, abdomen, and pelvis\nwas performed post-bolus intravenous injection of 120 ml of Imeron 400.\nImaging conducted in arterial, portal venous, and venous phases. Oral\ncontrast agent administered with Micropaque 1:7 in water and Gastrolux\n1:33 in water. Thin-slice reconstructions and secondary coronal and\nsagittal reformats were performed.\n\n**Chest**: Presence of struma nodosa. Bilateral minor pleural effusions\nwith adjacent atelectasis, more pronounced on the right and extending\ninto the interlobar region. No signs of infiltrative changes. Isolated\nsmall nodular opacities in the right lung. Few small bullae noted.\nMediastinal lymph nodes mildly enlarged up to 0.5 cm; axillary and hilar\nnodes are not enlarged. No pericardial effusion observed.\n\n**Abdomen/Pelvis**: Known esophageal and fundal varices present. Liver\ndemonstrates nodular changes in the context of known Child-Pugh B stage\ncirrhosis. A solid hepatic cellular carcinoma lesion in segment II and\ndiffuse HCC nodules in segments V/VII/VIII visualized, corroborating\nprior MRI findings. They show pronounced arterial enhancement and\ncentral washout. Splenomegaly noted. Adrenal glands unremarkable. Renal\nand urinary systems are inconspicuous. No intestinal motility\nabnormalities detected. Marked ascites present; no pathologically\nenlarged abdominal lymph nodes noted upon limited assessment.\n\n**Skeletal**: Moderate coxarthrosis bilaterally. An old, minimally\ndisplaced fracture of the right 7th rib noted. Advanced degenerative\nchanges in thoracic vertebrae 10, 12, and lumbar spine.\nPost-vertebroplasty status at thoracic vertebra 9. Hemangioma at\nthoracic vertebra 11.\n\n**Assessment**:\n\n- Marked ascites in the setting of liver cirrhosis with multifocal HCC\n lesions, as corroborated by prior MRI. No evidence of extrahepatic\n or lymphatic spread.\n\n- Bilateral minor pleural effusions with associated atelectasis.\n\n- Skeletal findings include moderate coxarthrosis and degenerative\n changes in the spine.\n\nOverall, the scan provides vital information that aligns with and\nelaborates upon existing clinical and imaging data.\n\n**Histology**:\n\n**Pathology from 06/19/2020:**\n\n[Clinical Data:]{.underline} Hepatocellular carcinoma, hydropic\ndecompensated liver cirrhosis Child B,\n\n[Extraction date:]{.underline} 06/13/2020\n\n[Material:]{.underline} 1 Liquid material 7 ml light yellow\n\n[Editing]{.underline}: Papanicolaou and MGG staining\n\n\\+ Protein precipitation\n\n\\+ Erythrocytes\n\n\\+ Lymphocytes\n\n(+) Granulocytes Eosinophils\n\n\\+ Histiocytic cell forms\n\n\\+ Mesothelium\n\n\\+ Active mesothelium\n\n**Other**: Single mononuclear cells with large, eccentric nuclei with\nnucleoli and a narrow cytoplasmic space, partly with signet ring cells.\n\n**Supplementary findings from 06/19/2020**\n\n[Processing]{.underline}: Cell block, HE\n\n**Microscopic:**\n\nAs announced, from the remaining liquid material a cell block was\nprepared. In the HE stain only isolated evidence of mononuclear Cells\nand some blood. No cell atypia.\n\n**Critical Findings Report:** After examination of the remaining liquid\nmaterial in the cell block no Extension of the initial findings in the\nabsence of further diagnostic cell material. The finding is thus based\nexclusively on the Smear material:\n\n- Detection of a single-cell population consisting of cells with\n partial signet ring cell character. Differentially it could be The\n mesothelium may be a reactive change of the approaching mesothelium.\n Cells of an epithelial neoplasia are not visible on the present\n material. to be ruled out with certainty.\n\n**Diagnostic classification:** Suspicious\n\n**Current Recommendations:**\n\n- An appointment at our outpatient clinic to start therapy was\n organized for 06/26/2020.\n\n- An appointment for a health department check-up with varicose vein\n status survey and, if necessary, repeat rubber band ligation has\n been scheduled for 07/22/2020. Please come to the endoscopy on this\n day at 08:30 am fasting with current lab results. incl. coagulation,\n signed consent form as well as SARS-CoV-2 PCR not older than 48h.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report to you on Mrs. Laura Miller, born 04/03/1967, whom we examined\non 06/08/2020 in the course of a consultation.\n\n**Consilar Request:**\n\n- Liver cirrhosis, Child-Pugh B, ethyltoxic genesis\n\n- HCC\n\n- Laboratory albumin: 2.6\n\n- Nutritional advice requested\n\n**Nutritional counseling in cirrhosis of the liver:**\n\n- Albumin at 2.6\n\n- 70kg at admission (stable weight in recent years).\n\n- Height: 1.72m\n\n- BMI falsified by ascites\n\n- Patient reports that she always a \\\"bad eater\\\"\n\n- She reports to eat less due to numerous medication intake\n\n- Patient is noticeably overwhelmed and seems very burdened by\n diagnosis\n\n**Assessment:**\n\n- Protein malnutrition with inadequate oral nutrition\n\n- Patient appears desperate and overwhelmed, questionable compliance\n\n**Recommendations: **\n\n- High-calorie food for more choices (already ordered)\n\n- High-calorie drinks (contains more protein)\n\n- Incorporate protein-rich snacks such as yogurt, sippy cups,\n crispbread\n\n- with cheese.\n\n- A high-energy, high-protein food choice was made with the patient\\'s\n discussed in detail\n\n- Contact details were handed out\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 08/21/2020 to\n08/23/2020.\n\n**Diagnoses**:\n\n- MRI of the liver: disseminated HCC foci in all segments, the largest\n foci is localized in segments 5 / 7 / 8\n\n<!-- -->\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: esophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Current Presentation:** Mrs. Miller presented electively for\ngastroscopy for variceal screening with continuation of banding therapy\ndue to esophageal variceal bleeding.\n\n**Medical History**: For a detailed medical history, we refer to\nprevious reports from our department. In summary, we present a liver\ncirrhosis due to ethyl toxicity leading to the development of multifocal\nHCC. Similar to the liver board decision of 06/13/20, a recommendation\nfor systemic therapy with Lenvatinib or Sorafenib was made in the\nsetting of partially compensated Child B7 cirrhosis with multifocal HCC\nin both lobes of the liver.\n\n**Therapy and Course:** Upon admission, the patient was in\nage-appropriate general condition and largely symptom-free. There were\nno signs of acute infection, jaundice, encephalopathic symptoms, or GI\nbleeding. No irregularities in bowel movements or urination were\nreported. The patient denied abdominal pain and dyspnea. There were no\nknown allergies.\n\nOn the day of admission, an uncomplicated gastroscopy was performed,\nincluding the application of 4 rubber band ligations for residual\nesophageal varices. Post-interventional pain was adequately controlled\nwith double-standard doses of Pantoprazole and intravenous analgesic\ntherapy. The further inpatient course was uneventful, and the patient\ntolerated the post-interventional diet without signs of GI bleeding.\n\nBased on laboratory findings and clinical evaluation, particularly with\nregressed ascites, a compensated Child A6 cirrhosis was confirmed.\nTherefore, a re-presentation at our interdisciplinary liver board was\ninitiated for discussion of potential treatment options in the context\nof compensated liver function.\n\nAs per the consensus recommendation from the liver board, a follow-up\ngastroscopy is scheduled within the next two weeks. Depending on the\nvariceal status, systemic therapy with Atezolizumab/Bevacizumab or\nLenvatinib will follow.\n\nThroughout the monitoring period, the patient remained stable in terms\nof circulation and hemoglobin levels. Therefore, on 08/23/20, we\ndischarged Mrs. Miller for outpatient follow-up care. The patient was\nthoroughly informed about reasons that necessitate immediate\nre-presentation. Please note the listed procedural appointments.\n\n**Physical Examination:** Awake, alert, oriented\n\n- Heart: Regular heart tones, no murmurs\n\n- Lungs: Clear vesicular breath sounds, no crackles or wheezes\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, palpable firm liver edge under the rib cage, no palpable\n spleen enlargement, non-painful renal angle\n\n- Extremities: Good peripheral pulses, no edema\n\n- Neurology: No focal neurological deficits.\n\n**EGD on 08/21/2020:**\n\n**Findings:**\n\n**Esophagus**: Unobstructed intubation of the esophagus under direct\nvision. Multiple variceal cords and scarring changes due to banding were\nobserved in the lower half of the esophagus. Z-line at 35 cm\ndiaphragmatic passage at 39 cm. Two variceal cords extend along the\nsmall curve into the stomach, two of the varices show alarm signs (red\nspots). 4 rubber band ligations were performed.\n\n**Stomach**: In the proximal corpus a picture of portal hypertensive\ngastropathy, otherwise unremarkable. No fundus varices.\n\n**Duodenum**: Good unfolding of the duodenal bulb, contact-sensitive\nmucosa. Good insight into the descending part of the duodenum. Overall,\nunremarkable mucosa.\n\n**Assessment:** Esophageal varices, Gastroesophageal varices Type I.\nBanding therapy.\n\n**Current Recommendations:**\n\n- Regular clinical and laboratory checks by the primary care\n physician.\n\n- In case of fever, acute deterioration of the general condition, or\n clinical signs of bleeding such as melena or hematemesis, we request\n immediate re-presentation, even at night and on weekends, through\n our interdisciplinary emergency department.\n\n- Decision of the liver board: Improvement of liver function with\n alcohol abstinence, but also progression of multifocal HCC over 2\n months without tumor-specific therapy. Consensus: Repeat EGD in 7-14\n days, depending on variceal status, Atezolizumab/Bevacizumab, or\n Lenvatinib.\n\n- Follow-up appointment on 09/11/20 in our HCC outpatient clinic for\n clinical control and explanation of the EGD.\n\n- Follow-up in our endoscopy for EGD to determine variceal status and\n possible banding -\\> Please bring a COVID PCR test (maximum 48 hours\n old) for inpatient admission.\n\nIf complaints persist or worsen, we recommend immediate re-presentation.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 09/18/2020 to\n09/20/2020.\n\n**Diagnoses:**\n\n- 4-time banding therapy with 4 rubber band ligations for residual\n esophageal varices without alarm signs\n\n- Hepatocellular Carcinoma (HCC)\n\n- MR Liver: Disseminated HCC lesions in all segments, with the largest\n lesion located in segments 5/7/8\n\n- Decompensated cirrhosis of the liver (Child B) since 05/20 due to\n ethyltoxic origin.\n\n- Transfusion-dependent anemia due to a history of variceal bleeding.\n\n- Osteoporotic thoracic vertebral fracture of vertebra BWK8 (OF3) with\n kyphoplasty.\n\n- Portal hypertension with portosystemic collaterals\n\n- Splenomegaly\n\n- Cholelithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- History of stroke (2016)\n\n- Allergies: Amalgam\n\n**Presentation:** Mrs. Miller\\'s elective presentation was for a\nfollow-up examination for known esophageal varices.\n\n**Medical History:** For a detailed medical history, please refer to\nprevious reports from our department. In summary, in June 2020, the\npatient was diagnosed with decompensated liver cirrhosis attributed to\nethyltoxicity. MR imaging showed multifocal HCC. According to the liver\nboard decision on 06/15/20, initial therapy was recommended with\nLenvatinib or Sorafenib for partially compensated Child B7 cirrhosis\nwith multifocal HCC in both liver lobes. Despite improvement in liver\nfunction with alcohol cessation, there was a short-term progression of\nmultifocal HCC without tumor-specific therapy, leading to a\nrecommendation for a repeat variceal screening on 08/28/20. Depending on\nthe findings, therapy with Atezolizumab/Bevacizumab or Lenvatinib was\nadvised. The last EGD was performed on 08/21/20, revealing esophageal\nvarices with alarm signs, and a 4-time banding was performed.\n\n**Physical Examination upon Admission:** Blood pressure: 80/150 mmHg,\nheart rate 88/min, temperature 36.4°C, SpO2 97% in room air.\n\nPatient in good general condition and normal mental status. Mrs. Miller\nis fully oriented. Pupils are equal and reactive.\n\n- Cardiovascular: Clear heart sounds, no murmurs.\n\n- Lungs: Equal breath sounds bilaterally, no crackles, resonant\n percussion.\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, liver and spleen not palpable.\n\n- Extremities: No edema, good peripheral pulses. No focal neurological\n deficits.\n\n**Course and Therapy:** On the day of admission, the EGD was performed\nwithout complications. Residual varices without warning signs were\nobserved, and a 4-time rubber band ligation was performed. Portal\nhypertensive gastropathy was also diagnosed. After the procedure, the\npatient was transferred to our gastroenterological normal ward.\n\nThe post-interventional course was uneventful. There were no clinical or\nlaboratory signs of post-interventional bleeding. The diet was\nreintroduced without any issues. Therefore, on 09/20/2020, we discharged\nMrs. Miller for outpatient care. We request a follow-up appointment at\nour in-house HCC outpatient clinic. Additionally, we request a follow-up\nEGD with variceal control.\n\n\n\n\nHere is the query:\nAs of the consultation on 06/08/2020, what was Mrs. Miller's nutritional status?\n\nChoose the correct answer from the following options:\nA. Overweight\nB. Underweight\nC. Protein malnutrition\nD. Adequate nutrition\nE. Not assessed\n\n\nYour response:\n", "role": "user" }, { "content": "Protein malnutrition", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\n\nWe are writing to report on the outpatient treatment of Mrs. Laura\nMiller, born on 04/03/1967, on 05/22/2020.\n\n**Diagnosis**: Osteoporotic vertebral body sintering (lumbar vertebra 2\nand thoracic vertebra 8).\n\n**Medical History**: Mrs. Miller presents with pain in her back, legs\nradiating, after fall on the back 6 weeks ago. The complaints were\nprogressive with intermittent paresthesia in both legs.\n\n**Other Diagnoses** (not fully collectible):\n\n- Status post apoplexy\n\n**Current Medication (**not ascertainable):\n\n- Blood pressure medication\n\n- Osteoporosis medication\n\n- No anticoagulation.\n\n**Physical Examination: Lumbar spine:** Skin without pathological\nfindings. No redness, no evidence of infection.\n\nTapping pain over thoracic spine/lumbar spine, no compression pain, no\ntorsion pain, no pressure pain over spinous process.\n\nRadiation of pain into the right and left leg, paravertebral muscle\nhardness.\n\nNo paresthesias in the genital area, no breech anesthesia, no peripheral\nneurologic deficits, No bladder or rectal dysfunction.\n\nPeripheral Circulation/Motor function/Sensitivity intact.\n\nStrength grade on all sides: Hip Flex/Ex: 5/5, Knee Flex/Ex: 5/5,\n\nFoot extensor muscles of the lower leg/flexor muscles of the lower leg:\n3/5.\n\nBig toe extensor muscles of the lower leg/big toe flexor muscles of the\nlower leg: 2/5.\n\n**Thoracic Spine 2 levels from 05/22/2020, Lumbar spine in 2 planes from\n05/22/2020:**\n\nClinical indication: Status post fall\n\nQuestion: new fracture?\n\nPreliminary images: none comparable\n\n**Findings**\n\n1\\) [Thoracic Spine]{.underline}: Multiple thoracic vertebral bodies\nexhibit decreased height, most notably at the central region where a\nmeasurement of approximately 17 mm suggests significant height loss and\npotential acute fracture. Additionally, there are endplate impressions\nin individual vertebrae of the lower thoracic spine. Aortic sclerosis is\npresent, along with degenerative changes throughout the thoracic\nvertebrae. The osseous structure presents osteoporotic features. A\nsuspected hemangioma is identified in a vertebral body of the lower\nthoracic spine.\n\n2\\) [Lumbar Spine]{.underline}: In a presumed five-segment lumbar spine,\nthe L1 vertebra shows a subtle reduction in height with a questionable\nendplate impression. Osteoporotic features are evident in the bony\nstructure.\n\n**Assessment:** Multiple fractures are evident in both thoracic\nvertebrae and the first lumbar vertebra, some of which may be acute. MRI\nis recommended for further evaluation. Osseous structure displays\npronounced osteoporotic features.\n\nGrade III esophageal varices present without definitive high-risk\nstigmata. Varices also noted at the gastroesophageal junction,\nclassified as GOV 1 according to Sarin\\'s classification. Band ligation\nof the varices is not performed, as no unambiguous source of bleeding is\nidentifiable and a significant portion of the stomach remains outside\nthe field of view.\n\n**Recommendation**: Terlipressin, monitor surveillance, Erythromycin\n\n**Computed Tomography Thoracic spine from 05/22/2020:**\n\nFracture at the base plate of lumbar vertebra 2 with involvement of the\nposterior margin. Left lateral, no significant reduction in height of\nthe vertebral body. No tension of the spine.\n\nSuspicion of new small fracture also at the cover plate at thoracic\nvertebra 8.\n\nMultiple, older, osteoporotic compression fractures at the thoracic\nspine and\n\nupper lumbar spine.\n\n**Additional Finding:**\n\nLiver cirrhosis with multiple nodules, low ascites, and portal vein\ncongestion. Splenomegaly. If not already known, further workup of liver\nlesions is recommended. Hydrops of the gallbladder.\n\n**Current Recommendations**: There is a general indication for admission\nof the patient and further diagnostics before surgical treatment of the\nfractures. Mrs. Miller is generally opposed to surgical care. She was\nthoroughly informed about the risks (progression, cross-section, death).\n\nRe-presentation with current bone densitometry and update of\nosteoporosis medication, as well as current holospinal MRI. In the\nmeantime, analgesia as needed using Acetaminophen 500mg 1-1-1 under\ngastric protection.\n\n**Esophagogastroduodenoscopy from 05/22/2020:**\n\n[Esophagus]{.underline}: Unobstructed intubation of the esophageal\nopening was achieved under direct visualization. In the upper third of\nthe esophagus, multiple prominent varices protrude into the lumen,\nunaltered by air insufflation. In the middle third, there are areas with\nwhitish overlying material that do not resemble the typical white nipple\nsign. Despite meticulous inspection, no active bleeding sites were\nidentified. The Z-line reveals isolated minor erosions. Cardiac\nsphincter closure is complete.\n\n[Stomach]{.underline}: Full distension of the gastric lumen was\naccomplished with air insufflation. The major curvature of the stomach\ncontained food mixed with hematin. The mucosal surface was similarly\ncoated with hematin, but no active bleeding was discernible in the\nvisualized areas. Peristaltic movement was widespread. Upon\nretroflexion, pronounced varices were noted near the cardiac region on\nthe lesser curvature. The pylorus was unremarkable and easily\ntraversable.\n\n[Duodenum]{.underline}: Adequate distension of the duodenal bulb was\nachieved, providing a clear view up to the descending part of the\nduodenum. Overall, the mucosa appeared normal with minor remnants of\nhematin, and no source of bleeding was identified.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about Mrs. Laura Miller, born on 04/03/1967, who was in\nour inpatient treatment from 05/27/2020 to 06/22/2020.\n\n**Diagnoses**: Initial diagnosis of hepatocellular carcinoma.\n\n- MRI liver: disseminated HCC foci in all segments, the largest foci\n is localized in segments 5 / 7 / 8\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: sophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: Residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Physical Examination:** Patient in mildly reduced general and normal\nnutritional status (BMI 20.3).\n\n- Lungs: Vesicular breath sound, no pathological secondary sounds.\n SpO2 96%.\n\n- Heart: Pure, rhythmic. Systolic with maximum at Erb\\'s point and\n continuation into the carotids. HR: 87/min. BP: 124/54mmHg\n\n- Abdomen: Lively bowel sounds, no tenderness, no guarding, no\n resistance, no peritonism. Soft abdomen. Liver not enlarged,\n palpable. Renal bed not palpable.\n\n- Extremities: Edema of the lower extremities on both sides, foot\n pulses bilaterally well palpable.\n\n- Spine: No tap pain.\n\n- Orienting neurological examination: Right leg weakness, known\n paresis of the extensor muscles of the lower leg/flexor muscles of\n the lower leg.\n\n**Therapy and Progression:** Mrs. Miller was taken over for suspected\nupper GI bleeding. Initially, the patient had presented with increasing\nback pain since approximately 6 weeks at status post fall in the Park\nClinic on 04/26/2020. The patient was known there for her stroke in\n2016. On the day of admission to the Park Clinic, normochromic\nnormocytic anemia (Hemoglobin 3 g/dL) was noticed, which is why the\ntransfer to our clinic was made.\n\nOn inpatient admission, the patient presented in slightly reduced\ngeneral condition. She reported having black stools once. In addition,\nMs. Miller had coffee ground-like emesis once. Dyspnea, angina pectoris\ncomplaints, and B symptoms were denied. There were no problems with\nmicturition. Recently, there were no abnormalities in bowel movements.\nSo far, no colonoscopy has been performed. There were no known\nintestinal diseases in the family.\n\n[Noxae]{.underline}: Ex-nicotine use (since 1996, previously cumulative\nca. 3 PY), occasional alcohol consumption (probably abstinent for about\n5 years).\n\nLaboratory results showed that the patient had elevated infectious\nparameters. The\n\nurinalysis was unremarkable. X-ray chest showed no clear picture of\npneumonia. In a first emergency esophagogastroduodenoscopy on\n05/28/2020, esophageal varices °III were found without clear signs of\nrisk. Furthermore, varices in the area of the cardia (GOV 1 after Sarin)\nwere seen. When the source of bleeding was inconclusive, it was referred\nto a banding initially waived. In a renewed esophagogastroduodenoscopy\nin the morning of 05/30/2020, 2 ampoules of Histoacryl were applied to\nthe cardia varices. In addition, the picture of an incipient\nportal-hypertensive gastropathy. Antibiotic intravenous therapy with\nceftriaxone was initiated. At 06/13/2020, a\nre-esophagogastroduodenoscopy took place, during which a renewed twofold\nbanding of the esophageal varices was performed with injection of 0.5 ml\nHistoacryl. Abdominal ultrasound showed a picture of liver cirrhosis\nwith splenomegaly and perihepatic ascites. In addition, the liver showed\nmultiple echo-poor nodes in the right lobe and a suspicious\n2.4x3.6x4.4cm echo-poor area with a halo in SII. This was followed by an\nMRI of the liver, in which the HCC in segment II was confirmed by\nimaging.\n\nMultiple additional arterial hypervascularized areas/round foci in all\nliver lobes without definite washout. There is no evidence of suspicious\nnodular changes on CT chest/abdomen/pelvis. At an in-house liver\nconference, systemic therapy (Lenvatinib or Sorafenib in Child B7) was\nrecommended.\n\nDue to the back pain, a holospinal MRI was performed, which showed a\nsubacute cover plate compression fracture in the thoracic vertebra 8 as\nwell as multiple older compression fractures of the thoracic spine and\nupper lumbar spine. The colleagues of neurosurgery were consulted, who\ngave the indication for surgery. On 06/14/2020, the planned surgery with\nkyphoplasty thoracic vertebra 8 under C-arm fluoroscopy could be\nperformed without complications. Postoperatively, the patient remained\ncirculatory stable.\n\nDue to auscultatory suspicion of aortic valve stenosis, further\nclarification was performed by cardiac echography, showing no\nhigher-grade valvular vitiation.\n\nWe are transferring Mrs. Miller in improved general condition to the\nSenior Citizens\\' Residence Seaview. If you have any questions, please\ndo not hesitate to contact us.\n\n**Addition:**\n\n**Ultrasound of the upper abdomen on 05/27/2020:**\n\nLimited assessable due to meteorism.\n\n**Liver**: Liver dimensions are within normal limits, measuring 15.9 cm\nin the craniocaudal axis. Echotexture demonstrates inhomogeneous\ngranularity. There is hepatic margin convexity and nodular surface\nappearance. Rarification of hepatic veins. Segment III reveals two\nhypoechoic lesions measuring 3 cm and 1 cm in diameter. Portal vein\ndemonstrates orthograde flow with a maximum velocity of 17 cm/s.\n\n**Gallbladder:** Gallbladder is partially contracted; its wall appears\nunremarkable without sonographic evidence of cholecystitis. No\ntenderness elicited upon sonographic examination.\n\n**Biliary Tract**: Intrahepatic bile ducts are patent. Common hepatic\nduct measures 6 mm in diameter. Common bile duct appears transiently\ndilated up to 9 mm and is otherwise unremarkable as far as can be\nvisualized prepapillary.\n\n**Pancreas**: Limited visualization of the pancreas; however, the\nvisible parenchyma appears homogeneously echoic.\n\n**Spleen**: Spleen is enlarged, measuring 13 x 4 cm, with homogeneous\nparenchyma.\n\n**Kidneys**: Kidneys are morphologically unremarkable, without evidence\nof pelvicalyceal system dilation.\n\n**Abdominal Vessels**: Aorta is partially visualized and appears within\nnormal calibers.\n\nIntestinal/Peritoneal Cavity: No evidence of free intraperitoneal fluid.\n\nUrinary Bladder/Genitalia: Urinary bladder is adequately distended,\nappearing unremarkable upon limited assessment. Uterus is not\nvisualized.\n\n**Virology from 05/28/2020:**\n\n- SARS CoV-2 PCR PCR negative Geq/ml\n\n- Findings: No detection of SARS-CoV-2 by PCR in the submitted\n material.\n\n**Chest X-ray a.p. from 05/28/2020:**\n\nLimited assessability in supine position, malrotation. The diaphragmatic\ncrests are smooth. The marginal sinuses are free of effusions and\ncalluses. Heart and mediastinum lie cryptically. The aorta is sclerosed.\nCranialization of the vessels as well as slightly elevated vascular\nmarkings in the supine position, especially in the right upper field.\nDystelectasis on the right. Sharply defined vertical shadowing in the\nleft upper field. The upper mediastinum is narrow, the trachea is in the\nmidline and is not constricted. Degenerative changes in the cervical\nspine. Overlying foreign material.\n\n**Assessment**: Sharply defined vertical shadowing in the left upper\nfield. Dystelectasis on the right side. Conventional radiographic\nexamination No evidence of a mass. No effusion.\n\n**Esophagogastroduodenoscopy of 05/28/2020:**\n\n**Esophagus**: Successful intubation of the esophageal orifice under\ndirect visualization. Multiple intraluminal protrusions noted in the\nupper third of the esophagus. Non-collapsible variceal strands observed\nupon air insufflation, beginning from the middle third. Whitish\nproliferations seen at multiple sites, not consistent with typical white\nnipple signs. No evidence of active bleeding on close inspection. Z-line\nobserved with isolated minor erosions. Cardiac sphincter fully\ncompetent.\n\n**Stomach**: Gastric lumen fully distended under air insufflation.\nCorpus predominantly contains hematin-laden food remnants. Mucosal\nsurface also stained with hematin but without visible active bleeding.\nPeristalsis noted throughout. Distinct coronary vasculature observed on\nthe lesser curvature. Pylorus unremarkable, offering no resistance to\npassage.\n\n**Duodenum**: Bulbus duodeni well-formed. Pars descendens duodeni\nvisualized clearly. Overall mucosa appears unremarkable, with scattered\nhematin remnants observed without an identifiable bleeding source.\n\n**Assessment**: Esophageal varices graded as °III, with no definitive\nhigh-risk stigmata. Varices also noted in the cardia, classified as GOV\n1 according to Sarin\\'s classification. Ligation of varices was not\nperformed due to the absence of an identifiable bleeding source and\nincomplete visualization of the gastric lumen.\n\n**Ultrasound of the abdomen on 05/29/2020:**\n\n**Quality of Exam**: Limited due to patient non-cooperation and\nmeteorism.\n\n**Liver**: Liver size is paradoxically reported both as normal at 15.9\ncm and enlarged at 18.7 cm. Margins are rounded. Echotexture is markedly\ninhomogeneous with nodular surface. Multiple hypoechoic nodules are\npresent in the right lobe, along with a suspicious hypoechoic area\nmeasuring 2.4 x 3.6 x 4.4 cm with peripheral halo in segment II. Hepatic\nveins are rarified. Portal vein shows orthograde flow with a vmax of 28\ncm/s.\n\n**Gallbladder**: Morphologically unremarkable with no wall thickening.\nCholelithiasis noted with concretions measuring at least 2 to 1.6 cm.\n\n**Biliary Tract:** Intrahepatic bile ducts are not dilated; Common\nhepatic duct measures up to 8.5 mm and common bile duct measures 6.6 mm\nin diameter.\n\n**Pancreas**: Partially visualized; adequacy of assessment is\ncompromised.\n\n**Spleen**: Enlarged with homogeneous internal echotexture.\n\n**Kidneys**: Morphologically unremarkable; no evidence of\nhydronephrosis.\n\n**Abdominal Vessels:** Aorta is not dilated.\n\n**Gastrointestinal**: Perihepatic ascites noted. Both small and large\nintestines appear unremarkable upon limited assessment.\n\n**Urinary Bladder/Genitalia:** Bladder is moderately filled and\nunremarkable in shape and size.\n\n**Assessment**: Limited study due to patient non-cooperation and\nmeteorism. Findings are suggestive of liver cirrhosis and grade I\nascites. Additional findings include suspected hepatic space-occupying\nlesions, splenomegaly, and cholelithiasis. Mild dilation of DHC and DC\nobserved without signs of intrahepatic cholestasis.\n\n**Virology from 06/01/2020:**\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HAV IgG 0.73 negative\n Anti HAV IgM \\<0.1 negative\n\n**Interpretation:** Serologically no evidence of fresh or expired\ninfection with\n\nHepatitis A virus, no immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n HBs antigen 0.21 negative\n Anti HBs \\<0.1 negative\n Anti HBc 0.1 negative\n\n**Interpretation:** Serologically no evidence of acute, chronic or\nexpired Hepatitis B virus infection. No immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HCV 0.06 negative\n\n**Interpretation:** Serologically no evidence of hepatitis C virus\ninfection. At possible fresh infection resubmission in 2-4 weeks and HCV\nPCR recommended.\n\n**MRI total spine plain from 06/04/2020:**\n\n**Technique**: T2 Dixon Sagittal and T2 Axial MRI Sequences. Coverage\nextends from the craniocervical junction to the sacrum.\n\n**Findings:**\n\n**General Spine:** Full extent from craniocervical junction to sacrum\nvisualized. Conus medullaris appropriately located at T12-L1 level.\nMyelon demonstrates uniform width and homogeneous signal. Evaluation of\nthoracolumbar transition and lumbar spine is compromised by artifact\nsuperimposition from ascites.\n\n**Cervical Spine:** Irregular alignment of the posterior vertebral body\nmargins noted, with evidence of disc protrusions and ligamentum flavum\nhypertrophy. Focal T2 hyperintensity observed at C5 level. No evidence\nof prevertebral soft tissue proliferation.\n\n**Thoracic Spine**: Maintained alignment of the posterior vertebral body\nmargins. Multiple anterior endplate compression fractures noted at T5,\nT8, T9, T11, T12 levels. Focal T2 hyperintensity near the anterior\nendplate of T8 involving the posterior margin, indicative of a\nnon-displaced fracture without spinal canal compromise. Hypertrophic\nfacet joint arthrosis at T10-T11 levels resulting in relative spinal\nnarrowing. Bilateral pleural effusions noted, more pronounced on the\nright, with a maximum width of approximately 2 cm. No evidence of\nsignificant neuroforaminal stenosis.\n\n**Lumbar Spine:** Maintained alignment of posterior vertebral body\nmargins. Known anterior endplate compression fractures at L1 and\nbaseplate compression fracture at L2. No evidence of pathological T2\nedema within the vertebral bodies, although assessment is limited due to\nsuperimposed artifacts from ascites. Spinal canal dimensions appear\nadequate throughout. Moderate fatty degeneration of sacral bone noted.\n\n**Assessment**: Evaluation limited due to ascites-related artifacts.\nSubacute anterior endplate compression fracture at T8, along with\nseveral other likely older compression fractures in the thoracic and\nupper lumbar spine. Bilateral pleural effusions observed. Multiple\nneuroforaminal narrowings as detailed above.\n\n**MR Liver plain + contast agent from 06/06/2020**\n\n**Findings:**\n\n1) [Lesion 1]{.underline}\n\n- Size of the lesion 41 mm\n\n- Segment 2\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: yes\n\n- Pseudocapsule: yes\n\n- Behavior delayed leaching: yes\n\n- pseudocapsule macrovascular invasion: no\n\n2) [Lesion 2]{.underline}\n\n- Size of the lesion 104 mm\n\n- Segment 5 / 7 / 8\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: no\n\n- Pseudocapsule: no\n\n- Behavior delayed washing out: no\n\n- Pseudocapsule: no\n\n- Macrovascular invasion: yes\n\n**Comments:**\n\n- MRI with Gadovist intravenous.\n\n- Multiple other satellite foci in all liver segments.\n\n- Signs of liver cirrhosis with nodular liver parenchyma and\n hypertrophy of the left lobe.\n\n- Cholecystolithiasis and gallbladder hydrops. No cholestasis.\n\n- Varices of the esophagus and fundus. Splenomegaly. Ascites. Pleural\n effusions on both sides.\n\n- Lymph node (approximately 8 mm) between the small curvature of the\n Stomach and S1 of the liver.\n\n- Axial hernia.\n\n**Assessment:** Milan fulfilled**.** Dissiminated HCC foci in all\nsegments, the largest foci being in segments 5 / 7 / 8 localized. Portal\nhypertension with bypass circulation and splenomegaly. Ascites and\npleural effusions.\n\n**Microbiology from 06/09/2020:**\n\n[Material]{.underline}: Ascites in blood culture bottles\n\n[Microscopic]{.underline}: No cells, no germs\n\n- Anaerobic culture negative after 48 hours\n\n- So far, no growth in the anaerobic cultures. The cultures are\n incubated for a total of 5 days. In case of growth of anaerobes we\n will send you a follow-up report.\n\n- No growth after 48 hours\n\n**Esophagogastroduodenoscopy of 06/11/2020:**\n\n**Esophagus**: In the distal esophagus, multiple band-like ulcerations\nas well as residual varices with risk signs that may not completely pass\nair insufflation. Z-line without erosions.\n\n**Stomach**: Mosaic-like occupancy of the gastric mucosa. With inversion\nthe\n\nknown small-curved lateral cardiavarii, which is hard on palpation with\nclosed forceps after histoacryl injection. Directly next to it, another\ncardiavarice can now be seen, which has not yet been injected with\nhistoacryl and is soft on palpation.\n\n**Duodenum**: Endoscopic therapy: Injection of 0.5 mL Histoacryl (+0.5\nmL Lipoidol) in the new cardiavarice. Application of 3 rubber band\nligatures to the residual varices in the esophagus.\n\n**Assessment:** Residual varices in the esophagus, application of 3\nrubber band ligations; portal hypertensive gastropathy\n\n**Spine-whole: 2 planes from 06/13/2020**\n\nThe perpendicular of C7 protrudes about 15 mm laterally to the left of\nsacral vertebra 1 in the anterior-posterior image and about 9.3 cm in\nfront of sacral vertebra 1 in the lateral ray path. Slight left convex\nscoliosis thoracolumbally with thoracic counter-swing (Cobb angle \\< 10°\nin each case). The lungs are unremarkable as far as technically\nassessable.\n\n**Assessment**: decompensated positive sagittal spinal imbalance. There\nis no relevant lateral trunk overhang.\n\n**Critical Findings Report:**\n\nA conspicuous single cell population of cells with partial signet ring\ncell character is detected in the smears. A cell block is prepared from\nthe remaining liquid material for further typing of these cells. A\nfollow-up report will follow.\n\n**Thoracic spine in 2 planes from 06/15/2020:**\n\n**Findings**: Thoracic vertebra 8: Post-kyphoplasty status with notable\nimprovement in vertebral height, now measuring 21 mm compared to a\npreoperative height of 13 mm. Mild straightening of the vertebral column\nobserved at this level.\n\nThoracic vertebra 9: Known older anterior endplate collapse.\n\nThoracolumbar spine: Multisegmental height reduction in vertebral bodies\nconsistent with osteoporotic changes. No signs of contrast\nextravasation.\n\nAdditional Finding: Pre-existing calcified structure projecting onto the\nleft upper abdomen; likely unrelated to current surgical site.\n\n**Assessment**: Unremarkable postoperative imaging following kyphoplasty\nof T8. No evidence of postoperative sintering or newly identifiable\nfractures. Overall, the surgical intervention appears successful in\nincreasing vertebral height and stabilizing the fracture site.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 06/18/2020:**\n\n**Technique**: Multislice spiral CT of the chest, abdomen, and pelvis\nwas performed post-bolus intravenous injection of 120 ml of Imeron 400.\nImaging conducted in arterial, portal venous, and venous phases. Oral\ncontrast agent administered with Micropaque 1:7 in water and Gastrolux\n1:33 in water. Thin-slice reconstructions and secondary coronal and\nsagittal reformats were performed.\n\n**Chest**: Presence of struma nodosa. Bilateral minor pleural effusions\nwith adjacent atelectasis, more pronounced on the right and extending\ninto the interlobar region. No signs of infiltrative changes. Isolated\nsmall nodular opacities in the right lung. Few small bullae noted.\nMediastinal lymph nodes mildly enlarged up to 0.5 cm; axillary and hilar\nnodes are not enlarged. No pericardial effusion observed.\n\n**Abdomen/Pelvis**: Known esophageal and fundal varices present. Liver\ndemonstrates nodular changes in the context of known Child-Pugh B stage\ncirrhosis. A solid hepatic cellular carcinoma lesion in segment II and\ndiffuse HCC nodules in segments V/VII/VIII visualized, corroborating\nprior MRI findings. They show pronounced arterial enhancement and\ncentral washout. Splenomegaly noted. Adrenal glands unremarkable. Renal\nand urinary systems are inconspicuous. No intestinal motility\nabnormalities detected. Marked ascites present; no pathologically\nenlarged abdominal lymph nodes noted upon limited assessment.\n\n**Skeletal**: Moderate coxarthrosis bilaterally. An old, minimally\ndisplaced fracture of the right 7th rib noted. Advanced degenerative\nchanges in thoracic vertebrae 10, 12, and lumbar spine.\nPost-vertebroplasty status at thoracic vertebra 9. Hemangioma at\nthoracic vertebra 11.\n\n**Assessment**:\n\n- Marked ascites in the setting of liver cirrhosis with multifocal HCC\n lesions, as corroborated by prior MRI. No evidence of extrahepatic\n or lymphatic spread.\n\n- Bilateral minor pleural effusions with associated atelectasis.\n\n- Skeletal findings include moderate coxarthrosis and degenerative\n changes in the spine.\n\nOverall, the scan provides vital information that aligns with and\nelaborates upon existing clinical and imaging data.\n\n**Histology**:\n\n**Pathology from 06/19/2020:**\n\n[Clinical Data:]{.underline} Hepatocellular carcinoma, hydropic\ndecompensated liver cirrhosis Child B,\n\n[Extraction date:]{.underline} 06/13/2020\n\n[Material:]{.underline} 1 Liquid material 7 ml light yellow\n\n[Editing]{.underline}: Papanicolaou and MGG staining\n\n\\+ Protein precipitation\n\n\\+ Erythrocytes\n\n\\+ Lymphocytes\n\n(+) Granulocytes Eosinophils\n\n\\+ Histiocytic cell forms\n\n\\+ Mesothelium\n\n\\+ Active mesothelium\n\n**Other**: Single mononuclear cells with large, eccentric nuclei with\nnucleoli and a narrow cytoplasmic space, partly with signet ring cells.\n\n**Supplementary findings from 06/19/2020**\n\n[Processing]{.underline}: Cell block, HE\n\n**Microscopic:**\n\nAs announced, from the remaining liquid material a cell block was\nprepared. In the HE stain only isolated evidence of mononuclear Cells\nand some blood. No cell atypia.\n\n**Critical Findings Report:** After examination of the remaining liquid\nmaterial in the cell block no Extension of the initial findings in the\nabsence of further diagnostic cell material. The finding is thus based\nexclusively on the Smear material:\n\n- Detection of a single-cell population consisting of cells with\n partial signet ring cell character. Differentially it could be The\n mesothelium may be a reactive change of the approaching mesothelium.\n Cells of an epithelial neoplasia are not visible on the present\n material. to be ruled out with certainty.\n\n**Diagnostic classification:** Suspicious\n\n**Current Recommendations:**\n\n- An appointment at our outpatient clinic to start therapy was\n organized for 06/26/2020.\n\n- An appointment for a health department check-up with varicose vein\n status survey and, if necessary, repeat rubber band ligation has\n been scheduled for 07/22/2020. Please come to the endoscopy on this\n day at 08:30 am fasting with current lab results. incl. coagulation,\n signed consent form as well as SARS-CoV-2 PCR not older than 48h.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report to you on Mrs. Laura Miller, born 04/03/1967, whom we examined\non 06/08/2020 in the course of a consultation.\n\n**Consilar Request:**\n\n- Liver cirrhosis, Child-Pugh B, ethyltoxic genesis\n\n- HCC\n\n- Laboratory albumin: 2.6\n\n- Nutritional advice requested\n\n**Nutritional counseling in cirrhosis of the liver:**\n\n- Albumin at 2.6\n\n- 70kg at admission (stable weight in recent years).\n\n- Height: 1.72m\n\n- BMI falsified by ascites\n\n- Patient reports that she always a \\\"bad eater\\\"\n\n- She reports to eat less due to numerous medication intake\n\n- Patient is noticeably overwhelmed and seems very burdened by\n diagnosis\n\n**Assessment:**\n\n- Protein malnutrition with inadequate oral nutrition\n\n- Patient appears desperate and overwhelmed, questionable compliance\n\n**Recommendations: **\n\n- High-calorie food for more choices (already ordered)\n\n- High-calorie drinks (contains more protein)\n\n- Incorporate protein-rich snacks such as yogurt, sippy cups,\n crispbread\n\n- with cheese.\n\n- A high-energy, high-protein food choice was made with the patient\\'s\n discussed in detail\n\n- Contact details were handed out\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 08/21/2020 to\n08/23/2020.\n\n**Diagnoses**:\n\n- MRI of the liver: disseminated HCC foci in all segments, the largest\n foci is localized in segments 5 / 7 / 8\n\n<!-- -->\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: esophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Current Presentation:** Mrs. Miller presented electively for\ngastroscopy for variceal screening with continuation of banding therapy\ndue to esophageal variceal bleeding.\n\n**Medical History**: For a detailed medical history, we refer to\nprevious reports from our department. In summary, we present a liver\ncirrhosis due to ethyl toxicity leading to the development of multifocal\nHCC. Similar to the liver board decision of 06/13/20, a recommendation\nfor systemic therapy with Lenvatinib or Sorafenib was made in the\nsetting of partially compensated Child B7 cirrhosis with multifocal HCC\nin both lobes of the liver.\n\n**Therapy and Course:** Upon admission, the patient was in\nage-appropriate general condition and largely symptom-free. There were\nno signs of acute infection, jaundice, encephalopathic symptoms, or GI\nbleeding. No irregularities in bowel movements or urination were\nreported. The patient denied abdominal pain and dyspnea. There were no\nknown allergies.\n\nOn the day of admission, an uncomplicated gastroscopy was performed,\nincluding the application of 4 rubber band ligations for residual\nesophageal varices. Post-interventional pain was adequately controlled\nwith double-standard doses of Pantoprazole and intravenous analgesic\ntherapy. The further inpatient course was uneventful, and the patient\ntolerated the post-interventional diet without signs of GI bleeding.\n\nBased on laboratory findings and clinical evaluation, particularly with\nregressed ascites, a compensated Child A6 cirrhosis was confirmed.\nTherefore, a re-presentation at our interdisciplinary liver board was\ninitiated for discussion of potential treatment options in the context\nof compensated liver function.\n\nAs per the consensus recommendation from the liver board, a follow-up\ngastroscopy is scheduled within the next two weeks. Depending on the\nvariceal status, systemic therapy with Atezolizumab/Bevacizumab or\nLenvatinib will follow.\n\nThroughout the monitoring period, the patient remained stable in terms\nof circulation and hemoglobin levels. Therefore, on 08/23/20, we\ndischarged Mrs. Miller for outpatient follow-up care. The patient was\nthoroughly informed about reasons that necessitate immediate\nre-presentation. Please note the listed procedural appointments.\n\n**Physical Examination:** Awake, alert, oriented\n\n- Heart: Regular heart tones, no murmurs\n\n- Lungs: Clear vesicular breath sounds, no crackles or wheezes\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, palpable firm liver edge under the rib cage, no palpable\n spleen enlargement, non-painful renal angle\n\n- Extremities: Good peripheral pulses, no edema\n\n- Neurology: No focal neurological deficits.\n\n**EGD on 08/21/2020:**\n\n**Findings:**\n\n**Esophagus**: Unobstructed intubation of the esophagus under direct\nvision. Multiple variceal cords and scarring changes due to banding were\nobserved in the lower half of the esophagus. Z-line at 35 cm\ndiaphragmatic passage at 39 cm. Two variceal cords extend along the\nsmall curve into the stomach, two of the varices show alarm signs (red\nspots). 4 rubber band ligations were performed.\n\n**Stomach**: In the proximal corpus a picture of portal hypertensive\ngastropathy, otherwise unremarkable. No fundus varices.\n\n**Duodenum**: Good unfolding of the duodenal bulb, contact-sensitive\nmucosa. Good insight into the descending part of the duodenum. Overall,\nunremarkable mucosa.\n\n**Assessment:** Esophageal varices, Gastroesophageal varices Type I.\nBanding therapy.\n\n**Current Recommendations:**\n\n- Regular clinical and laboratory checks by the primary care\n physician.\n\n- In case of fever, acute deterioration of the general condition, or\n clinical signs of bleeding such as melena or hematemesis, we request\n immediate re-presentation, even at night and on weekends, through\n our interdisciplinary emergency department.\n\n- Decision of the liver board: Improvement of liver function with\n alcohol abstinence, but also progression of multifocal HCC over 2\n months without tumor-specific therapy. Consensus: Repeat EGD in 7-14\n days, depending on variceal status, Atezolizumab/Bevacizumab, or\n Lenvatinib.\n\n- Follow-up appointment on 09/11/20 in our HCC outpatient clinic for\n clinical control and explanation of the EGD.\n\n- Follow-up in our endoscopy for EGD to determine variceal status and\n possible banding -\\> Please bring a COVID PCR test (maximum 48 hours\n old) for inpatient admission.\n\nIf complaints persist or worsen, we recommend immediate re-presentation.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 09/18/2020 to\n09/20/2020.\n\n**Diagnoses:**\n\n- 4-time banding therapy with 4 rubber band ligations for residual\n esophageal varices without alarm signs\n\n- Hepatocellular Carcinoma (HCC)\n\n- MR Liver: Disseminated HCC lesions in all segments, with the largest\n lesion located in segments 5/7/8\n\n- Decompensated cirrhosis of the liver (Child B) since 05/20 due to\n ethyltoxic origin.\n\n- Transfusion-dependent anemia due to a history of variceal bleeding.\n\n- Osteoporotic thoracic vertebral fracture of vertebra BWK8 (OF3) with\n kyphoplasty.\n\n- Portal hypertension with portosystemic collaterals\n\n- Splenomegaly\n\n- Cholelithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- History of stroke (2016)\n\n- Allergies: Amalgam\n\n**Presentation:** Mrs. Miller\\'s elective presentation was for a\nfollow-up examination for known esophageal varices.\n\n**Medical History:** For a detailed medical history, please refer to\nprevious reports from our department. In summary, in June 2020, the\npatient was diagnosed with decompensated liver cirrhosis attributed to\nethyltoxicity. MR imaging showed multifocal HCC. According to the liver\nboard decision on 06/15/20, initial therapy was recommended with\nLenvatinib or Sorafenib for partially compensated Child B7 cirrhosis\nwith multifocal HCC in both liver lobes. Despite improvement in liver\nfunction with alcohol cessation, there was a short-term progression of\nmultifocal HCC without tumor-specific therapy, leading to a\nrecommendation for a repeat variceal screening on 08/28/20. Depending on\nthe findings, therapy with Atezolizumab/Bevacizumab or Lenvatinib was\nadvised. The last EGD was performed on 08/21/20, revealing esophageal\nvarices with alarm signs, and a 4-time banding was performed.\n\n**Physical Examination upon Admission:** Blood pressure: 80/150 mmHg,\nheart rate 88/min, temperature 36.4°C, SpO2 97% in room air.\n\nPatient in good general condition and normal mental status. Mrs. Miller\nis fully oriented. Pupils are equal and reactive.\n\n- Cardiovascular: Clear heart sounds, no murmurs.\n\n- Lungs: Equal breath sounds bilaterally, no crackles, resonant\n percussion.\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, liver and spleen not palpable.\n\n- Extremities: No edema, good peripheral pulses. No focal neurological\n deficits.\n\n**Course and Therapy:** On the day of admission, the EGD was performed\nwithout complications. Residual varices without warning signs were\nobserved, and a 4-time rubber band ligation was performed. Portal\nhypertensive gastropathy was also diagnosed. After the procedure, the\npatient was transferred to our gastroenterological normal ward.\n\nThe post-interventional course was uneventful. There were no clinical or\nlaboratory signs of post-interventional bleeding. The diet was\nreintroduced without any issues. Therefore, on 09/20/2020, we discharged\nMrs. Miller for outpatient care. We request a follow-up appointment at\nour in-house HCC outpatient clinic. Additionally, we request a follow-up\nEGD with variceal control.\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n\n\n\n\nHere is the query:\nWhat was Mr. Chapman's hemoglobin level upon last discharge from inpatient care?\n\nChoose the correct answer from the following options:\nA. 13.5 g/dL\nB. 14.3 g/dL\nC. 7.6 g/dL\nD. 7.8 g/dL\nE. 14.3 g/dL\n\n\nYour response:\n", "role": "user" }, { "content": "14.3 g/dL", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report to you about Mrs. Linda Mayer, born on 01/12/1948, who\npresented to our outpatient clinic on 07/13/19.\n\n**Diagnoses:**\n\n- BIRADS IV, recommended biopsy during breast diagnostics.\n\n- Left breast carcinoma: iT1b; iN0; MX; ER: 12/12; PR: 2/12; Her-2:\n neg; Ki67: 15%.\n\n**Other Diagnoses: **\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Pemphigus vulgaris under azathioprine therapy\n\n- Osteoporosis\n\n- Obesity with a BMI of 35\n\n- Undergoing immunosuppressive therapy with prednisolone\n\n**Family History:**\n\n- Sister deceased at age 39 from breast cancer.\n\n- Mother and grandmother (maternal and paternal) were diagnosed with\n breast cancer.\n\n**Medical History:** The CT thorax report indicates the presence of\ninflammatory foci, warranting further follow-up. The relevant data was\ndocumented and presented during the tumor conference. Subsequently, a\ntelephone conversation was conducted with the patient to discuss the\nnext steps.\n\n**Tumor board decision from 07/13/2019:**\n\n**Imaging: **\n\n1) MRI examination detected a unifocal lesion on the left external\n aspect, measuring approximately 2.4 cm in size.\n\n2) CT scan (thorax/abdomen 07/12/2019) revealed a previously known\n liver lesion, likely a hemangioma. No evidence of metastases was\n identified. Nonspecific, small foci were observed in the lungs,\n likely indicative of post-inflammatory changes.\n\n**Recommendations:**\n\n1. If no metastasis (M0): Fast-track BRCA testing is recommended.\n\n2. If BRCA testing returns negative: Proceed with a selective excision\n of the left breast after ultrasound-guided fine needle marking and\n sentinel lymph node biopsy on the left side. Additionally, perform\n Endopredict analysis on the surgical specimen.\n\n**Current Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ------------------------------- ------------ ----------- ---------------\n Aspirin 100mg Oral 1-0-0\n Simvastatin (Zocor) 40mg Oral 0-1-0\n Haloperidol (Haldol) 100mg Oral ½-0-½\n Zopiclone (Imovane) 7.5mg Oral 0-0-1\n Trazodone (Desyrel) 100mg Oral 0-0-½-\n Calcium Supplement (Caltrate) 500mg Oral 1-0-1\n Nystatin (Bio-Statin) As advised Oral 1-1-1-1\n Pantoprazole (Protonix) 40mg Oral 1-0-0\n Prednisolone (Prelone) 40mg Oral As advised\n Tramadol/Naloxone (Ultram) 50/4mg Oral 1-0-1\n Acyclovir (Zovirax) 800mg Oral 1-1-1\n\n**Mammography and Tomosynthesis from 07/8/2019:**\n\n[Findings]{.underline}**: **During the inspection and palpation, no\nsignificant findings were noted on either side. Some areas with higher\nmammographic density were observed, which slightly limited the\nassessment. However, during the initial examination, a small\narchitectural irregularity was identified on the outer left side. This\nirregularity appeared as a small, roundish compression measuring\napproximately 6mm and was visible only in the medio-lateral oblique\nimage, with a nipple distance of 8cm. Apart from this discovery, there\nwere no other suspicious focal findings on either side. No clustered or\nirregular microcalcifications were detected. Additionally, a long-term,\nunchanged observation noted some asymmetry with denser breast tissue\npresent on both sides, particularly on the outer aspects. Sonographic\nevaluation posed challenges due to the mixed echogenic glandular tissue.\nAs a possible corresponding feature to the questionable architectural\nirregularity on the outer left side, a blurred, echo-poor area with a\nvertical alignment measuring about 7x5mm was identified. Importantly, no\nother suspicious focal findings were observed, and there was no evidence\nof enlarged lymph nodes in the axilla on both sides.\n\n[Assessment]{.underline}**:** The observed finding on the left side\npresents an uncertain nature, categorized as BIRADS IVb. In contrast,\nthe finding on the right side appears benign, categorized as BIRADS II.\nTo gain a more conclusive understanding of the left-sided finding, we\nrecommend a histological assessment through a sonographically guided\nhigh-speed punch biopsy. An appointment has been scheduled with the\npatient to proceed with this biopsy and obtain a definitive\ndiagnosis.Formularbeginn\n\nFormularende**Current Recommendations:**\\\nA fast-track decision will be made regarding tumor genetics, and the\npatient will be notified of the appointment via telephone. The patient\nshould bring the pathology blocks from Fairview Clinic on the day of\nblood collection for genetic testing, along with a referral for an\nEndopredict test. A multidisciplinary team meeting will be convened\nafter the Endopredict test and genetic testing results are available. If\nthere is persistence or worsening of symptoms, we strongly advise the\npatient to seek immediate re-evaluation. Additionally, outside of\nregular office hours, the patient can seek assistance at the emergency\ncare unit in case of emergency.\n\n**MRI from 07/11/2019:**\n\n[Technique:]{.underline} Breast MRI (3T scanner) with dedicated mammary\nsurface coil: \n\n[Findings:]{.underline} The overall contrast enhancement was observed\nbilaterally to evaluate the Grade II findings. There was low to moderate\nsmall-spotted contrast enhancement with slightly limited assessability.\nThe contrast dynamics revealed a patchy, confluent, blurred, and\nelongated contrast enhancement, corresponding to the primary lesion,\nwhich measured approximately 2.4 cm on the lower left exterior. Single\nspicules were noted, and the lesion appeared hypointense in T1w imaging.\nNo suspicious focal findings with contrast enhancement were detected on\nthe right side. Small axillary lymph nodes were observed on the left\nside, but they did not appear suspicious based on MR morphology.\nAdditionally, there were no suspicious lymph nodes on the right side.\n\n[Assessment:]{.underline} An unifocal primary lesion measuring\napproximately 2.4 cm in diameter was identified on the lower left\nexterior. It exhibited patchy confluent enhancement and architectural\ndisturbance, with single spicules. No evidence of suspicious lymph nodes\nwas found. The left side is categorized as BIRADS 6, indicating a high\nsuspicion of malignancy, while the right side is categorized as BIRADS\n2, indicating a benign finding.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide you with an update on the medical condition of\nMrs. Linda Mayer, born on 01/12/1948, who attended our outpatient clinic\non 08/02/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast (17mm)\n\n- Histological grade G3, estrogen receptor (ER) and progesterone\n receptor (PR) negative.\n\n- Postmenopausal for the past eight years.\n\n- Previous surgical history includes an appendectomy.\n\n- Allergies: Hay fever\n\n \n\n**Current Presentation**: The patient sought consultation following a\nconfirmed diagnosis of DCIS (Ductal Carcinoma In Situ) in the right\nbreast, which was determined through a vacuum-assisted biopsy.\n\n**Physical Examination**: Upon physical examination, there is evidence\nof a post-intervention hematoma located in the upper right quadrant of\nthe right breast. However, the clip from the biopsy is not clearly\nvisible. A sonographic examination of the right axilla reveals no\nabnormalities.\n\n**Current Recommendations:**\n\n- Imaging studies have been conducted.\n\n- A case presentation is scheduled for our mammary conference\n tomorrow.\n\n- Subsequently, planning for surgery will commence, including the\n evaluation of sentinel lymph nodes following a right mastectomy and\n axillary lymph node dissection.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient care at our facility on 08/29/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast, measuring 17mm in size, classified as Grade 3, and\n testing negative for estrogen receptors (ER) and progesterone\n receptors (PR).\n\n- Mrs. Mayer has been postmenopausal for eight years.\n\n- Notable allergy: Hay fever\n\n**Tumor Board Decision:** Mammography imaging revealed a clip associated\nwith a focal finding in the right breast adjacent to calcifications.\n\n[Recommendation]{.underline}: Proceed with sentinel lymph node\nevaluation after right mastectomy, including clip localization on the\nright side.\n\n**Current Presentation**: During the patient\\'s recent outpatient visit,\nan extensive pre-operative consultation was conducted. This discussion\ncovered the indications for the surgery, details of the surgical\nprocess, potential alternative options, as well as general and specific\nrisks associated with the procedure. These risks included the\npossibility of an aesthetically suboptimal outcome and the chance of\nencountering an R1 situation. The patient did not have any further\nquestions and provided written consent for the procedure.\n\n**Physical Examination:** Both breasts appear normal upon inspection and\npalpation. The right axilla shows no abnormalities.\n\n**Medical History:** Mrs. Linda Mayer presented to our clinic with a\nvacuum biopsy-confirmed DCIS of the right breast for therapeutic\nintervention. The decision for surgery was reached following a\ncomprehensive review by our interdisciplinary breast board. After an\nextensive discussion of the procedure\\'s scope, associated risks, and\nalternative options, the patient provided informed consent for the\nproposed surgery.\n\n**Preoperative Procedure:** Sonographic and mammographic fine needle\nmarking of the remaining findings and the clip in the right breast.\n\n**Surgical Report:** Team time-out conducted with colleagues of\nanesthesia. Patient positioned in the supine position. Surgical site\ndisinfection and sterile draping. Marking of the incision site.\n\nA semicircular incision was made laterally on the right breast.\nVisualization and dissection along the marking wire towards the marked\nfinding. Excision of the marked findings, with a safety margin of\napproximately 1-2 cm. The excised specimen measured approximately 4 x 5\nx 3 cm. Markings using standard protocol (green thread cranially, blue\nthread ventrally). The excised specimen was sent for preparation\nradiography. Hemostasis was meticulously ensured. Insertion of a 10Ch\nBlake drain into the segmental cavity, followed by suturing.\nVerification of a blood-dry wound cavity. Preparation radiography\nincluded the marked area and the marking wires. The excised material was\ntransferred to our pathology colleagues for histological examination.\nSubdermal and intracutaneous sutures with Monocryl 3/0 in a continuous\nmanner. Application of Steristrips and dressing. Instruments, swabs, and\ncloths were accounted for per the nurse\\'s checklist. The patient was\ncorrectly positioned throughout the operation. The anesthesiologic\ncourse was without significant problems. A thorax compression bandage\nwas applied in the operating room as a preventive measure against\nbleeding.\n\n**Postoperative Procedure:** Pain management, thrombosis prophylaxis,\napplication of a pressure dressing, drainage under suction.\n\n**Examinations:** **Digital Mammography performed on 08/29/2019**\n\n[Clinical indication]{.underline}: DCIS right\n\n[Question]{.underline}: Please send specimen + Mx-FNM\n\n**Findings**: Sonographically guided wire marking of the maximum\nmicrocalcification group measuring about 12 mm. Local hematoma cavity\nand inset clip marking directly cranial to the finding. Stitch direction\nfrom lateral to medial. The wire is positioned with the tip caudal to\nthe clip in close proximity to the microcalcification. Additional\nmarking of the focal localization on the skin. Documentation of the wire\ncourse in two planes.\n\n- Telephone discussion of findings with the surgeon.\n\n- Preparation radiography and preparation sonography are recommended.\n\n- Marking wire and suspicious focal findings centrally included in the\n preparation.\n\n- Intraoperative report of findings has been conveyed to the surgeon.\n\n**Current Recommendations:**\n\n- Scheduled for inpatient admission on ward 22 tomorrow.\n\n- Right breast mastectomy with sentinel lymph node evaluation.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to update you on the clinical course of Mrs. Linda Mayer,\nborn on 01/12/1948, who was under our inpatient care from 08/30/2019 to\n09/12/2019.\n\n**Diagnosis:** Vacuum-assisted biopsy confirmed Ductal Carcinoma In Situ\n(DCIS) in the right breast, measuring 17mm, Grade 3, ER/PR negative.\n\n**Tumor Board Decision (07/13/2019):**\n\n[Imaging:]{.underline} Clip identified in focal lesion in the right\nbreast, adjacent to calcifications.\n\n[Recommendation]{.underline}**:** Spin Echo following fine-needle\nlocalization with mammography-guided control of the clip in the right\nbreast.\n\n[Subsequent Recommendation (08/27/2019):]{.underline} Radiation therapy\nto the right breast. Regular follow-up is advised.\n\n**Medical History:** Ms. Linda Mayer presented to our facility on\n08/30/2019 for the aforementioned surgical procedure. After a\ncomprehensive discussion regarding the surgical plan, potential risks,\nand possible complications, the patient consented to proceed. The\nsurgery was executed without complications on 09/01/2019. The\npostoperative course was unremarkable, allowing for Ms. Mayer\\'s\ndischarge on 09/12/2019 in stable condition and with no signs of wound\nirritation.\n\n**Histopathological Findings (09/01/2019):**\n\nThe resected segment from the right breast showed a maximum necrotic\nzone of 1.6 cm with foreign body reaction, chronic resorptive\ninflammation, fibrosis, and residual hemorrhage. These findings\nprimarily correspond to the pre-biopsy site. Surrounding this were areas\nof DCIS with solid and cribriform growth patterns and comedonecrosis,\nWHO Grade 3, Nuclear Grade 3, with a reconstructed extent of 3.5 cm.\nResection margins were as follows: ventral 0.15 cm, caudal 0.2 cm,\ndorsal 0.4 cm, with remaining margins exceeding 0.5 cm. TNM\nClassification (8th Edition, 2017): pTis (DCIS), R0, G3. Additional\nimmunohistochemical studies are underway to determine hormone receptor\nstatus; a supplementary report will follow.\n\n**Postoperative Plan:**\n\nThe patient was educated on standard postoperative care and the\nimportance of immediate re-evaluation for any persistent or worsening\nsymptoms. Radiation therapy to the right breast is planned, along with\nregular follow-up appointments.\n\nShould you have any questions or require further clarification, we are\nreadily available. For urgent concerns outside of regular office hours,\nemergency care is available at the Emergency Department.\n\n**Internal Histopathological Findings Report**\n\n**Clinical Data:** DCIS in the right breast (17 mm), Grade 3, ER/PR\nnegative.\n\n**Macroscopic Examination:**\n\nThe resected mammary segment from the right breast, marked with dual\nthreads and containing a fine-needle marker inserted ventro-laterally,\nmeasures 4.5 x 5.5 x 3 cm (HxWxD) and weighs 35 grams. The specimen was\nsectioned from medial to lateral into 14 lamellae. The cut surface\npredominantly shows yellowish, lobulated mammary parenchyma with sparse\nstriated whitish glandular components. A DCIS-suspected area, up to 2.1\ncm in size, is evident caudally and centro-ventrally (from lamellae\n4-10), displaying both reddish-hemorrhagic and whitish-nodular\nindurations. Minimal distances from the suspicious area to the resection\nmargins are as follows: cranial 2 cm, caudal 0.2 cm, dorsal 0.2 cm,\nventral 0.1 cm, medial 1.6 cm, lateral 2.5 cm. The suspect area was\ncompletely embedded. Ink markings: green/cranial, yellow/caudal,\nblue/ventral, black/dorsal.\n\n**Microscopic Examination:**\n\nHistological sections of the mammary parenchyma reveal fibro-lipomatous\nstroma and glandular lobules with a two-layered epithelial lining. In\nlamellae 3-6 and 11, solid and cribriform epithelial proliferations are\nevident. Cells are cuboidal with variably enlarged, predominantly\nmoderately pleomorphic, round to oval nuclei. Comedo-like necroses are\noccasionally observed in secondary lumina. Microscopic distances to the\ndeposition margins are consistent with the macroscopic findings. The\nsurrounding stroma in lamellae 6-9 shows extensive geographic adipose\ntissue necrosis, multinucleated foreign body-type giant cells, foamy\ncell macrophages, collagen fiber proliferation, and fresh hemorrhages.\n\n**Supplemental Immunohistochemical Findings\n(09/04/2019):** **Microscopy:** In the meantime, the material was\nfurther processed as announced.\n\nHere, the previously described intraductal epithelial growths, each with\nnegative staining reaction for the estrogen and progesterone receptor\n(with regular external and internal control reaction).\n\n \n\n**Critical Findings:**\n\nResected mammary segment with paracentral, max. 1.6 cm necrotic zone\nwith foreign body reaction, chronic resorptive. Chronic resorptive\ninflammation, fibrosis, and hemorrhage remnants (primarily corresponding\nto the pre-biopsy site), and surrounding portions of ductal carcinoma in\nsitu. Ductal carcinoma in situ, solid and rib-shaped growth type with\ncomedonecrosis, WHO grade 3, nuclear grade 3. The resection was locally\ncomplete with the following Safety margins: ventral 0.15 cm, caudal 0.2\ncm, dorsal 0.4 cm, and the remaining sedimentation margins more than 0.5\ncm.\n\nTNM classification (8th edition 2017): pTis (DCIS), R0, G3.\n\n[Hormone receptor status:]{.underline}\n\n- Estrogen receptor: negative (0%).\n\n- Progesterone receptor: negative (0%).\n\n \n\n \n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient treatment on 27/09/2019.\n\n**Diagnoses**: Left breast carcinoma; iT1c; iN0; MX; ER:12/12; PR:2/12;\nHer-2: neg; Ki67:15%, BRCA 2 mutation.\n\n**Other Diagnoses**:\n\n- Hailey-Hailey disease - currently regressing under prednisolone.\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 due to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage (Abrasio) in 2004\n\n- Hysterectomy in 2005\n\n**Allergies**: Hay fever\n\n**Imaging**:\n\n- CT revealed a cystic lesion in the liver, not suspicious for\n metastasis. Granulomatous, post-inflammatory changes in the lung.\n\n- An MRI of the left breast showed a unifocal lesion on the outer left\n side with a 2.4 cm extension.\n\n**Histology: **Gene score of 6.5, indicating a high-risk profile (pT2 or\npN1) if BRCA negative.\n\n**Recommendation**: If BRCA negative, SE left mamma after ultrasound-FNM\nwith correlation in Mx and SLNB on the left.\n\n**Current Presentation**: Mrs. Linda Mayer presented for pre-operative\nevaluation for left mastectomy. BRCA testing confirmed a BRCA2 mutation,\nwarranting bilateral subcutaneous mastectomy and SLNB on the left.\nReconstruction with implants and mesh is planned, along with a breast\nlift as requested by the patient.\n\n**Macroscopy:**\n\n**Left Subcutaneous Mastectomy (Blue/Ventral, Green/Cranial):**\n\n- Specimen Size: 17 x 15 x 6 cm (Height x Width x Depth), Weight: 410\n g\n\n- Description: Dual filament-labeled subcutaneous mastectomy specimen\n\n- Specimen Workup: 27 lamellae from lateral to medial\n\n- Tumor-Suspect Area (Lamellae 17-21): Max. 1.6 cm, white dermal,\n partly blurred\n\n- Margins from Tumor Area: Ventral 0.1 cm, Caudal 1 cm, Dorsal 1.2 cm,\n Cranial \\> 5 cm, Lateral \\> 5 cm, Medial \\> 2 cm\n\n- Remaining Mammary Parenchyma: Predominantly yellowish lipomatous\n with focal nodular appearance\n\n- Ink Markings: Cranial/Green, Caudal/Yellow, Ventral/Blue,\n Dorsal/Black\n\n - A: Lamella 17 - Covers dorsal and caudal\n\n - B: Lamella 18 - Covers ventral\n\n - C: Lamella 19 - Covers ventral\n\n - D: Blade 21 - Covers ventral\n\n - E: Lamella 20 - Reference cranial\n\n - F: Lamella 16 - Immediately laterally following mammary\n parenchyma\n\n - G: Blade 22 - Reference immediately medial following mammary\n tissue\n\n - H: Lamella 12 - Central section\n\n - I: Lamella 8 - Documented section top/outside\n\n - J: Lamella 3 - Vestigial section below/outside\n\n - K: Lamella 21 - White-nodular imposing area\n\n - L: Lamella 8 - Further section below/outside with nodular area\n\n - M: Lateral border lamella perpendicularly\n\n - N: Medial border lamella perpendicular (Exemplary)\n\n**Second Sentinel Lymph Node on the Left:**\n\n- Specimen: Maximum of 6 cm of fat tissue resectate with 1 to 2 cm of\n lymph nodes and smaller nodular indurations.\n\n- A, B: One lymph node each divided\n\n- C: Further nodular indurations\n\n**Palpable Lymph Nodes Level I:**\n\n- Specimen: One max. 4.5 cm large fat resectate with nodular\n indurations up to 1.5 cm in size\n\n- A: One nodular induration divided\n\n- B: Further nodular indurated portions\n\n**Right Subcutaneous Mastectomy:**\n\n- Specimen: Double thread-labeled 450 g subcutaneous mastectomy\n specimen\n\n- Assumed Suture Markings: Blue (Ventral) and Green (Cranial)\n\n- Dorsal Fascia Intact\n\n- [Specimen Preparation:]{.underline} 16 lamellae from medial to\n lateral\n\n- Predominantly yellowish lobulated with streaky, beige, impinging\n strands of tissue\n\n- Isolated hemorrhages in the parenchyma\n\n- Ink Markings: Green = Cranial, Yellow = Caudal, Blue = Ventral,\n Black = Dorsal\n\n<!-- -->\n\n- A: Medial border lamella perpendicular (Exemplary)\n\n- B: Lamella 5 with reference ventrally (below inside)\n\n- C: Lamella 8 with reference ventrally (below inside)\n\n- D: Lamella 6 with ventral and dorsal reference (upper inside)\n\n- E: Blade 8 with ventral and dorsal cover (top inside)\n\n- F: Blade 11 with cover dorsal and caudal (bottom outside)\n\n- G: Blade 13 with dorsal cover (bottom outside)\n\n- H: Blade 10 with ventral and dorsal cover (top outside)\n\n- I: Lamella 14 with reference cranial and dorsal and bleeding in\n (upper outer)\n\n- J: Lateral border lamella perpendicular (Exemplary)\n\n**Microscopy:**\n\n1\\) In the tumor-suspicious area, a blurred large fibrosis zone with\nstar-shaped extensions is visible. Intercalated are single-cell and\nstranded epithelial cells with a high nuclear-cytoplasmic ratio. The\nnuclei are monomorphic with finely dispersed chromatin, at most, very\nisolated mitoses. Adjacent distended glandular ducts with a discohesive\ncell proliferate with the same cytomorphology. Sporadically, preexistent\nglandular ducts are sheared disc-like by the infiltrative tumor cells.\nSamples from the nodular area of lamella 21 show areas of cell-poor\nhyaline sclerosis with partly ectatically dilated glandular ducts.\n\n2\\) Second lymph node with partial infiltrates of the neoplasia described\nabove. The cells here are relatively densely packed. Somewhat increased\nmitoses. In the lymph nodes, iron deposition is also in the sinus\nhistiocytes.\n\n3\\) Lymph nodes with partly sparse iron deposition. No epithelial foreign\ninfiltrates.\n\n4\\) Regular mammary gland parenchyma. No tumor infiltrates. Part of the\nglandular ducts are slightly cystically dilated.\n\n**Preliminary Critical Findings Report: **\n\nLeft breast carcinoma measuring max 1.6 cm diagnosed as moderately\ndifferentiated invasive lobular carcinoma, B.R.E. score 6 (3+2+1, G2).\nPresence of tumor-associated and peritumoral lobular carcinoma in situ.\nResection status indicates locally complete excision of both invasive\nand non-invasive carcinoma; minimal margins as follows: ventral \\<0.1\ncm, caudal 0.2 cm, dorsal 0.8 cm, remaining margins ≥0.5 cm. Nodal\nstatus reveals max 0.25 cm metastasis in 1/5 nodes, 0/2 additional\nnodes, without extracapsular spread. Right mammary gland from\nsubcutaneous mastectomy shows tumor-free parenchyma.\n\n**TNM classification (8th ed. 2017):** pT1c, pTis (LCIS), pN1a, G2, L0,\nV0, Pn0, R0. Investigations to determine tumor biology were initiated.\nAddendum follows.\n\n**Supplementary findings on 10/07/2019**\n\nEditing: immunohistochemistry:** **\n\nEstrogen receptor, Progesterone receptor, Her2neu, MIB-1 (block 1D).\n\n**Critical Findings Report:** Breast carcinoma on the left with a 1.6 cm\ninvasive lobular carcinoma, moderately differentiated, with a B.R.E.\nscore of 6 (3+2+1, G2). Additionally, tumor-associated and peritumoral\nlobular carcinoma in situ are noted. Resection status confirms locally\ncomplete excision of both invasive and non-invasive carcinomas; minimal\nresection margins are ventral \\<0.1 cm, caudal (LCIS) 0.2 cm, dorsal 0.8\ncm, and all other margins ≥0.5 cm. Nodal assessment reveals a single\nmetastasis with a maximum dimension of 0.25 cm among 7 lymph nodes,\nspecifically found in 1/5 nodes, with no additional metastasis in 0/2\nnodes and no extracapsular extension. Contralateral right mammary gland\nfrom subcutaneous mastectomy is tumor-free.\n\nTumor biology of the invasive carcinoma demonstrates strong positive\nestrogen receptor expression in 100% of tumor cells, strong positive\nprogesterone receptor expression in 1% of tumor cells, negative HER2/neu\nstatus (Score 1+), and a Ki67 (MIB-1) proliferation index of 25%.\n\n**TNM classification (8th Edition 2017):** pT1c, pTis (LCIS), pN1a (1/7\nECE-, sn), G2, L0, V0, Pn0, R0.\n\n**Surgery Report (Vac Change + Irrigation)**: Indication for VAC change.\nAfter a detailed explanation of the procedure, its risks, and\nalternatives, the patient agrees to the proposed procedure.\n\nThe course of surgery: Proper positioning in a supine position. Removal\nof the VAC sponge. A foul odor appears from the wound cavity. Careful\ndisinfection of the surgical area. Sterile draping. Detailed inspection\nof the wound conditions. Wound debridement with removal of fibrin\ncoatings and freshening of the wound. Resection of necrotic material in\nplaces with sharp spoon. Followed by extensive Irrigation of the entire\nwound bed and wound edges using 1 l Polyhexanide solution. Renewed VAC\nsponge application according to standard.\n\n**Postoperative procedure**: Pain medication, thrombosis prophylaxis,\ncontinuation of antibiotic therapy. In the case of abundant\nStaphylococcus aureus and isolated Pseudomosas in the smear and still\nclinical suspected infection, extension of antibiotic treatment to\nMeropenem.\n\n**Surgery Report: Implant Placement**\n\n**Type of Surgery:** Implant placement and wound closure.\n\n**Report:** After infection and VAC therapy, clean smears and planning\nof reinsertion. Informed consent. Intraoperative consults: Anesthesia.\n\n**Course of Surgery:** Team time out. Removal VAC sponge. Disinfection\nand covering. Irrigation of the wound cavity with Serasept. Blust\nirrigation. Fixation cranially and laterally with 4 fixation sutures\nwith Vircryl 2-0. Choice of trial implant. Temporary insertion. Control\nin sitting and lying positions. Choice of the implant. Repeated\ndisinfection. Change of gloves. Insertion of the implant into the\npocket. Careful hemostasis. Insertion of a Blake drain into the wound\ncavity. Suturing of the drainage. Subcutaneous sutures with Monocryl\n3-0.\n\n**Type of Surgery:** Prophylactic open Laparoscopy, extensive\nadhesiolysis\n\n**Type of Anesthesia:** ITN\n\n**Report:** Patient presented for prophylactic right adnexectomy in the\ncourse of hysterectomy and left adnexectomy due to genetic burden.\nIntraoperatively, secondary wound closure was to be performed in the\ncase of a right mammary wound weeping more than one year\npostoperatively. The patient agreed to the planned procedure in writing\nafter receiving detailed information about the extent, the risks, and\nthe alternatives.\n\n**Course of the Operation:** Team time out with anesthesia colleagues.\nFlat lithotomy positioning, disinfection, and sterile draping. Placement\nof permanent transurethral catheter. Subumbilical incision and\ndissection onto the fascia. Opening of the fascia and suturing of the\nsame. Exposure of the peritoneum and opening of the same. Insertion of\nthe 10-mm optic trocar. Insertion of three additional trocars into the\nlower abdomen (left and center right, each 5mm; right 10mm). The\nfollowing situation is seen: when the camera is inserted from the\numbilical region, an extensive adhesion is seen. Only by changing the\ncamera to the right lower bay is extensive adhesiolysis possible. The\nomentum is fused with the peritoneum and the serosa of the uterus. Upper\nabdomen as far as visible inconspicuous.\n\nAfter hysterectomy and adnexectomy on the left side, adnexa on the right\nside atrophic and inconspicuous. The peritoneum is smooth as far as can\nbe seen.\n\nVisualization of the right adnexa and the suspensory ligament of ovary.\n\nCoagulation of the suspensory ligament of ovary ligament after\nvisualization of the ureter on the same side. Stepwise dissection of the\nadnexa from the pelvic wall.\n\nRecovery via endobag. Hemostasis. Inspection of the situs.\n\nRemoval of instrumentation under vision and draining of\npneumoperitoneum.\n\nClosure of the abdominal fascia at the umbilicus and right lower\nabdomen. Suturing of the skin with Monocryl 3/0. Compression bandage at\neach trocar insertion site. Inspection of the right mamma. In the area\nof the surgical scar laterally/externally, 2-3 small epithelium-lined\npore-like openings are visible; here, on pressure, discharge of rather\nviscous/sebaceous, non-odorous, or purulent fluid. No dehiscence is\nvisible, suspected. fistula ducts to the implant cavity. After\nconsultation with the mamma surgeon, a two-stage procedure was planned\nfor the treatment of the fistula tracts. Correct positioning and\ninconspicuous anesthesiological course. Instrumentation, swabs, and\ncloths complete according to the operating room nurse. Postoperative\nprocedures include analgesia, mobilization, thrombosis prophylaxis, and\nwaiting for histology.\n\n**Internal Histopathological Report** \n\n[Clinical information/question]{.underline}: Fistula formation mammary\nright. Dignity?\n\n[Macroscopy]{.underline}**:** Skin spindle from scar mammary right: fix.\na 2.4 cm long, stranded skin-subcutaneous excidate. Lamellation and\ncomplete embedding.\n\n[Processing]{.underline}**:** 1 block, HE\n\n[Microscopy]{.underline}**:** Histologic skin/subcutaneous\ncross-sections with overlay by a multilayered keratinizing squamous\nepithelium. The dermis with few inset regular skin adnexal structures,\nsparse to moderately dense mononuclear-dominated inflammatory\ninfiltrates, and proliferation of cell-poor, fiber-rich collagenous\nconnective tissue.\n\n**Critical Findings Report:** \n\nSkin spindle on scar mamma right: skin/subcutaneous resectate with\nfibrosis and chronic inflammation. To ensure that all findings are\nrecorded, the material will be further processed. A follow-up report\nwill follow.\n\n[Microscopy]{.underline}**:** In the meantime, the material was further\nprocessed as announced. The van Gieson stain showed extensive\nproliferation of collagenous and, in some places elastic fibers. Also in\nthe additional immunohistochemical staining against no evidence of\natypical epithelial infiltrates.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n CRP 7.8 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 11.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 3.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to provide an update on Mrs. Linda Mayer, born on\n01/12/1948, who received inpatient care at our facility from 01/01/2021\nto 01/14/2021.\n\n**Diagnosis:** Hailey-Hailey disease.\n\n- Upon admission, the patient was under treatment with Acitretin 25mg.\n\n**Other Diagnoses**:\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 die to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage in 2004\n\n- Hysterectomy in 2005\n\n**Medical History:** Mrs. Linda Mayer was referred to our hospital for\nthe management of Hailey-Hailey disease after assessment in our\noutpatient clinic. She reported a worsening of painful skin erosions on\nher neck and inner thighs over a span of approximately 3 weeks.\nItchiness was not reported. Prior attempts at treatment, including the\ntopical use of Fucicort, Prednisolone with Octenidine, and Polidocanol\ngel, had provided limited relief. She denied any other physical\ncomplaints, dyspnea, B symptoms, infections, or irregularities in stool\nand micturition.\n\nHer history revealed the initial onset of Hailey-Hailey disease,\ninitially presenting as itching followed by skin erosions, which\nsubsequently healed with scarring. The diagnosis was established at the\nFairview Clinic. Previous therapeutic interventions included systemic\ncortisone shock therapy, as-needed application of Fucicort ointment, and\naxillary laser therapy.\n\n**Family History:**\n\n- Father: Hailey-Hailey Disease (M. Hailey-Hailey)\n\n- Mother and Sister: Breast carcinoma\n\n**Psychosocial History:** Socially, Ms. Linda Mayer is described as a\nretiree, having previously worked as a nurse.\n\n**Physical Examination on Admission:**\n\nHeight: 16 cm, Body Weight: 80.0 kg, BMI: 29.7\n\n**Physical Examination Findings:**\n\nGenerally stable condition with increased nutritional status. Her\nconsciousness was unremarkable, and cranial mobility was free. Ocular\nmobility was regular, with prompt pupillary reflexes to accommodation\nand light. She exhibited a normal heart rate, and cardiac and pulmonary\nexaminations were unremarkable. No heart murmurs were detected. Renal\nbed and spine were not palpable. Further internal and orienting\nneurological examinations revealed no pathological findings.\n\n**Skin Findings on Admission:** Sharp erosions, approximately 10x10 cm\nin size, with a livid-erythematous base, partly crusty, were observed on\nthe neck and proximal inner thighs.\n\nIn the axillary regions on both sides, there were marginal,\nlivid-erythematous, well-demarcated plaques interspersed with scarring\nstrands, more pronounced on the right side.\n\nSkin type II.\n\nMucous membranes appeared normal. Dermographism was noted to be ruber.\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------ ------------ -------------------------------\n Prednisolone (Deltasone) 5 mg 1.5-0-0-0-0-0\n Aspirin (Bayer) 100 mg 0-1-0-0-0-0\n Simvastatin (Zocor) 40 mg 0-0-0-0-1\n Pantoprazole (Protonix) 45.1 mg 1-0-0-0-0\n Acitretin (Soriatane) 25 mg 1-0-0-0-0\n Tetrabenazine (Xenazine) 111 mg 0.25-0.25-0.25-0.25-0.25-0.25\n Letrozole (Femara) 2.5 mg 0-0-1-0\n Risedronate Sodium (Actonel) 35 mg 1-0-0-0-0\n Acetaminophen (Tylenol) 500 mg 0-1-0-1\n Naloxone (Narcan) 8.8 mg 1-0-1-0\n Eszopiclone (Lunesta) 7.5 mg 0-0-1-0\n\n**Other Findings:** MRSA Smears:\n\n- Nasal Smear: Normal flora, no MRSA.\n\n- Throat Swab: Normal flora, no MRSA.\n\n- Non-lesional Skin Smear: Normal flora.\n\n- Lesional Skin Swab: Abundant Pseudomonas aeruginosa, abundant\n Klebsiella oxytoca, and abundant Serratia sp., sensitive to\n piperacillin-tazobactam.\n\n**Therapy and Progression:** Mrs. Linda Mayer was admitted on 01/01/2021\nas an inpatient for a refractory exacerbation of previously diagnosed\nHailey-Hailey disease. On admission, both bacteriological and\nmycological smears were conducted, which indicated abundant levels of\nPseudomonas aeruginosa, Klebsiella oxytoca, and Serratia sp. Lab tests\nshowed a CRP level of 2.83 mg/dL and a leukocyte count of 8.8 G/L.\n\nInitial topical therapy consisted of Zinc oxide ointment, Clotrimazole\npaste, and Triamcinolone Acetonide shake lotion. Treatment was modified\non 01/04/2021 to include Clotrimazole (Lotrimin) paste in the mornings\nand methylprednisolone emulsion in the evenings. Starting on 01/08,\neosin aqueous solution was introduced for application on the thighs,\nserving antiseptic and drying purposes. A hydrophilic prednicarbate\ncream at 0.25% concentration, combined with octenidine at 0.1%, was\napplied to the neck and thighs twice daily, also starting on 01/08. For\nshowering, octenidine-based wash lotion was utilized. Additionally, Mrs.\nLinda Mayer received an emulsifying ointment as part of her treatment.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are providing an update on our patient Mrs. Linda Mayer, born on\n01/12/1948, who presented to our outpatient clinic on 09/22/2021.\n\n**Diagnoses:** M. Hailey-Hailey\n\n**Medical History:**\n\n- Diagnosis of M. Hailey-Hailey at the Fairview Clinic\n\n<!-- -->\n\n- Treatment involved systemic steroid shock therapy, laser therapy,\n and the initiation of Acitretin in October 2021, with no observed\n improvement.\n\n<!-- -->\n\n- A dermabrasion procedure was scheduled on 03/18/2021, during a\n previous inpatient admission.\n\n- Acitretin 25mg has been administered daily, with favorable outcomes\n noted when using Triamcinolone/Triclosan or Prednisolone +\n Octenidine.\n\n- A history of mastectomy with Vacuum-Assisted Closure (VAC) has\n resulted in breast erosion.\n\n**Skin Findings:**\n\n- Erythematous and partially mottled lesions have been identified in\n the axillary and inguinal regions, with some scarring observed in\n the axillary area.\n\n- On 04/28/2021, somewhat erosive plaques were noted in the inguinal\n regions.\n\n- As of 05/05/2021 discrete erosions are currently present on both\n forearms.\n\n**Current Recommendations:**\n\n- Inpatient admission is scheduled for September 2021.\n\n- The prescribed treatment plan includes topical prednicarbate\n (Dermatop) 0.25% with Octenidine 0.1%, per NRF 11.145, in a 50g\n container, to be applied once daily for 1-2 weeks.\n\n- Hydrocortisone 5% in a suitable base, 200g, is to be applied daily.\n\n- The regimen also includes prednicarbate (Dermatop) combined with\n Octenidine.\n\n- Acitretin will be continued temporarily.\n\n- A follow-up appointment in the outpatient clinic is scheduled for\n three months from now.\n\n- Discontinuation of Acitretin.\n\n- It is recommended to avoid the use of compresses on the erosions to\n prevent constant trauma.\n\n- Topical therapy with petrolatum-based wound ointment and sterile\n compresses.\n\n\n\n\nHere is the query:\nConsidering Mrs. Mayer's medications that were present in 2019 and 2021, which drug's dosing frequency was reduced in the second regimen, likely indicating a clinical improvement?\n\nChoose the correct answer from the following options:\nA. Aspirin\nB. Simvastatin\nC. Pantoprazole\nD. Prednisolone\nE. Acyclovir\n\n\nYour response:\n", "role": "user" }, { "content": "Prednisolone", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report to you about Mrs. Linda Mayer, born on 01/12/1948, who\npresented to our outpatient clinic on 07/13/19.\n\n**Diagnoses:**\n\n- BIRADS IV, recommended biopsy during breast diagnostics.\n\n- Left breast carcinoma: iT1b; iN0; MX; ER: 12/12; PR: 2/12; Her-2:\n neg; Ki67: 15%.\n\n**Other Diagnoses: **\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Pemphigus vulgaris under azathioprine therapy\n\n- Osteoporosis\n\n- Obesity with a BMI of 35\n\n- Undergoing immunosuppressive therapy with prednisolone\n\n**Family History:**\n\n- Sister deceased at age 39 from breast cancer.\n\n- Mother and grandmother (maternal and paternal) were diagnosed with\n breast cancer.\n\n**Medical History:** The CT thorax report indicates the presence of\ninflammatory foci, warranting further follow-up. The relevant data was\ndocumented and presented during the tumor conference. Subsequently, a\ntelephone conversation was conducted with the patient to discuss the\nnext steps.\n\n**Tumor board decision from 07/13/2019:**\n\n**Imaging: **\n\n1) MRI examination detected a unifocal lesion on the left external\n aspect, measuring approximately 2.4 cm in size.\n\n2) CT scan (thorax/abdomen 07/12/2019) revealed a previously known\n liver lesion, likely a hemangioma. No evidence of metastases was\n identified. Nonspecific, small foci were observed in the lungs,\n likely indicative of post-inflammatory changes.\n\n**Recommendations:**\n\n1. If no metastasis (M0): Fast-track BRCA testing is recommended.\n\n2. If BRCA testing returns negative: Proceed with a selective excision\n of the left breast after ultrasound-guided fine needle marking and\n sentinel lymph node biopsy on the left side. Additionally, perform\n Endopredict analysis on the surgical specimen.\n\n**Current Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ------------------------------- ------------ ----------- ---------------\n Aspirin 100mg Oral 1-0-0\n Simvastatin (Zocor) 40mg Oral 0-1-0\n Haloperidol (Haldol) 100mg Oral ½-0-½\n Zopiclone (Imovane) 7.5mg Oral 0-0-1\n Trazodone (Desyrel) 100mg Oral 0-0-½-\n Calcium Supplement (Caltrate) 500mg Oral 1-0-1\n Nystatin (Bio-Statin) As advised Oral 1-1-1-1\n Pantoprazole (Protonix) 40mg Oral 1-0-0\n Prednisolone (Prelone) 40mg Oral As advised\n Tramadol/Naloxone (Ultram) 50/4mg Oral 1-0-1\n Acyclovir (Zovirax) 800mg Oral 1-1-1\n\n**Mammography and Tomosynthesis from 07/8/2019:**\n\n[Findings]{.underline}**: **During the inspection and palpation, no\nsignificant findings were noted on either side. Some areas with higher\nmammographic density were observed, which slightly limited the\nassessment. However, during the initial examination, a small\narchitectural irregularity was identified on the outer left side. This\nirregularity appeared as a small, roundish compression measuring\napproximately 6mm and was visible only in the medio-lateral oblique\nimage, with a nipple distance of 8cm. Apart from this discovery, there\nwere no other suspicious focal findings on either side. No clustered or\nirregular microcalcifications were detected. Additionally, a long-term,\nunchanged observation noted some asymmetry with denser breast tissue\npresent on both sides, particularly on the outer aspects. Sonographic\nevaluation posed challenges due to the mixed echogenic glandular tissue.\nAs a possible corresponding feature to the questionable architectural\nirregularity on the outer left side, a blurred, echo-poor area with a\nvertical alignment measuring about 7x5mm was identified. Importantly, no\nother suspicious focal findings were observed, and there was no evidence\nof enlarged lymph nodes in the axilla on both sides.\n\n[Assessment]{.underline}**:** The observed finding on the left side\npresents an uncertain nature, categorized as BIRADS IVb. In contrast,\nthe finding on the right side appears benign, categorized as BIRADS II.\nTo gain a more conclusive understanding of the left-sided finding, we\nrecommend a histological assessment through a sonographically guided\nhigh-speed punch biopsy. An appointment has been scheduled with the\npatient to proceed with this biopsy and obtain a definitive\ndiagnosis.Formularbeginn\n\nFormularende**Current Recommendations:**\\\nA fast-track decision will be made regarding tumor genetics, and the\npatient will be notified of the appointment via telephone. The patient\nshould bring the pathology blocks from Fairview Clinic on the day of\nblood collection for genetic testing, along with a referral for an\nEndopredict test. A multidisciplinary team meeting will be convened\nafter the Endopredict test and genetic testing results are available. If\nthere is persistence or worsening of symptoms, we strongly advise the\npatient to seek immediate re-evaluation. Additionally, outside of\nregular office hours, the patient can seek assistance at the emergency\ncare unit in case of emergency.\n\n**MRI from 07/11/2019:**\n\n[Technique:]{.underline} Breast MRI (3T scanner) with dedicated mammary\nsurface coil: \n\n[Findings:]{.underline} The overall contrast enhancement was observed\nbilaterally to evaluate the Grade II findings. There was low to moderate\nsmall-spotted contrast enhancement with slightly limited assessability.\nThe contrast dynamics revealed a patchy, confluent, blurred, and\nelongated contrast enhancement, corresponding to the primary lesion,\nwhich measured approximately 2.4 cm on the lower left exterior. Single\nspicules were noted, and the lesion appeared hypointense in T1w imaging.\nNo suspicious focal findings with contrast enhancement were detected on\nthe right side. Small axillary lymph nodes were observed on the left\nside, but they did not appear suspicious based on MR morphology.\nAdditionally, there were no suspicious lymph nodes on the right side.\n\n[Assessment:]{.underline} An unifocal primary lesion measuring\napproximately 2.4 cm in diameter was identified on the lower left\nexterior. It exhibited patchy confluent enhancement and architectural\ndisturbance, with single spicules. No evidence of suspicious lymph nodes\nwas found. The left side is categorized as BIRADS 6, indicating a high\nsuspicion of malignancy, while the right side is categorized as BIRADS\n2, indicating a benign finding.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide you with an update on the medical condition of\nMrs. Linda Mayer, born on 01/12/1948, who attended our outpatient clinic\non 08/02/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast (17mm)\n\n- Histological grade G3, estrogen receptor (ER) and progesterone\n receptor (PR) negative.\n\n- Postmenopausal for the past eight years.\n\n- Previous surgical history includes an appendectomy.\n\n- Allergies: Hay fever\n\n \n\n**Current Presentation**: The patient sought consultation following a\nconfirmed diagnosis of DCIS (Ductal Carcinoma In Situ) in the right\nbreast, which was determined through a vacuum-assisted biopsy.\n\n**Physical Examination**: Upon physical examination, there is evidence\nof a post-intervention hematoma located in the upper right quadrant of\nthe right breast. However, the clip from the biopsy is not clearly\nvisible. A sonographic examination of the right axilla reveals no\nabnormalities.\n\n**Current Recommendations:**\n\n- Imaging studies have been conducted.\n\n- A case presentation is scheduled for our mammary conference\n tomorrow.\n\n- Subsequently, planning for surgery will commence, including the\n evaluation of sentinel lymph nodes following a right mastectomy and\n axillary lymph node dissection.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient care at our facility on 08/29/2019.\n\n**Diagnoses:**\n\n- Vacuum-assisted biopsy-confirmed ductal carcinoma in situ (DCIS) of\n the right breast, measuring 17mm in size, classified as Grade 3, and\n testing negative for estrogen receptors (ER) and progesterone\n receptors (PR).\n\n- Mrs. Mayer has been postmenopausal for eight years.\n\n- Notable allergy: Hay fever\n\n**Tumor Board Decision:** Mammography imaging revealed a clip associated\nwith a focal finding in the right breast adjacent to calcifications.\n\n[Recommendation]{.underline}: Proceed with sentinel lymph node\nevaluation after right mastectomy, including clip localization on the\nright side.\n\n**Current Presentation**: During the patient\\'s recent outpatient visit,\nan extensive pre-operative consultation was conducted. This discussion\ncovered the indications for the surgery, details of the surgical\nprocess, potential alternative options, as well as general and specific\nrisks associated with the procedure. These risks included the\npossibility of an aesthetically suboptimal outcome and the chance of\nencountering an R1 situation. The patient did not have any further\nquestions and provided written consent for the procedure.\n\n**Physical Examination:** Both breasts appear normal upon inspection and\npalpation. The right axilla shows no abnormalities.\n\n**Medical History:** Mrs. Linda Mayer presented to our clinic with a\nvacuum biopsy-confirmed DCIS of the right breast for therapeutic\nintervention. The decision for surgery was reached following a\ncomprehensive review by our interdisciplinary breast board. After an\nextensive discussion of the procedure\\'s scope, associated risks, and\nalternative options, the patient provided informed consent for the\nproposed surgery.\n\n**Preoperative Procedure:** Sonographic and mammographic fine needle\nmarking of the remaining findings and the clip in the right breast.\n\n**Surgical Report:** Team time-out conducted with colleagues of\nanesthesia. Patient positioned in the supine position. Surgical site\ndisinfection and sterile draping. Marking of the incision site.\n\nA semicircular incision was made laterally on the right breast.\nVisualization and dissection along the marking wire towards the marked\nfinding. Excision of the marked findings, with a safety margin of\napproximately 1-2 cm. The excised specimen measured approximately 4 x 5\nx 3 cm. Markings using standard protocol (green thread cranially, blue\nthread ventrally). The excised specimen was sent for preparation\nradiography. Hemostasis was meticulously ensured. Insertion of a 10Ch\nBlake drain into the segmental cavity, followed by suturing.\nVerification of a blood-dry wound cavity. Preparation radiography\nincluded the marked area and the marking wires. The excised material was\ntransferred to our pathology colleagues for histological examination.\nSubdermal and intracutaneous sutures with Monocryl 3/0 in a continuous\nmanner. Application of Steristrips and dressing. Instruments, swabs, and\ncloths were accounted for per the nurse\\'s checklist. The patient was\ncorrectly positioned throughout the operation. The anesthesiologic\ncourse was without significant problems. A thorax compression bandage\nwas applied in the operating room as a preventive measure against\nbleeding.\n\n**Postoperative Procedure:** Pain management, thrombosis prophylaxis,\napplication of a pressure dressing, drainage under suction.\n\n**Examinations:** **Digital Mammography performed on 08/29/2019**\n\n[Clinical indication]{.underline}: DCIS right\n\n[Question]{.underline}: Please send specimen + Mx-FNM\n\n**Findings**: Sonographically guided wire marking of the maximum\nmicrocalcification group measuring about 12 mm. Local hematoma cavity\nand inset clip marking directly cranial to the finding. Stitch direction\nfrom lateral to medial. The wire is positioned with the tip caudal to\nthe clip in close proximity to the microcalcification. Additional\nmarking of the focal localization on the skin. Documentation of the wire\ncourse in two planes.\n\n- Telephone discussion of findings with the surgeon.\n\n- Preparation radiography and preparation sonography are recommended.\n\n- Marking wire and suspicious focal findings centrally included in the\n preparation.\n\n- Intraoperative report of findings has been conveyed to the surgeon.\n\n**Current Recommendations:**\n\n- Scheduled for inpatient admission on ward 22 tomorrow.\n\n- Right breast mastectomy with sentinel lymph node evaluation.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to update you on the clinical course of Mrs. Linda Mayer,\nborn on 01/12/1948, who was under our inpatient care from 08/30/2019 to\n09/12/2019.\n\n**Diagnosis:** Vacuum-assisted biopsy confirmed Ductal Carcinoma In Situ\n(DCIS) in the right breast, measuring 17mm, Grade 3, ER/PR negative.\n\n**Tumor Board Decision (07/13/2019):**\n\n[Imaging:]{.underline} Clip identified in focal lesion in the right\nbreast, adjacent to calcifications.\n\n[Recommendation]{.underline}**:** Spin Echo following fine-needle\nlocalization with mammography-guided control of the clip in the right\nbreast.\n\n[Subsequent Recommendation (08/27/2019):]{.underline} Radiation therapy\nto the right breast. Regular follow-up is advised.\n\n**Medical History:** Ms. Linda Mayer presented to our facility on\n08/30/2019 for the aforementioned surgical procedure. After a\ncomprehensive discussion regarding the surgical plan, potential risks,\nand possible complications, the patient consented to proceed. The\nsurgery was executed without complications on 09/01/2019. The\npostoperative course was unremarkable, allowing for Ms. Mayer\\'s\ndischarge on 09/12/2019 in stable condition and with no signs of wound\nirritation.\n\n**Histopathological Findings (09/01/2019):**\n\nThe resected segment from the right breast showed a maximum necrotic\nzone of 1.6 cm with foreign body reaction, chronic resorptive\ninflammation, fibrosis, and residual hemorrhage. These findings\nprimarily correspond to the pre-biopsy site. Surrounding this were areas\nof DCIS with solid and cribriform growth patterns and comedonecrosis,\nWHO Grade 3, Nuclear Grade 3, with a reconstructed extent of 3.5 cm.\nResection margins were as follows: ventral 0.15 cm, caudal 0.2 cm,\ndorsal 0.4 cm, with remaining margins exceeding 0.5 cm. TNM\nClassification (8th Edition, 2017): pTis (DCIS), R0, G3. Additional\nimmunohistochemical studies are underway to determine hormone receptor\nstatus; a supplementary report will follow.\n\n**Postoperative Plan:**\n\nThe patient was educated on standard postoperative care and the\nimportance of immediate re-evaluation for any persistent or worsening\nsymptoms. Radiation therapy to the right breast is planned, along with\nregular follow-up appointments.\n\nShould you have any questions or require further clarification, we are\nreadily available. For urgent concerns outside of regular office hours,\nemergency care is available at the Emergency Department.\n\n**Internal Histopathological Findings Report**\n\n**Clinical Data:** DCIS in the right breast (17 mm), Grade 3, ER/PR\nnegative.\n\n**Macroscopic Examination:**\n\nThe resected mammary segment from the right breast, marked with dual\nthreads and containing a fine-needle marker inserted ventro-laterally,\nmeasures 4.5 x 5.5 x 3 cm (HxWxD) and weighs 35 grams. The specimen was\nsectioned from medial to lateral into 14 lamellae. The cut surface\npredominantly shows yellowish, lobulated mammary parenchyma with sparse\nstriated whitish glandular components. A DCIS-suspected area, up to 2.1\ncm in size, is evident caudally and centro-ventrally (from lamellae\n4-10), displaying both reddish-hemorrhagic and whitish-nodular\nindurations. Minimal distances from the suspicious area to the resection\nmargins are as follows: cranial 2 cm, caudal 0.2 cm, dorsal 0.2 cm,\nventral 0.1 cm, medial 1.6 cm, lateral 2.5 cm. The suspect area was\ncompletely embedded. Ink markings: green/cranial, yellow/caudal,\nblue/ventral, black/dorsal.\n\n**Microscopic Examination:**\n\nHistological sections of the mammary parenchyma reveal fibro-lipomatous\nstroma and glandular lobules with a two-layered epithelial lining. In\nlamellae 3-6 and 11, solid and cribriform epithelial proliferations are\nevident. Cells are cuboidal with variably enlarged, predominantly\nmoderately pleomorphic, round to oval nuclei. Comedo-like necroses are\noccasionally observed in secondary lumina. Microscopic distances to the\ndeposition margins are consistent with the macroscopic findings. The\nsurrounding stroma in lamellae 6-9 shows extensive geographic adipose\ntissue necrosis, multinucleated foreign body-type giant cells, foamy\ncell macrophages, collagen fiber proliferation, and fresh hemorrhages.\n\n**Supplemental Immunohistochemical Findings\n(09/04/2019):** **Microscopy:** In the meantime, the material was\nfurther processed as announced.\n\nHere, the previously described intraductal epithelial growths, each with\nnegative staining reaction for the estrogen and progesterone receptor\n(with regular external and internal control reaction).\n\n \n\n**Critical Findings:**\n\nResected mammary segment with paracentral, max. 1.6 cm necrotic zone\nwith foreign body reaction, chronic resorptive. Chronic resorptive\ninflammation, fibrosis, and hemorrhage remnants (primarily corresponding\nto the pre-biopsy site), and surrounding portions of ductal carcinoma in\nsitu. Ductal carcinoma in situ, solid and rib-shaped growth type with\ncomedonecrosis, WHO grade 3, nuclear grade 3. The resection was locally\ncomplete with the following Safety margins: ventral 0.15 cm, caudal 0.2\ncm, dorsal 0.4 cm, and the remaining sedimentation margins more than 0.5\ncm.\n\nTNM classification (8th edition 2017): pTis (DCIS), R0, G3.\n\n[Hormone receptor status:]{.underline}\n\n- Estrogen receptor: negative (0%).\n\n- Progesterone receptor: negative (0%).\n\n \n\n \n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mrs. Linda Mayer, born on\n01/12/1948, who received outpatient treatment on 27/09/2019.\n\n**Diagnoses**: Left breast carcinoma; iT1c; iN0; MX; ER:12/12; PR:2/12;\nHer-2: neg; Ki67:15%, BRCA 2 mutation.\n\n**Other Diagnoses**:\n\n- Hailey-Hailey disease - currently regressing under prednisolone.\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 due to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage (Abrasio) in 2004\n\n- Hysterectomy in 2005\n\n**Allergies**: Hay fever\n\n**Imaging**:\n\n- CT revealed a cystic lesion in the liver, not suspicious for\n metastasis. Granulomatous, post-inflammatory changes in the lung.\n\n- An MRI of the left breast showed a unifocal lesion on the outer left\n side with a 2.4 cm extension.\n\n**Histology: **Gene score of 6.5, indicating a high-risk profile (pT2 or\npN1) if BRCA negative.\n\n**Recommendation**: If BRCA negative, SE left mamma after ultrasound-FNM\nwith correlation in Mx and SLNB on the left.\n\n**Current Presentation**: Mrs. Linda Mayer presented for pre-operative\nevaluation for left mastectomy. BRCA testing confirmed a BRCA2 mutation,\nwarranting bilateral subcutaneous mastectomy and SLNB on the left.\nReconstruction with implants and mesh is planned, along with a breast\nlift as requested by the patient.\n\n**Macroscopy:**\n\n**Left Subcutaneous Mastectomy (Blue/Ventral, Green/Cranial):**\n\n- Specimen Size: 17 x 15 x 6 cm (Height x Width x Depth), Weight: 410\n g\n\n- Description: Dual filament-labeled subcutaneous mastectomy specimen\n\n- Specimen Workup: 27 lamellae from lateral to medial\n\n- Tumor-Suspect Area (Lamellae 17-21): Max. 1.6 cm, white dermal,\n partly blurred\n\n- Margins from Tumor Area: Ventral 0.1 cm, Caudal 1 cm, Dorsal 1.2 cm,\n Cranial \\> 5 cm, Lateral \\> 5 cm, Medial \\> 2 cm\n\n- Remaining Mammary Parenchyma: Predominantly yellowish lipomatous\n with focal nodular appearance\n\n- Ink Markings: Cranial/Green, Caudal/Yellow, Ventral/Blue,\n Dorsal/Black\n\n - A: Lamella 17 - Covers dorsal and caudal\n\n - B: Lamella 18 - Covers ventral\n\n - C: Lamella 19 - Covers ventral\n\n - D: Blade 21 - Covers ventral\n\n - E: Lamella 20 - Reference cranial\n\n - F: Lamella 16 - Immediately laterally following mammary\n parenchyma\n\n - G: Blade 22 - Reference immediately medial following mammary\n tissue\n\n - H: Lamella 12 - Central section\n\n - I: Lamella 8 - Documented section top/outside\n\n - J: Lamella 3 - Vestigial section below/outside\n\n - K: Lamella 21 - White-nodular imposing area\n\n - L: Lamella 8 - Further section below/outside with nodular area\n\n - M: Lateral border lamella perpendicularly\n\n - N: Medial border lamella perpendicular (Exemplary)\n\n**Second Sentinel Lymph Node on the Left:**\n\n- Specimen: Maximum of 6 cm of fat tissue resectate with 1 to 2 cm of\n lymph nodes and smaller nodular indurations.\n\n- A, B: One lymph node each divided\n\n- C: Further nodular indurations\n\n**Palpable Lymph Nodes Level I:**\n\n- Specimen: One max. 4.5 cm large fat resectate with nodular\n indurations up to 1.5 cm in size\n\n- A: One nodular induration divided\n\n- B: Further nodular indurated portions\n\n**Right Subcutaneous Mastectomy:**\n\n- Specimen: Double thread-labeled 450 g subcutaneous mastectomy\n specimen\n\n- Assumed Suture Markings: Blue (Ventral) and Green (Cranial)\n\n- Dorsal Fascia Intact\n\n- [Specimen Preparation:]{.underline} 16 lamellae from medial to\n lateral\n\n- Predominantly yellowish lobulated with streaky, beige, impinging\n strands of tissue\n\n- Isolated hemorrhages in the parenchyma\n\n- Ink Markings: Green = Cranial, Yellow = Caudal, Blue = Ventral,\n Black = Dorsal\n\n<!-- -->\n\n- A: Medial border lamella perpendicular (Exemplary)\n\n- B: Lamella 5 with reference ventrally (below inside)\n\n- C: Lamella 8 with reference ventrally (below inside)\n\n- D: Lamella 6 with ventral and dorsal reference (upper inside)\n\n- E: Blade 8 with ventral and dorsal cover (top inside)\n\n- F: Blade 11 with cover dorsal and caudal (bottom outside)\n\n- G: Blade 13 with dorsal cover (bottom outside)\n\n- H: Blade 10 with ventral and dorsal cover (top outside)\n\n- I: Lamella 14 with reference cranial and dorsal and bleeding in\n (upper outer)\n\n- J: Lateral border lamella perpendicular (Exemplary)\n\n**Microscopy:**\n\n1\\) In the tumor-suspicious area, a blurred large fibrosis zone with\nstar-shaped extensions is visible. Intercalated are single-cell and\nstranded epithelial cells with a high nuclear-cytoplasmic ratio. The\nnuclei are monomorphic with finely dispersed chromatin, at most, very\nisolated mitoses. Adjacent distended glandular ducts with a discohesive\ncell proliferate with the same cytomorphology. Sporadically, preexistent\nglandular ducts are sheared disc-like by the infiltrative tumor cells.\nSamples from the nodular area of lamella 21 show areas of cell-poor\nhyaline sclerosis with partly ectatically dilated glandular ducts.\n\n2\\) Second lymph node with partial infiltrates of the neoplasia described\nabove. The cells here are relatively densely packed. Somewhat increased\nmitoses. In the lymph nodes, iron deposition is also in the sinus\nhistiocytes.\n\n3\\) Lymph nodes with partly sparse iron deposition. No epithelial foreign\ninfiltrates.\n\n4\\) Regular mammary gland parenchyma. No tumor infiltrates. Part of the\nglandular ducts are slightly cystically dilated.\n\n**Preliminary Critical Findings Report: **\n\nLeft breast carcinoma measuring max 1.6 cm diagnosed as moderately\ndifferentiated invasive lobular carcinoma, B.R.E. score 6 (3+2+1, G2).\nPresence of tumor-associated and peritumoral lobular carcinoma in situ.\nResection status indicates locally complete excision of both invasive\nand non-invasive carcinoma; minimal margins as follows: ventral \\<0.1\ncm, caudal 0.2 cm, dorsal 0.8 cm, remaining margins ≥0.5 cm. Nodal\nstatus reveals max 0.25 cm metastasis in 1/5 nodes, 0/2 additional\nnodes, without extracapsular spread. Right mammary gland from\nsubcutaneous mastectomy shows tumor-free parenchyma.\n\n**TNM classification (8th ed. 2017):** pT1c, pTis (LCIS), pN1a, G2, L0,\nV0, Pn0, R0. Investigations to determine tumor biology were initiated.\nAddendum follows.\n\n**Supplementary findings on 10/07/2019**\n\nEditing: immunohistochemistry:** **\n\nEstrogen receptor, Progesterone receptor, Her2neu, MIB-1 (block 1D).\n\n**Critical Findings Report:** Breast carcinoma on the left with a 1.6 cm\ninvasive lobular carcinoma, moderately differentiated, with a B.R.E.\nscore of 6 (3+2+1, G2). Additionally, tumor-associated and peritumoral\nlobular carcinoma in situ are noted. Resection status confirms locally\ncomplete excision of both invasive and non-invasive carcinomas; minimal\nresection margins are ventral \\<0.1 cm, caudal (LCIS) 0.2 cm, dorsal 0.8\ncm, and all other margins ≥0.5 cm. Nodal assessment reveals a single\nmetastasis with a maximum dimension of 0.25 cm among 7 lymph nodes,\nspecifically found in 1/5 nodes, with no additional metastasis in 0/2\nnodes and no extracapsular extension. Contralateral right mammary gland\nfrom subcutaneous mastectomy is tumor-free.\n\nTumor biology of the invasive carcinoma demonstrates strong positive\nestrogen receptor expression in 100% of tumor cells, strong positive\nprogesterone receptor expression in 1% of tumor cells, negative HER2/neu\nstatus (Score 1+), and a Ki67 (MIB-1) proliferation index of 25%.\n\n**TNM classification (8th Edition 2017):** pT1c, pTis (LCIS), pN1a (1/7\nECE-, sn), G2, L0, V0, Pn0, R0.\n\n**Surgery Report (Vac Change + Irrigation)**: Indication for VAC change.\nAfter a detailed explanation of the procedure, its risks, and\nalternatives, the patient agrees to the proposed procedure.\n\nThe course of surgery: Proper positioning in a supine position. Removal\nof the VAC sponge. A foul odor appears from the wound cavity. Careful\ndisinfection of the surgical area. Sterile draping. Detailed inspection\nof the wound conditions. Wound debridement with removal of fibrin\ncoatings and freshening of the wound. Resection of necrotic material in\nplaces with sharp spoon. Followed by extensive Irrigation of the entire\nwound bed and wound edges using 1 l Polyhexanide solution. Renewed VAC\nsponge application according to standard.\n\n**Postoperative procedure**: Pain medication, thrombosis prophylaxis,\ncontinuation of antibiotic therapy. In the case of abundant\nStaphylococcus aureus and isolated Pseudomosas in the smear and still\nclinical suspected infection, extension of antibiotic treatment to\nMeropenem.\n\n**Surgery Report: Implant Placement**\n\n**Type of Surgery:** Implant placement and wound closure.\n\n**Report:** After infection and VAC therapy, clean smears and planning\nof reinsertion. Informed consent. Intraoperative consults: Anesthesia.\n\n**Course of Surgery:** Team time out. Removal VAC sponge. Disinfection\nand covering. Irrigation of the wound cavity with Serasept. Blust\nirrigation. Fixation cranially and laterally with 4 fixation sutures\nwith Vircryl 2-0. Choice of trial implant. Temporary insertion. Control\nin sitting and lying positions. Choice of the implant. Repeated\ndisinfection. Change of gloves. Insertion of the implant into the\npocket. Careful hemostasis. Insertion of a Blake drain into the wound\ncavity. Suturing of the drainage. Subcutaneous sutures with Monocryl\n3-0.\n\n**Type of Surgery:** Prophylactic open Laparoscopy, extensive\nadhesiolysis\n\n**Type of Anesthesia:** ITN\n\n**Report:** Patient presented for prophylactic right adnexectomy in the\ncourse of hysterectomy and left adnexectomy due to genetic burden.\nIntraoperatively, secondary wound closure was to be performed in the\ncase of a right mammary wound weeping more than one year\npostoperatively. The patient agreed to the planned procedure in writing\nafter receiving detailed information about the extent, the risks, and\nthe alternatives.\n\n**Course of the Operation:** Team time out with anesthesia colleagues.\nFlat lithotomy positioning, disinfection, and sterile draping. Placement\nof permanent transurethral catheter. Subumbilical incision and\ndissection onto the fascia. Opening of the fascia and suturing of the\nsame. Exposure of the peritoneum and opening of the same. Insertion of\nthe 10-mm optic trocar. Insertion of three additional trocars into the\nlower abdomen (left and center right, each 5mm; right 10mm). The\nfollowing situation is seen: when the camera is inserted from the\numbilical region, an extensive adhesion is seen. Only by changing the\ncamera to the right lower bay is extensive adhesiolysis possible. The\nomentum is fused with the peritoneum and the serosa of the uterus. Upper\nabdomen as far as visible inconspicuous.\n\nAfter hysterectomy and adnexectomy on the left side, adnexa on the right\nside atrophic and inconspicuous. The peritoneum is smooth as far as can\nbe seen.\n\nVisualization of the right adnexa and the suspensory ligament of ovary.\n\nCoagulation of the suspensory ligament of ovary ligament after\nvisualization of the ureter on the same side. Stepwise dissection of the\nadnexa from the pelvic wall.\n\nRecovery via endobag. Hemostasis. Inspection of the situs.\n\nRemoval of instrumentation under vision and draining of\npneumoperitoneum.\n\nClosure of the abdominal fascia at the umbilicus and right lower\nabdomen. Suturing of the skin with Monocryl 3/0. Compression bandage at\neach trocar insertion site. Inspection of the right mamma. In the area\nof the surgical scar laterally/externally, 2-3 small epithelium-lined\npore-like openings are visible; here, on pressure, discharge of rather\nviscous/sebaceous, non-odorous, or purulent fluid. No dehiscence is\nvisible, suspected. fistula ducts to the implant cavity. After\nconsultation with the mamma surgeon, a two-stage procedure was planned\nfor the treatment of the fistula tracts. Correct positioning and\ninconspicuous anesthesiological course. Instrumentation, swabs, and\ncloths complete according to the operating room nurse. Postoperative\nprocedures include analgesia, mobilization, thrombosis prophylaxis, and\nwaiting for histology.\n\n**Internal Histopathological Report** \n\n[Clinical information/question]{.underline}: Fistula formation mammary\nright. Dignity?\n\n[Macroscopy]{.underline}**:** Skin spindle from scar mammary right: fix.\na 2.4 cm long, stranded skin-subcutaneous excidate. Lamellation and\ncomplete embedding.\n\n[Processing]{.underline}**:** 1 block, HE\n\n[Microscopy]{.underline}**:** Histologic skin/subcutaneous\ncross-sections with overlay by a multilayered keratinizing squamous\nepithelium. The dermis with few inset regular skin adnexal structures,\nsparse to moderately dense mononuclear-dominated inflammatory\ninfiltrates, and proliferation of cell-poor, fiber-rich collagenous\nconnective tissue.\n\n**Critical Findings Report:** \n\nSkin spindle on scar mamma right: skin/subcutaneous resectate with\nfibrosis and chronic inflammation. To ensure that all findings are\nrecorded, the material will be further processed. A follow-up report\nwill follow.\n\n[Microscopy]{.underline}**:** In the meantime, the material was further\nprocessed as announced. The van Gieson stain showed extensive\nproliferation of collagenous and, in some places elastic fibers. Also in\nthe additional immunohistochemical staining against no evidence of\natypical epithelial infiltrates.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n CRP 7.8 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 11.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 3.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to provide an update on Mrs. Linda Mayer, born on\n01/12/1948, who received inpatient care at our facility from 01/01/2021\nto 01/14/2021.\n\n**Diagnosis:** Hailey-Hailey disease.\n\n- Upon admission, the patient was under treatment with Acitretin 25mg.\n\n**Other Diagnoses**:\n\n- History of apoplexy in 2016 with no residuals\n\n- Depressive episodes\n\n- Right hip total hip replacement\n\n- History of left adnexectomy in 1980 die to extrauterine pregnancy\n\n- Tubal sterilization in 1988.\n\n- Uterine curettage in 2004\n\n- Hysterectomy in 2005\n\n**Medical History:** Mrs. Linda Mayer was referred to our hospital for\nthe management of Hailey-Hailey disease after assessment in our\noutpatient clinic. She reported a worsening of painful skin erosions on\nher neck and inner thighs over a span of approximately 3 weeks.\nItchiness was not reported. Prior attempts at treatment, including the\ntopical use of Fucicort, Prednisolone with Octenidine, and Polidocanol\ngel, had provided limited relief. She denied any other physical\ncomplaints, dyspnea, B symptoms, infections, or irregularities in stool\nand micturition.\n\nHer history revealed the initial onset of Hailey-Hailey disease,\ninitially presenting as itching followed by skin erosions, which\nsubsequently healed with scarring. The diagnosis was established at the\nFairview Clinic. Previous therapeutic interventions included systemic\ncortisone shock therapy, as-needed application of Fucicort ointment, and\naxillary laser therapy.\n\n**Family History:**\n\n- Father: Hailey-Hailey Disease (M. Hailey-Hailey)\n\n- Mother and Sister: Breast carcinoma\n\n**Psychosocial History:** Socially, Ms. Linda Mayer is described as a\nretiree, having previously worked as a nurse.\n\n**Physical Examination on Admission:**\n\nHeight: 16 cm, Body Weight: 80.0 kg, BMI: 29.7\n\n**Physical Examination Findings:**\n\nGenerally stable condition with increased nutritional status. Her\nconsciousness was unremarkable, and cranial mobility was free. Ocular\nmobility was regular, with prompt pupillary reflexes to accommodation\nand light. She exhibited a normal heart rate, and cardiac and pulmonary\nexaminations were unremarkable. No heart murmurs were detected. Renal\nbed and spine were not palpable. Further internal and orienting\nneurological examinations revealed no pathological findings.\n\n**Skin Findings on Admission:** Sharp erosions, approximately 10x10 cm\nin size, with a livid-erythematous base, partly crusty, were observed on\nthe neck and proximal inner thighs.\n\nIn the axillary regions on both sides, there were marginal,\nlivid-erythematous, well-demarcated plaques interspersed with scarring\nstrands, more pronounced on the right side.\n\nSkin type II.\n\nMucous membranes appeared normal. Dermographism was noted to be ruber.\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------ ------------ -------------------------------\n Prednisolone (Deltasone) 5 mg 1.5-0-0-0-0-0\n Aspirin (Bayer) 100 mg 0-1-0-0-0-0\n Simvastatin (Zocor) 40 mg 0-0-0-0-1\n Pantoprazole (Protonix) 45.1 mg 1-0-0-0-0\n Acitretin (Soriatane) 25 mg 1-0-0-0-0\n Tetrabenazine (Xenazine) 111 mg 0.25-0.25-0.25-0.25-0.25-0.25\n Letrozole (Femara) 2.5 mg 0-0-1-0\n Risedronate Sodium (Actonel) 35 mg 1-0-0-0-0\n Acetaminophen (Tylenol) 500 mg 0-1-0-1\n Naloxone (Narcan) 8.8 mg 1-0-1-0\n Eszopiclone (Lunesta) 7.5 mg 0-0-1-0\n\n**Other Findings:** MRSA Smears:\n\n- Nasal Smear: Normal flora, no MRSA.\n\n- Throat Swab: Normal flora, no MRSA.\n\n- Non-lesional Skin Smear: Normal flora.\n\n- Lesional Skin Swab: Abundant Pseudomonas aeruginosa, abundant\n Klebsiella oxytoca, and abundant Serratia sp., sensitive to\n piperacillin-tazobactam.\n\n**Therapy and Progression:** Mrs. Linda Mayer was admitted on 01/01/2021\nas an inpatient for a refractory exacerbation of previously diagnosed\nHailey-Hailey disease. On admission, both bacteriological and\nmycological smears were conducted, which indicated abundant levels of\nPseudomonas aeruginosa, Klebsiella oxytoca, and Serratia sp. Lab tests\nshowed a CRP level of 2.83 mg/dL and a leukocyte count of 8.8 G/L.\n\nInitial topical therapy consisted of Zinc oxide ointment, Clotrimazole\npaste, and Triamcinolone Acetonide shake lotion. Treatment was modified\non 01/04/2021 to include Clotrimazole (Lotrimin) paste in the mornings\nand methylprednisolone emulsion in the evenings. Starting on 01/08,\neosin aqueous solution was introduced for application on the thighs,\nserving antiseptic and drying purposes. A hydrophilic prednicarbate\ncream at 0.25% concentration, combined with octenidine at 0.1%, was\napplied to the neck and thighs twice daily, also starting on 01/08. For\nshowering, octenidine-based wash lotion was utilized. Additionally, Mrs.\nLinda Mayer received an emulsifying ointment as part of her treatment.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are providing an update on our patient Mrs. Linda Mayer, born on\n01/12/1948, who presented to our outpatient clinic on 09/22/2021.\n\n**Diagnoses:** M. Hailey-Hailey\n\n**Medical History:**\n\n- Diagnosis of M. Hailey-Hailey at the Fairview Clinic\n\n<!-- -->\n\n- Treatment involved systemic steroid shock therapy, laser therapy,\n and the initiation of Acitretin in October 2021, with no observed\n improvement.\n\n<!-- -->\n\n- A dermabrasion procedure was scheduled on 03/18/2021, during a\n previous inpatient admission.\n\n- Acitretin 25mg has been administered daily, with favorable outcomes\n noted when using Triamcinolone/Triclosan or Prednisolone +\n Octenidine.\n\n- A history of mastectomy with Vacuum-Assisted Closure (VAC) has\n resulted in breast erosion.\n\n**Skin Findings:**\n\n- Erythematous and partially mottled lesions have been identified in\n the axillary and inguinal regions, with some scarring observed in\n the axillary area.\n\n- On 04/28/2021, somewhat erosive plaques were noted in the inguinal\n regions.\n\n- As of 05/05/2021 discrete erosions are currently present on both\n forearms.\n\n**Current Recommendations:**\n\n- Inpatient admission is scheduled for September 2021.\n\n- The prescribed treatment plan includes topical prednicarbate\n (Dermatop) 0.25% with Octenidine 0.1%, per NRF 11.145, in a 50g\n container, to be applied once daily for 1-2 weeks.\n\n- Hydrocortisone 5% in a suitable base, 200g, is to be applied daily.\n\n- The regimen also includes prednicarbate (Dermatop) combined with\n Octenidine.\n\n- Acitretin will be continued temporarily.\n\n- A follow-up appointment in the outpatient clinic is scheduled for\n three months from now.\n\n- Discontinuation of Acitretin.\n\n- It is recommended to avoid the use of compresses on the erosions to\n prevent constant trauma.\n\n- Topical therapy with petrolatum-based wound ointment and sterile\n compresses.\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/18/2018 to\n03/01/2018.\n\n**Diagnoses: **\n\n- Malignant melanoma of the left scapula, TD 16 mm, exophytic\n ulcerating, invasion stage - III, R0\n\n- **Mutation analysis:** BRAF status: mutated. PD-L1 status: PD-L1\n tumor proportion score (TPS): \\<1%. Immune cell infiltrate (IC): 2%\n of tumor area. PD-L1 combined-positive score (CPS): 2.\n\n- **History:** Ms. Done was admitted to the hospital with high grade\n suspicion of malignant melanoma of the back. The patient reported a\n skin lesion that had been present for approximately 4 weeks. The\n lesion had grown rapidly during this time and appeared to be oozing\n and bleeding. She presented to our outpatient clinic, where she was\n advised to undergo surgical excision in case of suspected\n malignancy.\n\n- Questions about B-symptoms, AP complaints, stool or urine\n abnormalities were negated.\n\n- System Therapy (Adjuvant Treatment for Stage III Melanoma): 1\n\n02/22/18: 1st dose pembrolizumab 200mg\n\n03/15/18: 2nd dose Pembrolizumab 200mg\n\n04/05/18: 3rd dose Pembrolizumab 200mg\n\n04/26/18: 4th dose Pembrolizumab 200mg\n\n05/17/18: 5th dose Pembrolizumab 200mg\n\n06/07/18: 6th dose Pembrolizumab 200mg\n\n06/28/18: 7th dose Pembrolizumab 200mg\n\n07/19/18: 8th dose Pembrolizumab 200mg\n\n08/09/18: 9th dose Pembrolizumab 200mg i.v.\n\n**Physical examination findings:** 52-year-old female patient in normal\ngeneral condition, nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement normal. Pupils are equal and\nreactive to light and accommodation. Regular, normocardial heart rate\nduring recording. Cor and pulmo auscultatory and percutaneously\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall, liver\nand spleen not enlarged, no pain to palpation, no resistance to\npalpation, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged cervical, submandibular, supra- and infraclavicular, axillary\nand inguinal lymph nodes palpable. inguinal lymph nodes palpable.\nFurther internal and orienting neurological examination neurological\nexamination remained without pathological findings.\n\n**Skin findings:** In the area of the left scapula, a table tennis-ball\nsized area with a slightly fissured, oozing, pink-black pigmented\nsurface. On the cranial side an irregularly black-brown pigmented macula\nof about 3.2x1.2 cm is visible.\n\n**PET/CT with 203 MBq (F-18)-Fluorodeoxyglucose from 02/18/2018: **\n\nWeight: 66 kg, blood glucose: 118 mg/dL. 20 mg furosemide; acquisition\nstart 91 min after tracer injection; 821 mm scan length á () mm/s in\nflow technique (neck to proximal thigh); oral and i.v. contrast (1.5\nmL/kg, i.v., max. 120 mL). Quantitative analysis of\nattenuation-corrected image data using SUV calculation.\n\n**Findings:**\n\nCT: In case of known contrast agent allergy, premedication was performed\nwith one ampoule each of H1 and H2 antihistamine. The contrast-enhanced\nexamination proceeded without complications during the course.\n\nNeck: Symmetrical visualization of the soft tissues of the neck. No\nevidence of pathologically enlarged cervical lymph nodes. Struma nodosa\nwith several hypodense nodes on the right side up to max. approx. 1 cm.\n\nThorax: Cutaneous/subcutaneous irregular-shaped lesion caudal to the\nright scapula. Limited assessability in the lung window with motion\nartifacts and shallow inspiration depth. As far as assessable, no\nevidence of larger suspicious intrapulmonary pulmonary round foci. No\ninfiltrate. No pleural effusion. No evidence of pathologically enlarged\nlymph nodes mediastinal, hilar and axillary bilaterally.\n\nAbdomen/pelvis: Normal contrast of liver parenchyma without evidence of\nsuspicious focal liver lesions. Portal vein and hepatic veins perfused\nregularly. Gallbladder without irritation. Spleen with accessory spleen,\npancreas and adrenal glands bds. regular. Kidneys perfused at the same\nside. No urinary retention. Nephrolithiasis on the right side.\nVisualization of the parenchymatous upper abdominal organs. No evidence\nof pathologically enlarged coeliacal, mesenteric, retroperitoneal,\niliac, and inguinal lymph nodes. Inhomogeneously contrasted enlarged\nprostate. Urinary bladder wall, as far as assessable with low filling\ncircumferentially wall thickened.\n\nSkeleton: no evidence of suspicious osteodestructive lesions. Osteopenia\nwith degenerative skeletal changes.\n\nPET:\n\nIncreased tracer enhancement of the suspicious lesion caudal to left\nscapula, indicative of a melanoma (SUVmax 67). Focal intense tracer\nenhancement in the right thyroid lobe (SUVmax approximately 7.9).\nElongated intense tracer enhancement in the lower abdomen ventrally\nmedian without clear correlate, most consistent with contamination.\nOtherwise, unremarkable activity distribution in the study area.\n\nAssessment:\n\nNo evidence of metabolically active metastases in the study area.\n\n**Operation report from** **02/22/2018**:\n\nProcedure: Excision of malignant melanoma on the left upper back.\n\nPreoperative Diagnosis: Malignant melanoma, left upper back.\n\nPostoperative Diagnosis: Malignant melanoma, left upper back.\n\nAnesthesia: Local anesthesia using 70 mL tumescent solution comprising\n0.21% Lidocaine/Ropivacaine with epinephrine.\n\nProcedure Details: The surgical area was prepped using Betadine. The\narea was draped in a sterile fashion. Excision of the exophytic tumor\nwas performed, measuring 51 x 20 x 15 mm. A safety margin of 10 mm was\nmaintained in depth, with the excision extending slightly into the\nsubcutaneous tissue but not beyond the fascia. This resulted in a total\ndefect size of 75 x 45 mm. The defect could not be closed with a simple\nprimary suture. Perforator vessels were coagulated, and the defect was\nbridged using skin flaps. Additional resection of Burow triangles was\ndone according to aesthetic units. The wound was closed using an\nintracutaneous suture technique. A continuous overhand blocked suture\nwas used with 3-0 Vicryl. The patient was advised that the visible\nsuture material could be removed between postoperative days 14 and 16. A\ndressing was applied, followed by a pressure dressing to minimize\nswelling and promote healing. Comments: The patient tolerated the\nprocedure well and was provided postoperative care instructions.\n\nPlan: Follow up in clinic for suture removal and wound assessment\nbetween postoperative days 14 and 16.\n\n**Histology Dermatohistology:** **02/23/2018.**\n\n**Gross Examination:** A roughly oval excision specimen measuring 48 x\n36 x 14 mm. The specimen is serially sectioned into lamellar stages A\nthrough H (8 cassettes).\n\n**Microscopic Examination:**\n\nStage A: Displays a benign epidermis and dermis without evidence of\nmelanocytic tumor cells.\n\nStage B: Features an irregularly thickened epidermis. At the center of\nthe section, melanocytic tumor cells are observed at the dermoepidermal\njunction (positive for MelanA stain). Additionally, abundant\nmelanophages and pigment deposits are noted. The lateral safety margin\nmeasures at least 8 mm.\n\nStage C: Resembles stage B. Atypical melanocytic tumor cells are present\nat the dermoepidermal junction. Upper dermis displays fibrosis,\ninflammation, and numerous melanophages (confirmed by positive MelanA\nstaining). The lateral safety margin is at least 6 mm.\n\nStage D: Central region shows melanocytic tumor cells in both the\nepidermis and upper dermis. There is significant inflammation,\nmelanophages, and pigment deposition (confirmed by MelanA staining).\n\nThe maximum lateral safety margin here is approximately 8 mm. A small\nlymph node in the subcutaneous fat tissue is also seen, infiltrated by\nmelanocytic tumor cells.\n\nThe tumor shows stages E, F, G and H: Exophytic, bovist-like growing\nulcerated hemorrhagic tumor consisting of completely pleomorphic tumor\ncells. These cells vary in morphology, appearing both nested and\nspindle-shaped, with clear cytoplasm and conspicuous nucleoli. Notable\npigment production is observed, as are numerous atypical mitoses.\nControl staining in stage F with MelanA is completely positive. The\nsections are entirely excised.\n\n**Diagnosis:** Exophytic, ulcerated malignant melanoma with a tumor\nthickness of at least 15 mm. The tumor invasion is categorized as stage\nIII.\n\n**Medication upon discharge: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ----------------------------------------- --------------- -------------- ------------------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Oral Once daily in the morning\n Enoxaparin (Lovenox) 0.2 mL Subcutaneous In the evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Oral Morning and evening\n Leuprorelin (Lupron Depot) 3.75 mg Depot Subcutaneous Every 4 weeks\n Fentanyl Transdermal System (Duragesic) 12 μg/hr Transdermal Changed every 3 days\n Pantoprazole (Protonix) 40 mg Oral Once daily in the morning\n Sevelamer (Renagel) 800 mg Oral Once daily in the morning\n Multivitamin One tablet Oral Once daily in the morning\n Torsemide (Demadex) 200 mg Oral Once daily in the morning\n Cholecalciferol (Dekristol) 20,000 IU Oral Once weekly\n Sodium Bicarbonate (Bicanorm) One tablet Oral Once daily in the morning\n Calcitriol (Rocaltrol) 0.25 μg Oral Once daily in the morning\n Valacyclovir (Valtrex) 500 mg Oral Half-tablet daily in the morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Oral Mornings on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Oral In the morning on day 1 and day 2 following daratumumab administration\n\n\n\n### text_1\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 10/23/2020 to\n11/01/2020.\n\n- Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\n according to UICC.\n\n- Therapies to date:\n\n- Resection of primary tumor (malignant melanoma) on the left upper\n back (02/2018)\n\n- 01/20 Microsurgical resection right frontal tumor\n\n- 02/20 Excision of empyema\n\n- 02-03/20: Radiation therapy\n\n- 05/02/20: Start of immunotherapy with Nivolumab & 05/26/20: Start of\n combination immunotherapy 60 mg nivolumab, 200 mg ipilimumab (-\\>\n drug exanthema)\n\n**Physical examination findings: **\n\nOn admission, the patient was awake and adequately oriented. Height:\n166cm, weight: 56kg. Nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement regular. Pupils equal, pupillary\nreflex responsive to accommodation and light. Regular, normocardial\nheart rate on admission. Heart and lung: auscultatory and percutaneous\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall Liver\nand spleen are not enlarged, no tenderness, no rebound palpable.\nResistences palpable, loud bowel sounds. No enlarged No enlarged\ncervical, submandibular, supra- and infraclavicular lymph nodes\npalpable. **Skin findings:** Pronounced xerosis cutis, raised skin\nfolds, some with erythema and fine lamellar scale and fine lamellar\nscale, especially on the arms and face. **Microbiology:** Nasal swab:\nnormal flora, no MRSA. Throat swab: Normal flora, no MRSA Virology:\n10/23/2020: No detection of SARS-CoV-2 by PCR in the submitted material.\n\n**Therapy and Progression:**\n\n**Summary:** The patient presented with exsiccation eczema on the arms,\nlegs, and face.\n\n**Treatment Details:** Topical Treatment for Eczema: Applied Desonide\nCream once daily to the affected areas. For maintenance, applied Eucerin\nCream daily to the body and a moisturizing ointment like Cetaphil to the\nface.\n\n**Antipruritic Treatment:** Prescribed Benadryl tablets, to be taken as\nneeded.\n\n**Oncology Consultation:** The patient was educated by our oncologist,\nDr. Ex, regarding adjuvant therapy options. The potential benefits and\nrisks of a combination immunotherapy with Nivolumab and Ipilimumab were\ndiscussed. The patient had already started Nivolumab 200 mg therapy on\n05/26/2020.\n\n**Incident on 10/28/2020**: The patient had an unattended fall,\nresulting in a hematoma on the left forehead. An emergency CT scan\nshowed no new fractures or acute hemorrhage but confirmed the presence\nof previously known cystic metastasis.\n\n**Operation report (01/02/2020): **\n\n**Diagnosis:** Hemorrhaged right frontal metastasis from previously\ndiagnosed malignant melanoma (ID 2018)\n\n**Procedure:** Microsurgical resection of right frontal mass with\nintraoperative neuromonitoring (MEPs stable) and neuronavigation via a\nleft frontolateral craniotomy.\n\nTime: 10:34 am Closure Time: 1:04 pm. Total Duration: 2 hours 30 minutes\n\n**Preoperative Evaluation:** Imaging identified a hemorrhage in the\nright frontal lobe. Given the patient\\'s history of malignant melanoma,\na hemorrhagic melanoma metastasis was suspected. No other intracranial\nmetastases were detected. The patient and their family were informed of\nthe surgical benefits and risks. After ample time for consideration and\nquestions, written informed consent was obtained.\n\n**Procedure Details:** The patient was positioned supine and intubated.\nThe head was secured in a Mayfield clamp and rotated 60° to the right.\nThe navigation dataset was reviewed. Using the navigation system, a left\nfrontotemporal craniotomy was planned. An arcuate incision line was\ndrawn. The surgical area was shaved, cleaned, and sterilized.\nProphylactic antibiotics and mannitol were administered. A time-out was\nconducted preoperatively. The skin was incised, and Raney clips were\ninserted. The left temporal muscle was split. Using the navigation\nsystem for guidance, a left frontolateral craniotomy was performed. The\nbone flap was carefully removed and preserved in an antibiotic solution\nfor later reimplantation. The dura mater was opened, and the operating\nmicroscope was introduced. Upon inspection, the tumor was evident.\n\n**MRI brain report (01/04/2020): **\n\n**Clinical Information:** Postoperative assessment following\nmicrosurgical resection of a left frontal hemorrhaged metastasis from\npreviously diagnosed malignant melanoma.\n\n**Technique:** Multiplanar, multisequence MRI of the brain, including\nT1-weighted, T2-weighted, FLAIR, diffusion-weighted imaging (DWI), and\npost-contrast T1-weighted sequences.\n\n**Findings:** There is evidence of a right frontotemporal craniotomy\nwith associated post-surgical changes in the right frontal region.\nTitanium plates and screws are noted securing the bone flap, causing\nminimal artifact. The previous tumor site in the right frontal lobe\nshows post-surgical changes with a well-circumscribed cavity. There is\nno evidence of residual enhancing tumor within this cavity on\npost-contrast sequences, suggesting complete resection. Surrounding this\ncavity, there\\'s mild edema, consistent with expected post-operative\nchanges. No other intracranial metastases. The ventricles are of normal\nsize and symmetric. There is no evidence of hydrocephalus. No midline\nshift or mass effect is observed. There are scattered foci of\nsusceptibility artifact in the surgical bed on gradient echo sequences,\nconsistent with expected postoperative blood products. Major\nintracranial vessels appear patent with no evidence of vascular\nocclusion or significant stenosis. The remaining brain parenchyma\nappears normal in signal intensity and morphology on all sequences. No\nother significant abnormalities are identified.\n\n**Impression:** Post-surgical changes in the left frontal lobe\nconsistent with recent tumor resection. There is no evidence of residual\ntumor in the surgical bed. Expected postoperative edema and blood\nproducts adjacent to the resection site. No new metastatic foci\nidentified. No evidence of complications such as hydrocephalus, midline\nshift, or vascular abnormalities.\n\n**Operation report (02/04/2020): **\n\n**Diagnosis:** Subfascial, epidural, and subdural empyema following\nresection of right frontal metastasis for malignant melanoma.\n\n**Procedure:** Empyema removal (subfascial, epidural, subdural) S\nIncision Time: 15:23 Closure Time: 04:01 PM Total Duration: 2 hours 31\nminutes\n\n**Preoperative Evaluation:** The patient had a prior surgical resection\nof a right frontal metastasis due to known malignant melanoma. On a\nrecent outpatient visit, a cerebrospinal fluid (CSF) cushion was\nidentified and punctured, revealing the presence of pathogens. Imaging\nindicated deep and subcutaneous abscesses, necessitating revision\nsurgery. The patient was adequately informed about the procedure,\nunderstood the associated risks, and provided written consent.\n\n**Procedure Details:** The patient was positioned supine with the head\nrotated approximately 60° in a Mayfield clamp. The surgical area was\nwashed and sterilized, focusing on the pre-existing access point. A team\ntime-out was conducted. Perioperative antibiotics were withheld until\nall samples for microbiology were obtained. The skin was incised,\nrevealing multiple layers of muscle. These were carefully dissected,\nleading to the identification and evacuation of the subcutaneous\nepifascial abscess. Infected muscle tissue and abscess walls were\nresected. The skull flap appeared loosened. A miniplate was removed, and\nupon further inspection, the dura mater appeared strained. It was\nincised and revealed turbid fluid, indicating a deep abscess. The dura\nmater was mobilized, though adherence to the cortex was observed around\nthe resection cavity, suggesting possible tumor regrowth. Affected areas\nwere carefully resected. After thorough irrigation, a drainage system\nwas inserted into the resection cavity. A duraplasty was performed,\nfollowed by the reimplantation of the bone flap using a miniplate. The\npatient was also included in a bone flap study and was randomized for\nflap reimplantation. After further irrigation, the wound was\nmeticulously closed, and a subfascial drain was inserted. The final\nclosure was completed with single button sutures. Under the guidance of\nthe operating microscope, the tumor was meticulously dissected from the\nsurrounding healthy tissue. Special care was taken to minimize damage to\nthe surrounding brain structures. The intraoperative neuromonitoring\nindicated stable MEPs throughout, suggesting that motor pathways\nremained undisturbed during the procedure. Throughout the resection,\nperiodic hemostasis was achieved using bipolar electrocautery to control\nbleeding. Following the complete resection of the tumor, the surgical\ncavity was irrigated with sterile saline to remove any residual debris.\nThe integrity of the surrounding brain tissue was assessed, and no\nimmediate complications were observed. The dura mater was sutured,\nensuring a watertight closure. A synthetic dural graft was used to\nreinforce the suture line. The preserved bone flap was reimplanted and\nsecured in place using titanium plates and screws. The temporal muscle\nand soft tissues were reapproximated and sutured in layers. The skin was\nclosed using a combination of absorbable sutures for the subcutaneous\nlayer and non-absorbable sutures for the skin. Sterile dressings were\napplied to the incision site. Postoperative Assessment: The procedure\nwas completed without complications. Immediate postoperative\nneurological examination revealed no new deficits. The patient was\ntransferred to the recovery room in stable condition, awaiting\nextubation by the anesthesiology team.\n\n**Recommendations:** Close monitoring in the neurological intensive care\nunit (NICU) is advised for the first 24 hours. Postoperative imaging,\ntypically an MRI, should be scheduled within the next 48 hours to assess\nthe extent of tumor resection and to rule out any postoperative\ncomplications.\n\n**Summary:** Mrs. Done\\'s recent hospital course was complicated by the\ndetection and subsequent excision of a hemorrhagic metastasis from a\nknown history of malignant melanoma. She continues to be on targeted\ntherapy with close monitoring. No new metastasis or recurrence has been\ndetected as of the last evaluation. The interdisciplinary approach\ninvolving the neurosurgery and oncology teams has been pivotal in her\nmanagement. Given the aggressive nature of melanoma, regular\nsurveillance and immediate action upon detection of new\nlesions/metastasis are paramount for her prognosis.\n\n**02-03/20: Radiation therapy **\n\nDiagnosis: Metastatic malignant melanoma with a focus on the right\nfrontal metastasis. Technique: Stereotactic radiosurgery (SRS) using a\nlinear accelerator (LINAC). Fractionation: Given the aggressive nature\nof malignant melanoma, a hypofractionated regimen was adopted. The\npatient underwent five sessions, each delivering a dose of 6 Gy for a\ncumulative total dose of 30 Gy.\n\nTreatment Planning: A simulation CT scan with a 1mm slice thickness was\nperformed in the treatment position, with a thermoplastic mask for\nimmobilization. The treatment planning system utilized the simulation\nCT, along with MRI for better tumor delineation. The target volume and\ncritical structures like the eyes, optic nerves, chiasm, and brainstem\nwere contoured. The radiation plan was optimized to ensure maximal dose\nto the target while sparing the critical structures.\n\nProcedure: At each session, patient positioning was verified using\ncone-beam CT (CBCT) to ensure precise targeting. Real-time monitoring\nwas employed to account for any intrafraction motion.\n\nSide Effects: The patient tolerated the treatment well. She reported\ntransient fatigue and mild scalp irritation, which resolved with\nconservative measures. No acute radiation-induced neurotoxicity was\nobserved.\n\n**Patient History Update: Mrs. Jane Done (DOB: 01/01/1966)**\n\n**General Status (10/03/2020):**\n\nMrs. Done presented in stable condition with stable vital signs.\nNeurologically, she\\'s intact with no new focal deficits. The surgical\nscars in the frontal region from previous operations are not fully\nhealed and there is some dehiscence and swelling, indicative of\ninfection. This wound complication can be traced back to her previous\nhistory of an empyema which required surgical intervention.\n\n**Dermatological Assessment:**\n\nThe previous exsiccation eczema, prominent on her arms, legs, and face,\nhas improved markedly. The treatment regimen involving consistent\nmoisturization and targeted topical therapies seems effective.\nImportantly, there were no new suspicious skin lesions or nodules noted\nduring her most recent full-body skin check.\n\n**Oncology Status:**\n\nMrs. Done remains on her immunotherapy regimen, specifically the\ncombination of Nivolumab and Ipilimumab. Her response has been positive,\nwith no new metastatic sites identified in the latest assessments. She\nhas displayed commendable compliance with this regimen and regular\nfollow-up evaluations.\n\n**Recent MRI Brain (09/30/2020):**\n\nHer latest multiplanar, multisequence MRI revealed post-surgical\nalterations in the right frontal lobe, consistent with previous\nobservations. Encouragingly, there was no sign of any residual or\nrecurrent tumor activity. Moreover, the MRI did not show any new\nintracranial metastatic sites or other significant abnormalities.\n\n**Thoracic CT Scan (10/01/2020): **\n\nTechnique: Post complication-free bolus i.v. administration of Imeron\n400, a multiline spiral CT was performed through the thorax during the\nvenous contrast phase, supplemented with thin-section, coronary, and\nsagittal secondary reconstructions.\n\nFindings: Multiple roundish subsolid nodules found bipulmonary, notably\na 4mm nodule in the right upper lobe. Blurred subpleural condensations\nin the left upper lobe. Another blurred bronchus-associated\nconsolidation was observed in the left upper lobe and pleurally in the\nleft dorsal lower lobe. No evidence of pathologically enlarged lymph\nnodes in the hilar, mediastinal, or axillary regions. Unchanged\npresentation of the left adrenal gland from the preliminary examination.\nThickened imprinting of the gastric wall noted. Ventrally emphasized\nspondylophytic attachments observed in the thoracic spine. No\nosteodestructive processes detected.\n\n**Impression:** Presence of multiple subsolid pulmonary nodules;\nrecommended follow-up in 4-6 weeks for potential (post-) inflammatory or\nmalignant genesis. No evidence of pathologically enlarged lymph nodes.\n\n**Abdomen/Pelvis CT Scan (10/01/2023): **\n\nTechnique: A low dose CT scan was taken of the abdomen and pelvis.\n\n**Findings:** Regular visualization of the acquired basal lung sections.\nOrthotopic kidneys without urinary stasis. No evidence of urinary\ncalculi. Suspected uterine fibroids attached to the uterus wall.\nEnlarged right ovary with minor calcifications. Assessment: Absence of\nurinary calculi. Possible uterine fibroids and an enlarged right ovary,\nsuggesting a specialized gynecological examination.\n\n**PICC Line Installation (10/02/2020)**\n\n**Diagnosis:**\n\nHome antibiotics required for wound healing disorder following discharge\ndue to an empyema.\n\n**Type of Surgery:**\n\nInstallation of a PICC line in the left basilic vein.\n\n**Anesthesia:**\n\nLocal anesthesia\n\n**Procedure Details:**\n\nThe patient was presented for long-term antibiotic treatment due to a\nwound healing disturbance post the discharge of an epidural abscess. The\nprimary aim was to apply a PICC-line catheter for the antibiotic\nregimen. A written informed consent was duly obtained prior to the\nprocedure.\n\nThe standard procedure began with the washing off and draping of the\npatient. A preoperative sonography of the arm veins was conducted. Based\non the sonographic results, it was decided to insert the catheter via\nthe left basilica vein.\n\nUnder venous congestion and following local anesthesia with 2mL Mecain,\na 2mm skin incision was made. The sonographically guided puncture was\nperformed successfully. Post this, the peel-away sheath was inserted.\nWith the wire in place, the catheter was advanced with its tip\npositioned approximately 2cm below the carina. The wire was subsequently\nremoved. Following this, the catheter was aspirated and flushed with\nNaCl to ensure its patency. A sterile fixation was then applied, and the\nwound was dressed.\n\n**Notes:**\n\nNo complications were observed during the procedure. The patient was\nadvised on the care and maintenance of the PICC line. Regular follow-ups\nare recommended to monitor the wound healing and the effectiveness of\nthe antibiotic treatment.\n\nThe patient was discharged with instructions and is scheduled for a\nfollow-up in two weeks.\n\n**Additional Therapeutic Engagements:**\n\nFor her overall well-being and to counter the side effects of her\ntreatment journey, Mrs. Done has been actively involved in physical\ntherapy sessions. These sessions focus on enhancing her strength and\nbalance, especially given the previous incident of an unattended fall.\nTo address the inevitable psychological strains of her diagnosis, she\nhas also been attending counseling sessions.\n\n**Current Recommendations:**\n\n-Continue the ongoing immunotherapy without changes.\n\n-Dermatological check-ups every month are advised for early detection of\nany potential skin abnormalities.\n\n-Regular neurological evaluations are crucial to ensure no emergence of\nnew deficits.\n\n-Imaging should be scheduled every six months for proactive monitoring.\n\n-Her physical therapy regimen should be ongoing to maintain and improve\nmobility.\n\n-Continue counseling to support her emotional and psychological\nwell-being.\n\n**Summary and Notes:**\n\nMrs. Done\\'s resilience and adherence to her treatments are commendable.\nHer progress is a testament to the integrated care approach she has been\nreceiving. Maintaining a proactive surveillance stance will be essential\nfor her long-term prognosis and quality of life.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe wish to provide an update regarding our mutual patient, Mrs. Jane\nDone, born on 01.01.1966. She was admitted to our clinic from 11/23/2020\nto 12/01/2020.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done presented for a follow-up visit on 11/23/2020. Over the past\nfew months, she reported fatigue and intermittent bouts of nausea. Of\nsignificant concern were newly identified skin changes located on her\nright arm.\n\n**Clinical Findings:**\n\nSkin: Multiple macules and patches on the right arm, the largest\nmeasuring about 1.5cm in diameter, hyperpigmented with irregular\nborders.\n\n**US: **\n\nUltrasound imaging of the right arm revealed no deep extension or\ninvasion of underlying structures. This preliminary assessment was\ncrucial, suggesting that if malignancy is present, it might be in early\nstages.\n\n**Histology: **\n\nHistological examination: Gross Description: The sample consists of\nmultiple tan-pink soft tissue fragments, aggregating to 1.8 cm in the\ngreatest dimension.\n\nMicroscopic description: Sections show a proliferation of atypical\nmelanocytes arranged in nests and as single units at the dermoepidermal\njunction. Some of these cells infiltrate the papillary dermis.\n\nImmunohistochemistry: The atypical cells are positive for HMB-45 and\nS-100. Melan A is focally positive. Ki-67 proliferation index is about\n10%.\n\nFinal Diagnosis: Dysplastic nevus with severe atypia; margins appear\nclear. Further excision is recommended to ensure complete removal and to\nrule out invasive melanoma.\n\n**Lab results: **\n\nComplete Blood Count (CBC):\n\nHemoglobin: 12.3 g/dL (Normal range: 12-16 g/dL)\n\nWhite Blood Cell Count: 6,200 cells/µL (Normal range: 4,000-11,000\ncells/µL)\n\nPlatelet Count: 290,000 cells/µL (Normal range: 150,000-450,000\ncells/µL)\n\nDifferential:\n\nNeutrophils 65%, Lymphocytes 25%, Monocytes 8%, Eosinophils 2%. B.\n\nLiver Function Tests (LFTs):\n\nALT (Alanine Aminotransferase): 40 U/L (Normal range: 7-56 U/L)\n\nAST (Aspartate Aminotransferase): 38 U/L (Normal range: 10-40 U/L)\n\nALP (Alkaline Phosphatase): 90 U/L (Normal range: 44-147 U/L)\n\nTotal Bilirubin: 1.0 mg/dL (Normal range: 0.1-1.2 mg/dL)\n\nAlbumin: 4.2 g/dL (Normal range: 3.4-5.4 g/dL)\n\nAssessment/Recommendations:\n\nGiven her history and the suspicious nature of the new skin changes, we\nhave decided to send the biopsy for urgent histological assessment.\n\nFurthermore, considering her reported symptoms, we have conducted a\nthorough internal check-up, including blood tests and liver function\ntests, to rule out any systemic side effects of the immunotherapy.\n\nWe recommend continuous monitoring of Mrs. Done's condition and kindly\nrequest your valuable input in managing her case optimally. A\nmultidisciplinary approach, given her complicated medical history, will\nbe most beneficial for the patient.\n\nPlease find attached the detailed examination and investigative reports\nfor your reference.\n\nWith kind regards,\n\n\n\n### text_3\n**Dear colleague, **\n\nWe wish to provide a comprehensive update regarding our mutual patient,\nMrs. Jane Done, born on 01.01.1966. She has had a history of various\nmedical conditions and treatments, which we believe is essential to\ndiscuss for her optimal management and was admitted to our clinical from\n01/01/2021 to 01/28/2021.\n\n**Previous Diagnoses and Therapies:**\n\nMetastatic malignant melanoma (presumed ID 2018); M1, stage IV according\nto UICC. Resection of primary tumor (malignant melanoma) on the left\nupper back (02/2018)\n\n01/20 Microsurgical resection right frontal tumor\n\n02/20 Excision of empyema\n\n02-03/20: Radiation therapy\n\n05/02/20: Start of immunotherapy with Nivolumab\n\n05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\nImaging 01/02/2021: PET/CT: Cervical lymph node metastasis;\n\ncMRI: no evidence of metastases. Contrast-enhancing meninges.\n\n**Virology: **\n\nUpon Admission: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load\nof 7,000 Geq/mL and a Ct value of 32.\n\nAt Discharge: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load of\n2,350 Geq/mL and a Ct value of 32.\n\n**Microbiology: **\n\nMRSA Screening Upon Admission: Nasal Swab: Normal flora detected; MRSA\nnot present. Throat Swab: Normal flora detected; MRSA not present.\n\nProcedures:\n\n\\- Presentation to neurology for CSF puncture (e.g., exclude\nmeningeosis)\n\n\\- Panel sequencing complement\n\n\\- Surgery/therapy: Neck dissection followed by adjuvant therapy with\npembrolizumab.\n\nClinical examination:\n\nExamination findings: Patient in normal general and nutritional\ncondition, consciousness unremarkable. Cranial mobility free, ocular\nmobility normal. Pupils are isocor, pupillary reflex prompt to\naccommodation and light. Regular, normocardial heart rate on admission.\nNo typical heart murmurs. Abdomen: abdominal wall soft, liver and spleen\nnot enlarged, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged in the axillary or inguinal region palpable.\n\nPET-CT from 01/02/2021:\n\nIntense metabolically active lymph node metastases, otherwise no\nevidence of vital tumor tissue in the study area.\n\n**PET CT report from 01/02/2021: **\n\nProcedure: PET/CT with 246 MBq (F-18)-fluorodeoxyglucose and a 60-minute\nuptake period.\n\nFindings: CT Findings: Neck: Right Level II: Three lymph nodes, largest\nmeasuring 2.1 x 1.8 cm with central necrosis. Right Level III: Two lymph\nnodes, largest measuring 1.5 x 1.2 cm. Left Level II: One lymph node\nmeasuring 1.3 x 1.1 cm. Left Level IV: Two lymph nodes, largest\nmeasuring 1.7 x 1.4 cm. Retropharyngeal space: One lymph node measuring\n1.0 x 0.9 cm.\n\nPET Findings: Neck: Right Level II: Increased FDG uptake with SUVmax of\n7.8, consistent with metastatic disease. Right Level III: Increased FDG\nuptake with SUVmax of 6.5. Left Level II: Increased FDG uptake with\nSUVmax of 6.0. Left Level IV: Increased FDG uptake with SUVmax of 7.2.\nRetropharyngeal space: Increased FDG uptake with SUVmax of 6.1.\nImpression: Cervical Lymph Nodes: Multiple pathologically enlarged\ncervical lymph nodes in bilateral level II, right level III, left level\nIV, and retropharyngeal space with increased FDG uptake, highly\nsuggestive of metastatic involvement from the known primary melanoma.\n\n**Surgery report 01/05/2021: **\n\nThe surgery commenced with a collaborative discussion with the\nanesthesia team and a standard team time-out was executed. The patient\nwas properly positioned, and the surgical site was aseptically draped.\nThe facial neuromonitoring system was set up and verified. Local\nanesthesia was then administered at the site of the skin incision, which\nwas located near the previous scar. This incision followed the anterior\nborder of the sternocleidomastoid muscle in a curved pattern. Upon\nincising the subcutaneous tissue, the external jugular vein became\nvisible and was selectively ligated. The encountered tissue appeared\nnotably fibrotic and scarred. A skin incision extended from the mastoid\nregion down nearly to the clavicle. The platysma muscle was subsequently\ncut. Due to the presence of a lymph node mass, the auricularis magnus\nnerve had to be severed. The sternocleidomastoid muscle and the\nposterior belly of the digastric muscle were then exposed. Multiple\ndarkened lymph node metastases were identified, both beneath the skin\nand within the sternocleidomastoid muscle. In subsequent steps, efforts\nwere made to distinguish the internal jugular vein from the surrounding\nscarred tissue. A lymph node mass, which exhibited characteristics\nhighly suggestive of metastasis (given its darkened color), was removed.\nThe accessory nerve was identified and preserved. Further dissection was\ndone posteriorly to the sternocleidomastoid muscle, in the direction of\nlevel V. An expansive mass of lymph nodes was excised in this region.\nThe trapezoid branch of the accessory nerve was visualized, and its\nfunction was monitored and preserved with the aid of neuromonitoring.\nThe removed lymph node mass, some excised tissue, and portions of the\nsternocleidomastoid muscle with embedded lymph nodes were sent for\nhistological analysis. During the procedure, care was taken to avoid\ndamaging major neck vessels and nerves. Concluding the procedure, 8 and\n10 French Redon drains were placed, the wound was closed in layers, and\nthen covered with a spray-on bandage, steristrips, and a pressure\ndressing. The surgical site appeared bloodless at the conclusion of the\nsurgery.\n\n**Macroscopy:**\n\n**Macroscopic Description:**\n\nDimensions: 6.8 x 0.7 x 0.4 cm spindle-shaped, non-oriented skin and\nsubcutaneous tissue resection. Central area shows an irritation-free,\nfine scar measuring up to 6.3 x 4.8 cm. The cut surface appears\nconsistently off-white.\n\nInk markings: soft tissue margin of specimen = green. A: central\nlamellae B: spindle tips perpendicular\n\nAnterior Margin of Upper Third of Sternocleidomastoid Muscle:\nDimensions: Four combined tissue samples totaling 4.7 x 3.8 x 1.1 cm.\n\nAppearance: Tan, fibrous soft tissues with multiple uniformly dark\nnodules on the cut surface, each measuring up to 1.1 cm.\n\nA, B: one nodule each halved C, D: other nodular sections E: remaining\ntan fibrous sections Anterior Margin of Lower Third of\nSternocleidomastoid Muscle: Largest measurement: 3.4 cm.\n\nAppearance: Grayish-brown with some fibrous regions and homogeneously\ndark-brown nodes up to 1.5 cm in size on the cut surface. A, B: one node\neach halved C: other nodes D: brown-fibrous sections Region V Occipital:\nLargest measurement: Two samples, each up to 3.8 cm.\n\nAppearance: Mixture of grayish-tan and light brown fibrous soft tissue\nwith nodes up to 2.2 cm, uniformly dark brown.\n\nA, B: one node halved C, D: another node halved each Processing: 16\nparaffin blocks, HE stained.\n\nMicroscopic Description: Dermis and subcutaneous resection shows\nscarring with fibrosis. Epidermis is regular, without any atypical\ncells. No evidence of melanoma or carcinoma. 2./3.\n\nMultiple nodular tumor clusters present in the soft tissue and skeletal\nmuscles, lacking lymph node structure. Tumor cells are polygonal, with\nsome spindle-shaped cells having moderately large, irregular nuclei and\nnoticeable nucleoli. Cytoplasm appears slightly granular with a light\nbrownish pigment.\n\nSeven lymph nodes (measuring up to 3.6 cm) indicate metastasis from the\npreviously mentioned tumor, with extracapsular spread. Four other lymph\nnodes are free from the tumor.\n\n**Critical Findings:** Multiple nodular soft tissue metastases, with the\nlargest measuring 1.3 cm, indicative of melanoma present in both soft\ntissue and muscle. Resection margins are mostly free of tumor, with the\nclosest approach being less than 0.15 cm (points 2 and 3). Seven lymph\nnodes (up to 3.6 cm in size) show metastasis from the melanoma, with\nextracapsular spread. Four lymph nodes are tumor-free (7 out of 11\nnodes, ECE positive) (point 4). Dermis and subcutaneous excision shows\nscarring fibrosis (point 1).\n\nFor the optimal management of Mrs. Done, close monitoring and a\nmultidisciplinary approach will be essential. Thank you for your\ncontinued collaboration in ensuring the best care for our mutual\npatient.\n\n**Lab values upon discharge: **\n\n **Parameter** **Result** **Reference Range** **Interpretation**\n -------------------------------- -------------- ---------------------------------------- ---------------------\n **Complete Blood Count (CBC)** \n Hemoglobin (Hb) 12.4 g/dL 12.0 - 16.0 g/dL Within normal range\n White Blood Cell (WBC) 9.2 x10\\^9/L 4.0 - 10.0 x10\\^9/L Within normal range\n Platelets 250 x10\\^9/L 150 - 400 x10\\^9/L Within normal range\n **Liver Function Tests (LFT)** \n AST 28 U/L 10 - 35 U/L Within normal range\n ALT 32 U/L 10 - 40 U/L Within normal range\n Total Bilirubin 0.8 mg/dL 0.2 - 1.2 mg/dL Within normal range\n **Kidney Function Test** \n Serum Creatinine 0.9 mg/dL 0.5 - 1.2 mg/dL Within normal range\n Blood Urea Nitrogen (BUN) 15 mg/dL 7 - 20 mg/dL Within normal range\n **Electrolytes** \n Sodium 138 mEq/L 135 - 145 mEq/L Within normal range\n Potassium 4.2 mEq/L 3.5 - 5.0 mEq/L Within normal range\n Chloride 101 mEq/L 95 - 105 mEq/L Within normal range\n **Thyroid Function Tests** \n TSH 3.1 mU/L 0.5 - 5.0 mU/L Within normal range\n Free T4 1.4 ng/dL 0.9 - 2.4 ng/dL Within normal range\n **Lipid Profile** \n Total Cholesterol 190 mg/dL \\< 200 mg/dL Desirable\n LDL Cholesterol 100 mg/dL \\< 100 mg/dL Optimal\n HDL Cholesterol 55 mg/dL \\> 40 mg/dL (Men), \\> 50 mg/dL (Women) Normal\n Triglycerides 110 mg/dL \\< 150 mg/dL Normal\n\n**Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ---------------- ------------ ----------- -----------------------------\n Pembrolizumab 200mg IV Every 3 weeks\n Nivolumab 60mg IV As per oncologist\\'s advice\n Ipilimumab 200mg IV As per oncologist\\'s advice\n Paracetamol 500mg Oral Every 4-6 hours as needed\n Omeprazole 20mg Oral Once daily\n\n\n\n### text_4\n**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/14/2022 to\n03/01/2022.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done showed multiple metastases in her CT examination. On physical\nexamination, Mrs. Done appears well-nourished and in no acute distress.\nHer vital signs are stable. Cardiovascular examination reveals regular\nheart sounds with no murmurs. Respiratory examination shows clear breath\nsounds bilaterally. Abdominal examination reveals no palpable masses or\norganomegaly. Neurological examination is within normal limits.\n\n**Radiology/Nuclear Medicine**\n\n**CT thorax/abdomen/pelvis + Contrast from 02/10/2022**\n\n**Technique:** Multi-phase, multi-slice computed tomography of the\nthorax, abdomen, and pelvis was performed following the intravenous\nadministration of contrast material. Coronal and sagittal\nreconstructions were obtained.\n\n**Thorax:** In the thoracic region, the lungs are notable for multiple\nnodular opacities across both lung fields, consistent with metastatic\ndeposits. The most sizable lesion is seen in the right upper lobe,\napproximately 1.5 cm in diameter. No associated cavitation or pleural\neffusion is detected. A concerning 2 cm mass abutting the lateral wall\nof the left ventricle is noted, raising the suspicion for cardiac\nmetastasis. The mediastinum also exhibits lymphadenopathy with a\ndominant node in the prevascular space, measuring 2.2 cm. Further, there\nare lytic lesions involving the sternum and right 4th rib, consistent\nwith osseous metastatic disease.\n\n**Abdomen/pelvis**: Liver shows multiple hypodense lesions throughout\nboth lobes, indicative of metastatic spread. The dominant lesion in the\nright lobe measures 3 cm. The kidneys, however, are unremarkable without\ndiscernible metastatic deposits. Retroperitoneal lymphadenopathy is also\npresent, highlighted by a node anterior to the aorta of 1.8 cm. In\naddition, there is a 2.5 cm mass identified within the left psoas\nmuscle, consistent with muscular metastasis. Both the left acetabulum\nand the right iliac wing manifest with lytic lesions, suggestive of\nmetastatic involvement. There is also enlargement of the bilateral\ninternal iliac lymph nodes, with the left side\\'s node measuring up to\n1.6 cm. Bladder, prostate, and rectum with no discernible pathology.\n\n**Impression**: Multiple pulmonary nodules consistent with pulmonary\nmetastases. Cardiac lesion suggestive of metastatic involvement.\nEvidence of skeletal metastases in the thorax and pelvis. Hepatic and\nmuscular metastases, indicative of disseminated disease. Lymphadenopathy\nin the mediastinal, retroperitoneal, and pelvic regions.\n\n**PET-CT scan from 02/11/2022**\n\n**Clinical Indication:** Follow-up evaluation of a known case of\nMetastatic Melanoma, Stage IV, M1c with notable findings from a CT scan\ndated 12/01/2014.\n\n**Technique:** Whole-body PET-CT scan was conducted after intravenous\nadministration of 18F-FDG. The patient fasted for 6 hours prior to the\nscan, and blood glucose levels were confirmed to be within the\nacceptable range. Both CT and PET images were acquired, and images were\nco-registered for optimal evaluation. Standard uptake values (SUVs) were\ncalculated for areas of interest.\n\n**Findings: **\n\n**Thorax:** Both lungs depict several hypermetabolic foci, corroborating\nthe CT findings of multiple nodules. The largest lesion in the right\nupper lobe demonstrates an SUVmax of 8.2, indicative of active metabolic\ndisease. The cardiac mass adjacent to the left ventricle, measuring\napproximately 2 cm, also reveals increased 18F-FDG uptake with an SUVmax\nof 9.5, strengthening the suspicion of cardiac metastasis. Enlarged\nmediastinal lymph nodes, particularly the node in the prevascular space,\nshows marked hypermetabolism with an SUVmax of 7.4. Notably, the lytic\nskeletal lesions identified on the CT in the sternum and right 4th rib\nalso display increased metabolic activity, consistent with metastatic\nbone disease.\n\n**Abdomen/Pelvis:** Hepatic lesions are congruent with the findings of\nthe preceding CT, showing heightened metabolic activity. The most\nprominent lesion in the right lobe exhibits an SUVmax of 8.8.\nRetroperitoneal lymph nodes are metabolically active, with the anterior\naortic node demonstrating an SUVmax of 6.9. The 2.5 cm left psoas muscle\nmass also reveals increased uptake with an SUVmax of 7.3, suggesting\nactive muscular metastasis. In the pelvic region, the lytic lesions\nidentified in the left acetabulum and right iliac wing on the CT confirm\ntheir malignant nature with notable metabolic activity. Bilateral\ninternal iliac lymph nodes show hypermetabolism with the left node\\'s\nSUVmax reaching 7.1. Other pelvic organs, including the bladder,\nprostate, and rectum, did not show any significant 18F-FDG uptake, in\nline with the unremarkable CT findings.\n\n**Impression:** The PET-CT findings are consistent with active\nmetastatic disease. There is evidence of hypermetabolic pulmonary\nnodules, a likely cardiac metastasis, hepatic and muscular metastases,\nand metabolically active skeletal lesions in both the thorax and pelvis.\nAdditionally, there is hypermetabolism in the lymph nodes across\nmultiple regions. These findings align closely with the previously\ndiagnosed metastatic melanoma, Stage IV, M1c**. **\n\n**Discussion**\n\nMrs. Done has been diagnosed with recurrent metastatic melanoma with\nlymph node involvement. This poses significant implications for her\nprognosis, emphasizing the need for urgent and comprehensive\nintervention.\n\nHer molecular profile has revealed the presence of the BRAF V600E\nmutation.\n\nOur recommended therapeutic combination includes Vemurafenib and\nCobimetinib, both of which are aimed at disrupting the aberrant BRAF-MEK\nsignaling cascade. Complementing this, we suggest the administration of\nPembrolizumab.\n\nMrs. Done is scheduled for six cycles of this treatment regimen. We will\nmonitor her laboratory parameters, such as blood counts, electrolytes,\nand hepatic and renal profiles, bi-weekly. It is imperative to note that\nany fevers surpassing 38.3°C warrant immediate medical attention.\n\nComprehensive patient education module has been designed to enable Mrs.\nDone to identify and manage any potential side effects efficiently.\n\nWe will ensure rigorous monitoring of her blood pressure and lipid\nmetrics, with the possibility of introducing alternative medications if\nclinical scenarios demand.\n\nWe deeply value your collaboration in Mrs. Done\\'s healthcare journey.\nOur team remains at your disposal for any queries or clarifications.\n\n\n\n\n\nHere is the query:\nWhat surgical steps were taken in Mrs. Done during the neck dissection procedure performed on 01/05/2021?\n\nChoose the correct answer from the following options:\nA. The auricularis magnus nerve could be preserved.\nB. The accessory nerve was identified and severed.\nC. The auricularis magnus nerve was severed, the accessory nerve was preserved.\nD. The accessory nerve could not be identified.\nE. The trapezoid branch of the accessory nerve was visualized, but could not be preserved.\n\n\nYour response:\n", "role": "user" }, { "content": "The auricularis magnus nerve was severed, the accessory nerve was preserved.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/18/2018 to\n03/01/2018.\n\n**Diagnoses: **\n\n- Malignant melanoma of the left scapula, TD 16 mm, exophytic\n ulcerating, invasion stage - III, R0\n\n- **Mutation analysis:** BRAF status: mutated. PD-L1 status: PD-L1\n tumor proportion score (TPS): \\<1%. Immune cell infiltrate (IC): 2%\n of tumor area. PD-L1 combined-positive score (CPS): 2.\n\n- **History:** Ms. Done was admitted to the hospital with high grade\n suspicion of malignant melanoma of the back. The patient reported a\n skin lesion that had been present for approximately 4 weeks. The\n lesion had grown rapidly during this time and appeared to be oozing\n and bleeding. She presented to our outpatient clinic, where she was\n advised to undergo surgical excision in case of suspected\n malignancy.\n\n- Questions about B-symptoms, AP complaints, stool or urine\n abnormalities were negated.\n\n- System Therapy (Adjuvant Treatment for Stage III Melanoma): 1\n\n02/22/18: 1st dose pembrolizumab 200mg\n\n03/15/18: 2nd dose Pembrolizumab 200mg\n\n04/05/18: 3rd dose Pembrolizumab 200mg\n\n04/26/18: 4th dose Pembrolizumab 200mg\n\n05/17/18: 5th dose Pembrolizumab 200mg\n\n06/07/18: 6th dose Pembrolizumab 200mg\n\n06/28/18: 7th dose Pembrolizumab 200mg\n\n07/19/18: 8th dose Pembrolizumab 200mg\n\n08/09/18: 9th dose Pembrolizumab 200mg i.v.\n\n**Physical examination findings:** 52-year-old female patient in normal\ngeneral condition, nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement normal. Pupils are equal and\nreactive to light and accommodation. Regular, normocardial heart rate\nduring recording. Cor and pulmo auscultatory and percutaneously\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall, liver\nand spleen not enlarged, no pain to palpation, no resistance to\npalpation, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged cervical, submandibular, supra- and infraclavicular, axillary\nand inguinal lymph nodes palpable. inguinal lymph nodes palpable.\nFurther internal and orienting neurological examination neurological\nexamination remained without pathological findings.\n\n**Skin findings:** In the area of the left scapula, a table tennis-ball\nsized area with a slightly fissured, oozing, pink-black pigmented\nsurface. On the cranial side an irregularly black-brown pigmented macula\nof about 3.2x1.2 cm is visible.\n\n**PET/CT with 203 MBq (F-18)-Fluorodeoxyglucose from 02/18/2018: **\n\nWeight: 66 kg, blood glucose: 118 mg/dL. 20 mg furosemide; acquisition\nstart 91 min after tracer injection; 821 mm scan length á () mm/s in\nflow technique (neck to proximal thigh); oral and i.v. contrast (1.5\nmL/kg, i.v., max. 120 mL). Quantitative analysis of\nattenuation-corrected image data using SUV calculation.\n\n**Findings:**\n\nCT: In case of known contrast agent allergy, premedication was performed\nwith one ampoule each of H1 and H2 antihistamine. The contrast-enhanced\nexamination proceeded without complications during the course.\n\nNeck: Symmetrical visualization of the soft tissues of the neck. No\nevidence of pathologically enlarged cervical lymph nodes. Struma nodosa\nwith several hypodense nodes on the right side up to max. approx. 1 cm.\n\nThorax: Cutaneous/subcutaneous irregular-shaped lesion caudal to the\nright scapula. Limited assessability in the lung window with motion\nartifacts and shallow inspiration depth. As far as assessable, no\nevidence of larger suspicious intrapulmonary pulmonary round foci. No\ninfiltrate. No pleural effusion. No evidence of pathologically enlarged\nlymph nodes mediastinal, hilar and axillary bilaterally.\n\nAbdomen/pelvis: Normal contrast of liver parenchyma without evidence of\nsuspicious focal liver lesions. Portal vein and hepatic veins perfused\nregularly. Gallbladder without irritation. Spleen with accessory spleen,\npancreas and adrenal glands bds. regular. Kidneys perfused at the same\nside. No urinary retention. Nephrolithiasis on the right side.\nVisualization of the parenchymatous upper abdominal organs. No evidence\nof pathologically enlarged coeliacal, mesenteric, retroperitoneal,\niliac, and inguinal lymph nodes. Inhomogeneously contrasted enlarged\nprostate. Urinary bladder wall, as far as assessable with low filling\ncircumferentially wall thickened.\n\nSkeleton: no evidence of suspicious osteodestructive lesions. Osteopenia\nwith degenerative skeletal changes.\n\nPET:\n\nIncreased tracer enhancement of the suspicious lesion caudal to left\nscapula, indicative of a melanoma (SUVmax 67). Focal intense tracer\nenhancement in the right thyroid lobe (SUVmax approximately 7.9).\nElongated intense tracer enhancement in the lower abdomen ventrally\nmedian without clear correlate, most consistent with contamination.\nOtherwise, unremarkable activity distribution in the study area.\n\nAssessment:\n\nNo evidence of metabolically active metastases in the study area.\n\n**Operation report from** **02/22/2018**:\n\nProcedure: Excision of malignant melanoma on the left upper back.\n\nPreoperative Diagnosis: Malignant melanoma, left upper back.\n\nPostoperative Diagnosis: Malignant melanoma, left upper back.\n\nAnesthesia: Local anesthesia using 70 mL tumescent solution comprising\n0.21% Lidocaine/Ropivacaine with epinephrine.\n\nProcedure Details: The surgical area was prepped using Betadine. The\narea was draped in a sterile fashion. Excision of the exophytic tumor\nwas performed, measuring 51 x 20 x 15 mm. A safety margin of 10 mm was\nmaintained in depth, with the excision extending slightly into the\nsubcutaneous tissue but not beyond the fascia. This resulted in a total\ndefect size of 75 x 45 mm. The defect could not be closed with a simple\nprimary suture. Perforator vessels were coagulated, and the defect was\nbridged using skin flaps. Additional resection of Burow triangles was\ndone according to aesthetic units. The wound was closed using an\nintracutaneous suture technique. A continuous overhand blocked suture\nwas used with 3-0 Vicryl. The patient was advised that the visible\nsuture material could be removed between postoperative days 14 and 16. A\ndressing was applied, followed by a pressure dressing to minimize\nswelling and promote healing. Comments: The patient tolerated the\nprocedure well and was provided postoperative care instructions.\n\nPlan: Follow up in clinic for suture removal and wound assessment\nbetween postoperative days 14 and 16.\n\n**Histology Dermatohistology:** **02/23/2018.**\n\n**Gross Examination:** A roughly oval excision specimen measuring 48 x\n36 x 14 mm. The specimen is serially sectioned into lamellar stages A\nthrough H (8 cassettes).\n\n**Microscopic Examination:**\n\nStage A: Displays a benign epidermis and dermis without evidence of\nmelanocytic tumor cells.\n\nStage B: Features an irregularly thickened epidermis. At the center of\nthe section, melanocytic tumor cells are observed at the dermoepidermal\njunction (positive for MelanA stain). Additionally, abundant\nmelanophages and pigment deposits are noted. The lateral safety margin\nmeasures at least 8 mm.\n\nStage C: Resembles stage B. Atypical melanocytic tumor cells are present\nat the dermoepidermal junction. Upper dermis displays fibrosis,\ninflammation, and numerous melanophages (confirmed by positive MelanA\nstaining). The lateral safety margin is at least 6 mm.\n\nStage D: Central region shows melanocytic tumor cells in both the\nepidermis and upper dermis. There is significant inflammation,\nmelanophages, and pigment deposition (confirmed by MelanA staining).\n\nThe maximum lateral safety margin here is approximately 8 mm. A small\nlymph node in the subcutaneous fat tissue is also seen, infiltrated by\nmelanocytic tumor cells.\n\nThe tumor shows stages E, F, G and H: Exophytic, bovist-like growing\nulcerated hemorrhagic tumor consisting of completely pleomorphic tumor\ncells. These cells vary in morphology, appearing both nested and\nspindle-shaped, with clear cytoplasm and conspicuous nucleoli. Notable\npigment production is observed, as are numerous atypical mitoses.\nControl staining in stage F with MelanA is completely positive. The\nsections are entirely excised.\n\n**Diagnosis:** Exophytic, ulcerated malignant melanoma with a tumor\nthickness of at least 15 mm. The tumor invasion is categorized as stage\nIII.\n\n**Medication upon discharge: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ----------------------------------------- --------------- -------------- ------------------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Oral Once daily in the morning\n Enoxaparin (Lovenox) 0.2 mL Subcutaneous In the evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Oral Morning and evening\n Leuprorelin (Lupron Depot) 3.75 mg Depot Subcutaneous Every 4 weeks\n Fentanyl Transdermal System (Duragesic) 12 μg/hr Transdermal Changed every 3 days\n Pantoprazole (Protonix) 40 mg Oral Once daily in the morning\n Sevelamer (Renagel) 800 mg Oral Once daily in the morning\n Multivitamin One tablet Oral Once daily in the morning\n Torsemide (Demadex) 200 mg Oral Once daily in the morning\n Cholecalciferol (Dekristol) 20,000 IU Oral Once weekly\n Sodium Bicarbonate (Bicanorm) One tablet Oral Once daily in the morning\n Calcitriol (Rocaltrol) 0.25 μg Oral Once daily in the morning\n Valacyclovir (Valtrex) 500 mg Oral Half-tablet daily in the morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Oral Mornings on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Oral In the morning on day 1 and day 2 following daratumumab administration\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 10/23/2020 to\n11/01/2020.\n\n- Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\n according to UICC.\n\n- Therapies to date:\n\n- Resection of primary tumor (malignant melanoma) on the left upper\n back (02/2018)\n\n- 01/20 Microsurgical resection right frontal tumor\n\n- 02/20 Excision of empyema\n\n- 02-03/20: Radiation therapy\n\n- 05/02/20: Start of immunotherapy with Nivolumab & 05/26/20: Start of\n combination immunotherapy 60 mg nivolumab, 200 mg ipilimumab (-\\>\n drug exanthema)\n\n**Physical examination findings: **\n\nOn admission, the patient was awake and adequately oriented. Height:\n166cm, weight: 56kg. Nutritional status, consciousness unremarkable.\nCranial mobility free, eye movement regular. Pupils equal, pupillary\nreflex responsive to accommodation and light. Regular, normocardial\nheart rate on admission. Heart and lung: auscultatory and percutaneous\nunremarkable. No typical heart murmurs. Abdomen: Abdominal wall Liver\nand spleen are not enlarged, no tenderness, no rebound palpable.\nResistences palpable, loud bowel sounds. No enlarged No enlarged\ncervical, submandibular, supra- and infraclavicular lymph nodes\npalpable. **Skin findings:** Pronounced xerosis cutis, raised skin\nfolds, some with erythema and fine lamellar scale and fine lamellar\nscale, especially on the arms and face. **Microbiology:** Nasal swab:\nnormal flora, no MRSA. Throat swab: Normal flora, no MRSA Virology:\n10/23/2020: No detection of SARS-CoV-2 by PCR in the submitted material.\n\n**Therapy and Progression:**\n\n**Summary:** The patient presented with exsiccation eczema on the arms,\nlegs, and face.\n\n**Treatment Details:** Topical Treatment for Eczema: Applied Desonide\nCream once daily to the affected areas. For maintenance, applied Eucerin\nCream daily to the body and a moisturizing ointment like Cetaphil to the\nface.\n\n**Antipruritic Treatment:** Prescribed Benadryl tablets, to be taken as\nneeded.\n\n**Oncology Consultation:** The patient was educated by our oncologist,\nDr. Ex, regarding adjuvant therapy options. The potential benefits and\nrisks of a combination immunotherapy with Nivolumab and Ipilimumab were\ndiscussed. The patient had already started Nivolumab 200 mg therapy on\n05/26/2020.\n\n**Incident on 10/28/2020**: The patient had an unattended fall,\nresulting in a hematoma on the left forehead. An emergency CT scan\nshowed no new fractures or acute hemorrhage but confirmed the presence\nof previously known cystic metastasis.\n\n**Operation report (01/02/2020): **\n\n**Diagnosis:** Hemorrhaged right frontal metastasis from previously\ndiagnosed malignant melanoma (ID 2018)\n\n**Procedure:** Microsurgical resection of right frontal mass with\nintraoperative neuromonitoring (MEPs stable) and neuronavigation via a\nleft frontolateral craniotomy.\n\nTime: 10:34 am Closure Time: 1:04 pm. Total Duration: 2 hours 30 minutes\n\n**Preoperative Evaluation:** Imaging identified a hemorrhage in the\nright frontal lobe. Given the patient\\'s history of malignant melanoma,\na hemorrhagic melanoma metastasis was suspected. No other intracranial\nmetastases were detected. The patient and their family were informed of\nthe surgical benefits and risks. After ample time for consideration and\nquestions, written informed consent was obtained.\n\n**Procedure Details:** The patient was positioned supine and intubated.\nThe head was secured in a Mayfield clamp and rotated 60° to the right.\nThe navigation dataset was reviewed. Using the navigation system, a left\nfrontotemporal craniotomy was planned. An arcuate incision line was\ndrawn. The surgical area was shaved, cleaned, and sterilized.\nProphylactic antibiotics and mannitol were administered. A time-out was\nconducted preoperatively. The skin was incised, and Raney clips were\ninserted. The left temporal muscle was split. Using the navigation\nsystem for guidance, a left frontolateral craniotomy was performed. The\nbone flap was carefully removed and preserved in an antibiotic solution\nfor later reimplantation. The dura mater was opened, and the operating\nmicroscope was introduced. Upon inspection, the tumor was evident.\n\n**MRI brain report (01/04/2020): **\n\n**Clinical Information:** Postoperative assessment following\nmicrosurgical resection of a left frontal hemorrhaged metastasis from\npreviously diagnosed malignant melanoma.\n\n**Technique:** Multiplanar, multisequence MRI of the brain, including\nT1-weighted, T2-weighted, FLAIR, diffusion-weighted imaging (DWI), and\npost-contrast T1-weighted sequences.\n\n**Findings:** There is evidence of a right frontotemporal craniotomy\nwith associated post-surgical changes in the right frontal region.\nTitanium plates and screws are noted securing the bone flap, causing\nminimal artifact. The previous tumor site in the right frontal lobe\nshows post-surgical changes with a well-circumscribed cavity. There is\nno evidence of residual enhancing tumor within this cavity on\npost-contrast sequences, suggesting complete resection. Surrounding this\ncavity, there\\'s mild edema, consistent with expected post-operative\nchanges. No other intracranial metastases. The ventricles are of normal\nsize and symmetric. There is no evidence of hydrocephalus. No midline\nshift or mass effect is observed. There are scattered foci of\nsusceptibility artifact in the surgical bed on gradient echo sequences,\nconsistent with expected postoperative blood products. Major\nintracranial vessels appear patent with no evidence of vascular\nocclusion or significant stenosis. The remaining brain parenchyma\nappears normal in signal intensity and morphology on all sequences. No\nother significant abnormalities are identified.\n\n**Impression:** Post-surgical changes in the left frontal lobe\nconsistent with recent tumor resection. There is no evidence of residual\ntumor in the surgical bed. Expected postoperative edema and blood\nproducts adjacent to the resection site. No new metastatic foci\nidentified. No evidence of complications such as hydrocephalus, midline\nshift, or vascular abnormalities.\n\n**Operation report (02/04/2020): **\n\n**Diagnosis:** Subfascial, epidural, and subdural empyema following\nresection of right frontal metastasis for malignant melanoma.\n\n**Procedure:** Empyema removal (subfascial, epidural, subdural) S\nIncision Time: 15:23 Closure Time: 04:01 PM Total Duration: 2 hours 31\nminutes\n\n**Preoperative Evaluation:** The patient had a prior surgical resection\nof a right frontal metastasis due to known malignant melanoma. On a\nrecent outpatient visit, a cerebrospinal fluid (CSF) cushion was\nidentified and punctured, revealing the presence of pathogens. Imaging\nindicated deep and subcutaneous abscesses, necessitating revision\nsurgery. The patient was adequately informed about the procedure,\nunderstood the associated risks, and provided written consent.\n\n**Procedure Details:** The patient was positioned supine with the head\nrotated approximately 60° in a Mayfield clamp. The surgical area was\nwashed and sterilized, focusing on the pre-existing access point. A team\ntime-out was conducted. Perioperative antibiotics were withheld until\nall samples for microbiology were obtained. The skin was incised,\nrevealing multiple layers of muscle. These were carefully dissected,\nleading to the identification and evacuation of the subcutaneous\nepifascial abscess. Infected muscle tissue and abscess walls were\nresected. The skull flap appeared loosened. A miniplate was removed, and\nupon further inspection, the dura mater appeared strained. It was\nincised and revealed turbid fluid, indicating a deep abscess. The dura\nmater was mobilized, though adherence to the cortex was observed around\nthe resection cavity, suggesting possible tumor regrowth. Affected areas\nwere carefully resected. After thorough irrigation, a drainage system\nwas inserted into the resection cavity. A duraplasty was performed,\nfollowed by the reimplantation of the bone flap using a miniplate. The\npatient was also included in a bone flap study and was randomized for\nflap reimplantation. After further irrigation, the wound was\nmeticulously closed, and a subfascial drain was inserted. The final\nclosure was completed with single button sutures. Under the guidance of\nthe operating microscope, the tumor was meticulously dissected from the\nsurrounding healthy tissue. Special care was taken to minimize damage to\nthe surrounding brain structures. The intraoperative neuromonitoring\nindicated stable MEPs throughout, suggesting that motor pathways\nremained undisturbed during the procedure. Throughout the resection,\nperiodic hemostasis was achieved using bipolar electrocautery to control\nbleeding. Following the complete resection of the tumor, the surgical\ncavity was irrigated with sterile saline to remove any residual debris.\nThe integrity of the surrounding brain tissue was assessed, and no\nimmediate complications were observed. The dura mater was sutured,\nensuring a watertight closure. A synthetic dural graft was used to\nreinforce the suture line. The preserved bone flap was reimplanted and\nsecured in place using titanium plates and screws. The temporal muscle\nand soft tissues were reapproximated and sutured in layers. The skin was\nclosed using a combination of absorbable sutures for the subcutaneous\nlayer and non-absorbable sutures for the skin. Sterile dressings were\napplied to the incision site. Postoperative Assessment: The procedure\nwas completed without complications. Immediate postoperative\nneurological examination revealed no new deficits. The patient was\ntransferred to the recovery room in stable condition, awaiting\nextubation by the anesthesiology team.\n\n**Recommendations:** Close monitoring in the neurological intensive care\nunit (NICU) is advised for the first 24 hours. Postoperative imaging,\ntypically an MRI, should be scheduled within the next 48 hours to assess\nthe extent of tumor resection and to rule out any postoperative\ncomplications.\n\n**Summary:** Mrs. Done\\'s recent hospital course was complicated by the\ndetection and subsequent excision of a hemorrhagic metastasis from a\nknown history of malignant melanoma. She continues to be on targeted\ntherapy with close monitoring. No new metastasis or recurrence has been\ndetected as of the last evaluation. The interdisciplinary approach\ninvolving the neurosurgery and oncology teams has been pivotal in her\nmanagement. Given the aggressive nature of melanoma, regular\nsurveillance and immediate action upon detection of new\nlesions/metastasis are paramount for her prognosis.\n\n**02-03/20: Radiation therapy **\n\nDiagnosis: Metastatic malignant melanoma with a focus on the right\nfrontal metastasis. Technique: Stereotactic radiosurgery (SRS) using a\nlinear accelerator (LINAC). Fractionation: Given the aggressive nature\nof malignant melanoma, a hypofractionated regimen was adopted. The\npatient underwent five sessions, each delivering a dose of 6 Gy for a\ncumulative total dose of 30 Gy.\n\nTreatment Planning: A simulation CT scan with a 1mm slice thickness was\nperformed in the treatment position, with a thermoplastic mask for\nimmobilization. The treatment planning system utilized the simulation\nCT, along with MRI for better tumor delineation. The target volume and\ncritical structures like the eyes, optic nerves, chiasm, and brainstem\nwere contoured. The radiation plan was optimized to ensure maximal dose\nto the target while sparing the critical structures.\n\nProcedure: At each session, patient positioning was verified using\ncone-beam CT (CBCT) to ensure precise targeting. Real-time monitoring\nwas employed to account for any intrafraction motion.\n\nSide Effects: The patient tolerated the treatment well. She reported\ntransient fatigue and mild scalp irritation, which resolved with\nconservative measures. No acute radiation-induced neurotoxicity was\nobserved.\n\n**Patient History Update: Mrs. Jane Done (DOB: 01/01/1966)**\n\n**General Status (10/03/2020):**\n\nMrs. Done presented in stable condition with stable vital signs.\nNeurologically, she\\'s intact with no new focal deficits. The surgical\nscars in the frontal region from previous operations are not fully\nhealed and there is some dehiscence and swelling, indicative of\ninfection. This wound complication can be traced back to her previous\nhistory of an empyema which required surgical intervention.\n\n**Dermatological Assessment:**\n\nThe previous exsiccation eczema, prominent on her arms, legs, and face,\nhas improved markedly. The treatment regimen involving consistent\nmoisturization and targeted topical therapies seems effective.\nImportantly, there were no new suspicious skin lesions or nodules noted\nduring her most recent full-body skin check.\n\n**Oncology Status:**\n\nMrs. Done remains on her immunotherapy regimen, specifically the\ncombination of Nivolumab and Ipilimumab. Her response has been positive,\nwith no new metastatic sites identified in the latest assessments. She\nhas displayed commendable compliance with this regimen and regular\nfollow-up evaluations.\n\n**Recent MRI Brain (09/30/2020):**\n\nHer latest multiplanar, multisequence MRI revealed post-surgical\nalterations in the right frontal lobe, consistent with previous\nobservations. Encouragingly, there was no sign of any residual or\nrecurrent tumor activity. Moreover, the MRI did not show any new\nintracranial metastatic sites or other significant abnormalities.\n\n**Thoracic CT Scan (10/01/2020): **\n\nTechnique: Post complication-free bolus i.v. administration of Imeron\n400, a multiline spiral CT was performed through the thorax during the\nvenous contrast phase, supplemented with thin-section, coronary, and\nsagittal secondary reconstructions.\n\nFindings: Multiple roundish subsolid nodules found bipulmonary, notably\na 4mm nodule in the right upper lobe. Blurred subpleural condensations\nin the left upper lobe. Another blurred bronchus-associated\nconsolidation was observed in the left upper lobe and pleurally in the\nleft dorsal lower lobe. No evidence of pathologically enlarged lymph\nnodes in the hilar, mediastinal, or axillary regions. Unchanged\npresentation of the left adrenal gland from the preliminary examination.\nThickened imprinting of the gastric wall noted. Ventrally emphasized\nspondylophytic attachments observed in the thoracic spine. No\nosteodestructive processes detected.\n\n**Impression:** Presence of multiple subsolid pulmonary nodules;\nrecommended follow-up in 4-6 weeks for potential (post-) inflammatory or\nmalignant genesis. No evidence of pathologically enlarged lymph nodes.\n\n**Abdomen/Pelvis CT Scan (10/01/2023): **\n\nTechnique: A low dose CT scan was taken of the abdomen and pelvis.\n\n**Findings:** Regular visualization of the acquired basal lung sections.\nOrthotopic kidneys without urinary stasis. No evidence of urinary\ncalculi. Suspected uterine fibroids attached to the uterus wall.\nEnlarged right ovary with minor calcifications. Assessment: Absence of\nurinary calculi. Possible uterine fibroids and an enlarged right ovary,\nsuggesting a specialized gynecological examination.\n\n**PICC Line Installation (10/02/2020)**\n\n**Diagnosis:**\n\nHome antibiotics required for wound healing disorder following discharge\ndue to an empyema.\n\n**Type of Surgery:**\n\nInstallation of a PICC line in the left basilic vein.\n\n**Anesthesia:**\n\nLocal anesthesia\n\n**Procedure Details:**\n\nThe patient was presented for long-term antibiotic treatment due to a\nwound healing disturbance post the discharge of an epidural abscess. The\nprimary aim was to apply a PICC-line catheter for the antibiotic\nregimen. A written informed consent was duly obtained prior to the\nprocedure.\n\nThe standard procedure began with the washing off and draping of the\npatient. A preoperative sonography of the arm veins was conducted. Based\non the sonographic results, it was decided to insert the catheter via\nthe left basilica vein.\n\nUnder venous congestion and following local anesthesia with 2mL Mecain,\na 2mm skin incision was made. The sonographically guided puncture was\nperformed successfully. Post this, the peel-away sheath was inserted.\nWith the wire in place, the catheter was advanced with its tip\npositioned approximately 2cm below the carina. The wire was subsequently\nremoved. Following this, the catheter was aspirated and flushed with\nNaCl to ensure its patency. A sterile fixation was then applied, and the\nwound was dressed.\n\n**Notes:**\n\nNo complications were observed during the procedure. The patient was\nadvised on the care and maintenance of the PICC line. Regular follow-ups\nare recommended to monitor the wound healing and the effectiveness of\nthe antibiotic treatment.\n\nThe patient was discharged with instructions and is scheduled for a\nfollow-up in two weeks.\n\n**Additional Therapeutic Engagements:**\n\nFor her overall well-being and to counter the side effects of her\ntreatment journey, Mrs. Done has been actively involved in physical\ntherapy sessions. These sessions focus on enhancing her strength and\nbalance, especially given the previous incident of an unattended fall.\nTo address the inevitable psychological strains of her diagnosis, she\nhas also been attending counseling sessions.\n\n**Current Recommendations:**\n\n-Continue the ongoing immunotherapy without changes.\n\n-Dermatological check-ups every month are advised for early detection of\nany potential skin abnormalities.\n\n-Regular neurological evaluations are crucial to ensure no emergence of\nnew deficits.\n\n-Imaging should be scheduled every six months for proactive monitoring.\n\n-Her physical therapy regimen should be ongoing to maintain and improve\nmobility.\n\n-Continue counseling to support her emotional and psychological\nwell-being.\n\n**Summary and Notes:**\n\nMrs. Done\\'s resilience and adherence to her treatments are commendable.\nHer progress is a testament to the integrated care approach she has been\nreceiving. Maintaining a proactive surveillance stance will be essential\nfor her long-term prognosis and quality of life.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding our mutual patient, Mrs. Jane\nDone, born on 01.01.1966. She was admitted to our clinic from 11/23/2020\nto 12/01/2020.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done presented for a follow-up visit on 11/23/2020. Over the past\nfew months, she reported fatigue and intermittent bouts of nausea. Of\nsignificant concern were newly identified skin changes located on her\nright arm.\n\n**Clinical Findings:**\n\nSkin: Multiple macules and patches on the right arm, the largest\nmeasuring about 1.5cm in diameter, hyperpigmented with irregular\nborders.\n\n**US: **\n\nUltrasound imaging of the right arm revealed no deep extension or\ninvasion of underlying structures. This preliminary assessment was\ncrucial, suggesting that if malignancy is present, it might be in early\nstages.\n\n**Histology: **\n\nHistological examination: Gross Description: The sample consists of\nmultiple tan-pink soft tissue fragments, aggregating to 1.8 cm in the\ngreatest dimension.\n\nMicroscopic description: Sections show a proliferation of atypical\nmelanocytes arranged in nests and as single units at the dermoepidermal\njunction. Some of these cells infiltrate the papillary dermis.\n\nImmunohistochemistry: The atypical cells are positive for HMB-45 and\nS-100. Melan A is focally positive. Ki-67 proliferation index is about\n10%.\n\nFinal Diagnosis: Dysplastic nevus with severe atypia; margins appear\nclear. Further excision is recommended to ensure complete removal and to\nrule out invasive melanoma.\n\n**Lab results: **\n\nComplete Blood Count (CBC):\n\nHemoglobin: 12.3 g/dL (Normal range: 12-16 g/dL)\n\nWhite Blood Cell Count: 6,200 cells/µL (Normal range: 4,000-11,000\ncells/µL)\n\nPlatelet Count: 290,000 cells/µL (Normal range: 150,000-450,000\ncells/µL)\n\nDifferential:\n\nNeutrophils 65%, Lymphocytes 25%, Monocytes 8%, Eosinophils 2%. B.\n\nLiver Function Tests (LFTs):\n\nALT (Alanine Aminotransferase): 40 U/L (Normal range: 7-56 U/L)\n\nAST (Aspartate Aminotransferase): 38 U/L (Normal range: 10-40 U/L)\n\nALP (Alkaline Phosphatase): 90 U/L (Normal range: 44-147 U/L)\n\nTotal Bilirubin: 1.0 mg/dL (Normal range: 0.1-1.2 mg/dL)\n\nAlbumin: 4.2 g/dL (Normal range: 3.4-5.4 g/dL)\n\nAssessment/Recommendations:\n\nGiven her history and the suspicious nature of the new skin changes, we\nhave decided to send the biopsy for urgent histological assessment.\n\nFurthermore, considering her reported symptoms, we have conducted a\nthorough internal check-up, including blood tests and liver function\ntests, to rule out any systemic side effects of the immunotherapy.\n\nWe recommend continuous monitoring of Mrs. Done's condition and kindly\nrequest your valuable input in managing her case optimally. A\nmultidisciplinary approach, given her complicated medical history, will\nbe most beneficial for the patient.\n\nPlease find attached the detailed examination and investigative reports\nfor your reference.\n\nWith kind regards,\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe wish to provide a comprehensive update regarding our mutual patient,\nMrs. Jane Done, born on 01.01.1966. She has had a history of various\nmedical conditions and treatments, which we believe is essential to\ndiscuss for her optimal management and was admitted to our clinical from\n01/01/2021 to 01/28/2021.\n\n**Previous Diagnoses and Therapies:**\n\nMetastatic malignant melanoma (presumed ID 2018); M1, stage IV according\nto UICC. Resection of primary tumor (malignant melanoma) on the left\nupper back (02/2018)\n\n01/20 Microsurgical resection right frontal tumor\n\n02/20 Excision of empyema\n\n02-03/20: Radiation therapy\n\n05/02/20: Start of immunotherapy with Nivolumab\n\n05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\nImaging 01/02/2021: PET/CT: Cervical lymph node metastasis;\n\ncMRI: no evidence of metastases. Contrast-enhancing meninges.\n\n**Virology: **\n\nUpon Admission: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load\nof 7,000 Geq/mL and a Ct value of 32.\n\nAt Discharge: SARS-CoV2 PCR (Nose/Throat): POSITIVE with a viral load of\n2,350 Geq/mL and a Ct value of 32.\n\n**Microbiology: **\n\nMRSA Screening Upon Admission: Nasal Swab: Normal flora detected; MRSA\nnot present. Throat Swab: Normal flora detected; MRSA not present.\n\nProcedures:\n\n\\- Presentation to neurology for CSF puncture (e.g., exclude\nmeningeosis)\n\n\\- Panel sequencing complement\n\n\\- Surgery/therapy: Neck dissection followed by adjuvant therapy with\npembrolizumab.\n\nClinical examination:\n\nExamination findings: Patient in normal general and nutritional\ncondition, consciousness unremarkable. Cranial mobility free, ocular\nmobility normal. Pupils are isocor, pupillary reflex prompt to\naccommodation and light. Regular, normocardial heart rate on admission.\nNo typical heart murmurs. Abdomen: abdominal wall soft, liver and spleen\nnot enlarged, vivid bowel sounds. Renal bed and spine not palpable. No\nenlarged in the axillary or inguinal region palpable.\n\nPET-CT from 01/02/2021:\n\nIntense metabolically active lymph node metastases, otherwise no\nevidence of vital tumor tissue in the study area.\n\n**PET CT report from 01/02/2021: **\n\nProcedure: PET/CT with 246 MBq (F-18)-fluorodeoxyglucose and a 60-minute\nuptake period.\n\nFindings: CT Findings: Neck: Right Level II: Three lymph nodes, largest\nmeasuring 2.1 x 1.8 cm with central necrosis. Right Level III: Two lymph\nnodes, largest measuring 1.5 x 1.2 cm. Left Level II: One lymph node\nmeasuring 1.3 x 1.1 cm. Left Level IV: Two lymph nodes, largest\nmeasuring 1.7 x 1.4 cm. Retropharyngeal space: One lymph node measuring\n1.0 x 0.9 cm.\n\nPET Findings: Neck: Right Level II: Increased FDG uptake with SUVmax of\n7.8, consistent with metastatic disease. Right Level III: Increased FDG\nuptake with SUVmax of 6.5. Left Level II: Increased FDG uptake with\nSUVmax of 6.0. Left Level IV: Increased FDG uptake with SUVmax of 7.2.\nRetropharyngeal space: Increased FDG uptake with SUVmax of 6.1.\nImpression: Cervical Lymph Nodes: Multiple pathologically enlarged\ncervical lymph nodes in bilateral level II, right level III, left level\nIV, and retropharyngeal space with increased FDG uptake, highly\nsuggestive of metastatic involvement from the known primary melanoma.\n\n**Surgery report 01/05/2021: **\n\nThe surgery commenced with a collaborative discussion with the\nanesthesia team and a standard team time-out was executed. The patient\nwas properly positioned, and the surgical site was aseptically draped.\nThe facial neuromonitoring system was set up and verified. Local\nanesthesia was then administered at the site of the skin incision, which\nwas located near the previous scar. This incision followed the anterior\nborder of the sternocleidomastoid muscle in a curved pattern. Upon\nincising the subcutaneous tissue, the external jugular vein became\nvisible and was selectively ligated. The encountered tissue appeared\nnotably fibrotic and scarred. A skin incision extended from the mastoid\nregion down nearly to the clavicle. The platysma muscle was subsequently\ncut. Due to the presence of a lymph node mass, the auricularis magnus\nnerve had to be severed. The sternocleidomastoid muscle and the\nposterior belly of the digastric muscle were then exposed. Multiple\ndarkened lymph node metastases were identified, both beneath the skin\nand within the sternocleidomastoid muscle. In subsequent steps, efforts\nwere made to distinguish the internal jugular vein from the surrounding\nscarred tissue. A lymph node mass, which exhibited characteristics\nhighly suggestive of metastasis (given its darkened color), was removed.\nThe accessory nerve was identified and preserved. Further dissection was\ndone posteriorly to the sternocleidomastoid muscle, in the direction of\nlevel V. An expansive mass of lymph nodes was excised in this region.\nThe trapezoid branch of the accessory nerve was visualized, and its\nfunction was monitored and preserved with the aid of neuromonitoring.\nThe removed lymph node mass, some excised tissue, and portions of the\nsternocleidomastoid muscle with embedded lymph nodes were sent for\nhistological analysis. During the procedure, care was taken to avoid\ndamaging major neck vessels and nerves. Concluding the procedure, 8 and\n10 French Redon drains were placed, the wound was closed in layers, and\nthen covered with a spray-on bandage, steristrips, and a pressure\ndressing. The surgical site appeared bloodless at the conclusion of the\nsurgery.\n\n**Macroscopy:**\n\n**Macroscopic Description:**\n\nDimensions: 6.8 x 0.7 x 0.4 cm spindle-shaped, non-oriented skin and\nsubcutaneous tissue resection. Central area shows an irritation-free,\nfine scar measuring up to 6.3 x 4.8 cm. The cut surface appears\nconsistently off-white.\n\nInk markings: soft tissue margin of specimen = green. A: central\nlamellae B: spindle tips perpendicular\n\nAnterior Margin of Upper Third of Sternocleidomastoid Muscle:\nDimensions: Four combined tissue samples totaling 4.7 x 3.8 x 1.1 cm.\n\nAppearance: Tan, fibrous soft tissues with multiple uniformly dark\nnodules on the cut surface, each measuring up to 1.1 cm.\n\nA, B: one nodule each halved C, D: other nodular sections E: remaining\ntan fibrous sections Anterior Margin of Lower Third of\nSternocleidomastoid Muscle: Largest measurement: 3.4 cm.\n\nAppearance: Grayish-brown with some fibrous regions and homogeneously\ndark-brown nodes up to 1.5 cm in size on the cut surface. A, B: one node\neach halved C: other nodes D: brown-fibrous sections Region V Occipital:\nLargest measurement: Two samples, each up to 3.8 cm.\n\nAppearance: Mixture of grayish-tan and light brown fibrous soft tissue\nwith nodes up to 2.2 cm, uniformly dark brown.\n\nA, B: one node halved C, D: another node halved each Processing: 16\nparaffin blocks, HE stained.\n\nMicroscopic Description: Dermis and subcutaneous resection shows\nscarring with fibrosis. Epidermis is regular, without any atypical\ncells. No evidence of melanoma or carcinoma. 2./3.\n\nMultiple nodular tumor clusters present in the soft tissue and skeletal\nmuscles, lacking lymph node structure. Tumor cells are polygonal, with\nsome spindle-shaped cells having moderately large, irregular nuclei and\nnoticeable nucleoli. Cytoplasm appears slightly granular with a light\nbrownish pigment.\n\nSeven lymph nodes (measuring up to 3.6 cm) indicate metastasis from the\npreviously mentioned tumor, with extracapsular spread. Four other lymph\nnodes are free from the tumor.\n\n**Critical Findings:** Multiple nodular soft tissue metastases, with the\nlargest measuring 1.3 cm, indicative of melanoma present in both soft\ntissue and muscle. Resection margins are mostly free of tumor, with the\nclosest approach being less than 0.15 cm (points 2 and 3). Seven lymph\nnodes (up to 3.6 cm in size) show metastasis from the melanoma, with\nextracapsular spread. Four lymph nodes are tumor-free (7 out of 11\nnodes, ECE positive) (point 4). Dermis and subcutaneous excision shows\nscarring fibrosis (point 1).\n\nFor the optimal management of Mrs. Done, close monitoring and a\nmultidisciplinary approach will be essential. Thank you for your\ncontinued collaboration in ensuring the best care for our mutual\npatient.\n\n**Lab values upon discharge: **\n\n **Parameter** **Result** **Reference Range** **Interpretation**\n -------------------------------- -------------- ---------------------------------------- ---------------------\n **Complete Blood Count (CBC)** \n Hemoglobin (Hb) 12.4 g/dL 12.0 - 16.0 g/dL Within normal range\n White Blood Cell (WBC) 9.2 x10\\^9/L 4.0 - 10.0 x10\\^9/L Within normal range\n Platelets 250 x10\\^9/L 150 - 400 x10\\^9/L Within normal range\n **Liver Function Tests (LFT)** \n AST 28 U/L 10 - 35 U/L Within normal range\n ALT 32 U/L 10 - 40 U/L Within normal range\n Total Bilirubin 0.8 mg/dL 0.2 - 1.2 mg/dL Within normal range\n **Kidney Function Test** \n Serum Creatinine 0.9 mg/dL 0.5 - 1.2 mg/dL Within normal range\n Blood Urea Nitrogen (BUN) 15 mg/dL 7 - 20 mg/dL Within normal range\n **Electrolytes** \n Sodium 138 mEq/L 135 - 145 mEq/L Within normal range\n Potassium 4.2 mEq/L 3.5 - 5.0 mEq/L Within normal range\n Chloride 101 mEq/L 95 - 105 mEq/L Within normal range\n **Thyroid Function Tests** \n TSH 3.1 mU/L 0.5 - 5.0 mU/L Within normal range\n Free T4 1.4 ng/dL 0.9 - 2.4 ng/dL Within normal range\n **Lipid Profile** \n Total Cholesterol 190 mg/dL \\< 200 mg/dL Desirable\n LDL Cholesterol 100 mg/dL \\< 100 mg/dL Optimal\n HDL Cholesterol 55 mg/dL \\> 40 mg/dL (Men), \\> 50 mg/dL (Women) Normal\n Triglycerides 110 mg/dL \\< 150 mg/dL Normal\n\n**Medication: **\n\n **Medication** **Dosage** **Route** **Frequency**\n ---------------- ------------ ----------- -----------------------------\n Pembrolizumab 200mg IV Every 3 weeks\n Nivolumab 60mg IV As per oncologist\\'s advice\n Ipilimumab 200mg IV As per oncologist\\'s advice\n Paracetamol 500mg Oral Every 4-6 hours as needed\n Omeprazole 20mg Oral Once daily\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe wish to provide an update regarding Mrs. Jane Done, born on\n01.01.1966. She was admitted to our clinic from 02/14/2022 to\n03/01/2022.\n\n**Previous Diagnoses and Therapies:**\n\n-Metastatic malignant melanoma (presumed ID 2018); M1, stage IV\naccording to UICC.\n\n-Resection of primary tumor (malignant melanoma) on the left upper back\n(02/2018)\n\n-01/20 Microsurgical resection right frontal tumor\n\n-02/20 Excision of empyema\n\n-02-03/20: Radiation therapy\n\n-05/02/20: Start of immunotherapy with Nivolumab\n\n-05/26/20: Start of combination immunotherapy 60 mg nivolumab, 200 mg\nipilimumab (resulting in drug exanthema)\n\n**Current Presentation:**\n\nMrs. Done showed multiple metastases in her CT examination. On physical\nexamination, Mrs. Done appears well-nourished and in no acute distress.\nHer vital signs are stable. Cardiovascular examination reveals regular\nheart sounds with no murmurs. Respiratory examination shows clear breath\nsounds bilaterally. Abdominal examination reveals no palpable masses or\norganomegaly. Neurological examination is within normal limits.\n\n**Radiology/Nuclear Medicine**\n\n**CT thorax/abdomen/pelvis + Contrast from 02/10/2022**\n\n**Technique:** Multi-phase, multi-slice computed tomography of the\nthorax, abdomen, and pelvis was performed following the intravenous\nadministration of contrast material. Coronal and sagittal\nreconstructions were obtained.\n\n**Thorax:** In the thoracic region, the lungs are notable for multiple\nnodular opacities across both lung fields, consistent with metastatic\ndeposits. The most sizable lesion is seen in the right upper lobe,\napproximately 1.5 cm in diameter. No associated cavitation or pleural\neffusion is detected. A concerning 2 cm mass abutting the lateral wall\nof the left ventricle is noted, raising the suspicion for cardiac\nmetastasis. The mediastinum also exhibits lymphadenopathy with a\ndominant node in the prevascular space, measuring 2.2 cm. Further, there\nare lytic lesions involving the sternum and right 4th rib, consistent\nwith osseous metastatic disease.\n\n**Abdomen/pelvis**: Liver shows multiple hypodense lesions throughout\nboth lobes, indicative of metastatic spread. The dominant lesion in the\nright lobe measures 3 cm. The kidneys, however, are unremarkable without\ndiscernible metastatic deposits. Retroperitoneal lymphadenopathy is also\npresent, highlighted by a node anterior to the aorta of 1.8 cm. In\naddition, there is a 2.5 cm mass identified within the left psoas\nmuscle, consistent with muscular metastasis. Both the left acetabulum\nand the right iliac wing manifest with lytic lesions, suggestive of\nmetastatic involvement. There is also enlargement of the bilateral\ninternal iliac lymph nodes, with the left side\\'s node measuring up to\n1.6 cm. Bladder, prostate, and rectum with no discernible pathology.\n\n**Impression**: Multiple pulmonary nodules consistent with pulmonary\nmetastases. Cardiac lesion suggestive of metastatic involvement.\nEvidence of skeletal metastases in the thorax and pelvis. Hepatic and\nmuscular metastases, indicative of disseminated disease. Lymphadenopathy\nin the mediastinal, retroperitoneal, and pelvic regions.\n\n**PET-CT scan from 02/11/2022**\n\n**Clinical Indication:** Follow-up evaluation of a known case of\nMetastatic Melanoma, Stage IV, M1c with notable findings from a CT scan\ndated 12/01/2014.\n\n**Technique:** Whole-body PET-CT scan was conducted after intravenous\nadministration of 18F-FDG. The patient fasted for 6 hours prior to the\nscan, and blood glucose levels were confirmed to be within the\nacceptable range. Both CT and PET images were acquired, and images were\nco-registered for optimal evaluation. Standard uptake values (SUVs) were\ncalculated for areas of interest.\n\n**Findings: **\n\n**Thorax:** Both lungs depict several hypermetabolic foci, corroborating\nthe CT findings of multiple nodules. The largest lesion in the right\nupper lobe demonstrates an SUVmax of 8.2, indicative of active metabolic\ndisease. The cardiac mass adjacent to the left ventricle, measuring\napproximately 2 cm, also reveals increased 18F-FDG uptake with an SUVmax\nof 9.5, strengthening the suspicion of cardiac metastasis. Enlarged\nmediastinal lymph nodes, particularly the node in the prevascular space,\nshows marked hypermetabolism with an SUVmax of 7.4. Notably, the lytic\nskeletal lesions identified on the CT in the sternum and right 4th rib\nalso display increased metabolic activity, consistent with metastatic\nbone disease.\n\n**Abdomen/Pelvis:** Hepatic lesions are congruent with the findings of\nthe preceding CT, showing heightened metabolic activity. The most\nprominent lesion in the right lobe exhibits an SUVmax of 8.8.\nRetroperitoneal lymph nodes are metabolically active, with the anterior\naortic node demonstrating an SUVmax of 6.9. The 2.5 cm left psoas muscle\nmass also reveals increased uptake with an SUVmax of 7.3, suggesting\nactive muscular metastasis. In the pelvic region, the lytic lesions\nidentified in the left acetabulum and right iliac wing on the CT confirm\ntheir malignant nature with notable metabolic activity. Bilateral\ninternal iliac lymph nodes show hypermetabolism with the left node\\'s\nSUVmax reaching 7.1. Other pelvic organs, including the bladder,\nprostate, and rectum, did not show any significant 18F-FDG uptake, in\nline with the unremarkable CT findings.\n\n**Impression:** The PET-CT findings are consistent with active\nmetastatic disease. There is evidence of hypermetabolic pulmonary\nnodules, a likely cardiac metastasis, hepatic and muscular metastases,\nand metabolically active skeletal lesions in both the thorax and pelvis.\nAdditionally, there is hypermetabolism in the lymph nodes across\nmultiple regions. These findings align closely with the previously\ndiagnosed metastatic melanoma, Stage IV, M1c**. **\n\n**Discussion**\n\nMrs. Done has been diagnosed with recurrent metastatic melanoma with\nlymph node involvement. This poses significant implications for her\nprognosis, emphasizing the need for urgent and comprehensive\nintervention.\n\nHer molecular profile has revealed the presence of the BRAF V600E\nmutation.\n\nOur recommended therapeutic combination includes Vemurafenib and\nCobimetinib, both of which are aimed at disrupting the aberrant BRAF-MEK\nsignaling cascade. Complementing this, we suggest the administration of\nPembrolizumab.\n\nMrs. Done is scheduled for six cycles of this treatment regimen. We will\nmonitor her laboratory parameters, such as blood counts, electrolytes,\nand hepatic and renal profiles, bi-weekly. It is imperative to note that\nany fevers surpassing 38.3°C warrant immediate medical attention.\n\nComprehensive patient education module has been designed to enable Mrs.\nDone to identify and manage any potential side effects efficiently.\n\nWe will ensure rigorous monitoring of her blood pressure and lipid\nmetrics, with the possibility of introducing alternative medications if\nclinical scenarios demand.\n\nWe deeply value your collaboration in Mrs. Done\\'s healthcare journey.\nOur team remains at your disposal for any queries or clarifications.\n\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was under our inpatient care from 03/25/2016 to\n03/30/2016.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- Uncomplicated biopsy, pending results\n\n- LifeVest has been adjusted\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Medical History:** The patient was admitted with suspected myocarditis\ndue to a significantly impaired pump function noticed during outpatient\nvisits. Anamnestically, the patient reported experiencing fatigue and\nexertional dyspnea since mid-December, with no recollection of a\npreceding infection. Antiviral therapy with Interferon/Ribavirin for\nchronic Hepatitis C had been ongoing since November. An outpatient\nevaluation had excluded relevant coronary artery disease.\n\n**Current Presentation:** Suspected inflammatory/dilated cardiomyopathy,\nIndication for biopsy\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Coronary Angiography**: Globally significantly impaired left\nventricular function (EF: 28%)\n\n[Myocardial biopsy:]{.underline} Uncomplicated retrieval of LV\nendomyocardial biopsies\n\n[Recommendation]{.underline}: A conservative medical approach is\nrecommended, and further therapeutic decisions will depend on the\nhistological, immunohistological, and molecular biological examination\nresults of the now-retrieved myocardial biopsies.\n\n[Procedure]{.underline}: Femoral closure system is applied, 6 hours of\nbed rest, administration of 100 mg/day of Aspirin for 4 weeks following\nleft ventricular heart biopsy.\n\n**Echocardiography before Heart Catheterization**:\n\nPerformed in sinus rhythm. Satisfactory ultrasound condition.\n\n[Findings]{.underline}: Moderately dilated left ventricle (LVDd 64mm).\nMarkedly reduced systolic LV function (EF 28%). Global longitudinal\nstrain (2D speckle tracking): -8.6%.\n\nRegional wall motion abnormalities: despite global hypokinesia, the\nposterolateral wall (basal) contracts best. Diastolic dysfunction Grade\n1 (LV relaxation disorder) (E/A 0.7) (E/E\\' mean 13.8). No LV\nhypertrophy. Morphologically age-appropriate heart valves. Moderately\ndilated left atrium (LA Vol. 71ml). Mild mitral valve insufficiency\n(Grade 1 on a 3-grade scale). Normal-sized right ventricle. Moderately\nreduced RV function Normal-sized right atrium. Minimal tricuspid valve\ninsufficiency (Grade 0-1 on a 3-grade scale). Systolic pulmonary artery\npressure in the normal range (systolic PAP 27mmHg).\n\nNo thrombus detected. Minimal pericardial effusion, circular, maximum\n2mm, no hemodynamic relevance.\n\n**Echocardiography after Heart Catheterization:**\n\n[Indication]{.underline}: Follow-up on pericardial effusion.\n\n[Examination]{.underline}: TTE at rest, including duplex and\nquantitative determination of parameters. [Echocardiographic\nFinding:]{.underline} Regarding pericardial effusion, the status is the\nsame. Circular effusion, maximum 2mm.\n\n**ECG after Heart Catheterization:**\n\n76/min, sinus rhythm, complete left bundle branch block.\n\n**Summary:** On 03/26/2016, biopsy and left heart catheterization were\nsuccessfully performed without complications. Here, too, the patient\nexhibited a significantly impaired pump function, currently at 28%.\n\n**Therapy and Progression:**\n\nThroughout the inpatient stay, the patient remained cardiorespiratorily\nstable at all times. Malignant arrhythmias were ruled out via telemetry.\nAfter the intervention, echocardiography showed no pericardial effusion.\nThe results of the endomyocardial biopsies are still pending. An\nappointment for results discussion and evaluation of further procedures\nat our facility should be scheduled in 3 weeks. Following the biopsy,\nAspirin 100 as specified should be given for 4 weeks. We intensified the\nongoing heart failure therapy and added Spironolactone to the\nmedication, recommending further escalation based on hemodynamic\ntolerability.\n\n**Current Recommendations:** Close cardiological follow-up examinations,\nelectrolyte monitoring, and echocardiography are advised. Depending on\nthe left ventricular ejection fraction\\'s course, the implantation of an\nICD or ICD/CRT system should be considered after 3 months. On the day of\ndischarge, we initiated the adjustment of a Life Vest, allowing the\npatient to return home in good general condition.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------ ------------- ---------------------\n Absolute Erythroblasts 0.01/nL \\< 0.01/nL\n Sodium 134 mEq/L 136-145 mEq/L\n Potassium 4.5 mEq/L 3.5-4.5 mEq/L\n Creatinine (Jaffé) 1.25 mg/dL 0.70-1.20 mg/dL\n Urea 50 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n CRP 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine 14.2 ng/L 9.30-17.00 ng/L\n TSH 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Erythrocytes 3.7 /pL 4.3-5.8/pL\n Leukocytes 9.56/nL 3.90-10.50/nL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n PTT Actin-FS 25.3 sec. 22.0-29.0 sec.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the pending findings of the myocardial biopsies\ntaken from Mr. David Romero, born on 02/16/1942 on 03/26/2016 due to the\ndeterioration of LV function from 40% to 28% after interferon therapy\nfor HCV infection.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Myocardial Biopsy on 01/27/2014:**\n\n[Molecular Biology:]{.underline}\n\nPCR examinations performed under the question of myocardial infection\nwith cardiotropic pathogens yielded a positive detection of HCV-specific\nRNA in myocardial tissue without quantification possibility\n(methodically determined). Otherwise, there was no evidence of\nmyocardial infection with enteroviruses, adenoviruses, Epstein-Barr\nvirus, Human Herpes Virus Type 6 A/B, or Erythrovirus genotypes 1/2 in\nthe myocardium.\n\n[Assessment]{.underline}: Positive HCV-mRNA detection in myocardial\ntissue. This positive test result does not unequivocally prove an\ninfection of myocardial cells, as contamination of the tissue sample\nwith HCV-infected peripheral blood cells cannot be ruled out in chronic\nhepatitis.\n\n**Histology and Immunohistochemistry**:\n\nUnremarkable endocardium, normal cell content of the interstitium with\nonly isolated lymphocytes and histiocytes in the histologically examined\nsamples. Quantitatively, immunohistochemically examined native\npreparations showed borderline high CD3-positive lymphocytes with a\ndiffuse distribution pattern at 10.2 cells/mm2. No increased\nperforin-positive cytotoxic T cells. The expression of cell adhesion\nmolecules is discreetly elevated. Otherwise, only slight perivascular\nbut no interstitial fibrosis. Cardiomyocytes are properly arranged and\nslightly hypertrophied (average diameter around 23 µm), the surrounding\ncapillaries are unremarkable. No evidence of acute\ninflammation-associated myocardial cell necrosis (no active myocarditis)\nand no interstitial scars from previous myocyte loss. No lipomatosis.\n\n[Assessment:]{.underline} Based on the myocardial biopsy findings, there\nis positive detection of HCV-RNA in the myocardial tissue samples, with\nthe possibility of tissue contamination with HCV-infected peripheral\nblood cells. Significant myocardial inflammatory reaction cannot be\ndocumented histologically and immunohistochemically. In the endocardial\nsamples, apart from mild hypertrophy of properly arranged\ncardiomyocytes, there are no significant signs of myocardial damage\n(interstitial fibrosis or scars from previous myocyte loss). Therefore,\nthe present findings do not indicate the need for specific further\nantiviral or anti-inflammatory therapy, and the existing heart failure\nmedication can be continued unchanged. If LV function impairment\npersists for an extended period, there is an indication for\nantiarrhythmic protection of the patient using an ICD.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe thank you for referring your patient Mr. David Romero, born on\n02/16/1942, to us for echocardiographic follow-up on 05/04/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Echocardiography: M-mode and 2-dimensional.**\n\nThe left ventricle measures approximately 65/56 mm (normal up to 56 mm).\n\nThe right atrium and right ventricle are of normal dimensions.\n\nGlobal progressive reduction in contractility, morphologically\nunremarkable.\n\nIn Doppler echocardiography, normal heart valves are observed.\n\nMitral valve insufficiency Grade I.\n\n[Assessment]{.underline}: Dilated cardiomyopathy with slightly reduced\nleft ventricular function. MI I TII °, PAP 23 mm Hg + CVP. No more\npulmonary embolism detectable.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942 to us for echocardiographic follow-up on 06/15/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Echocardiography from 06/15/2016**: Good ultrasound conditions.\n\nThe left ventricle is dilated to approximately 65/57 mm (normal up to 56\nmm). The left atrium is dilated to 48 mm. Normal thickness of the left\nventricular myocardium. Ejection fraction is around 28%. Heart valves\nshow normal flow velocities.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing,\npotassium and creatinine levels were obtained. If EF remains this low,\nan ICD may be indicated.\n\n**Lab results from 06/15/2016:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.8 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n Platelet Count 280 K/µL 150-370 K/µL\n MC 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting to you about Mr. David Romero, born on 02/16/1942, who\npresented himself at our Cardiology University Outpatient Clinic on\n06/30/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ---------------- ---------------\n Aspirin 100 mg/tablet 1-0-0\n Ramipril (Altace) 2.5 mg/tablet 1-0-1\n Carvedilol (Coreg) 12.5 mg/tablet 1-0-1\n Torasemide (Torem) 5 mg/tablet 1-0-0\n Spironolactone (Aldactone) 25 mg/tablet 1-0-0\n L-Thyroxine (Synthroid) 50 µg/tablet 1-0-0\n\n**Echocardiography on 06/30/2016:** In sinus rhythm. Adequate ultrasound\nwindow.\n\nModerately dilated left ventricle (LVDd 63mm). Significantly reduced\nsystolic LV function (EF biplane 29%). No LV hypertrophy.\n\n**ECG on 06/30/2016:** Sinus rhythm, regular tracing, heart rate 69/min,\ncomplete left bundle branch block, QRS 135 ms, ERBS with left bundle\nbranch block.\n\n**Assessment**: Mr. Romero presents himself for the follow-up assessment\nof known dilated cardiomyopathy. He currently reports minimal dyspnea.\nCoronary heart disease has been ruled out. No virus was detected\nbioptically. However, the recent echocardiography still shows severely\nimpaired LV function.\n\n**Current Recommendations:** Given the presence of left bundle branch\nblock, there is an indication for CRT-D implantation. For this purpose,\nwe have scheduled a pre-admission appointment, with the implantation\nplanned for 07/04/2016. We kindly request a referral letter. The\nLifeVest should continue to be worn until the implantation, despite the\npressure sores on the thorax.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was in our inpatient care from 07/04/2016 to\n07/06/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation:** The current admission was elective for CRT-D\nimplantation in dilated cardiomyopathy with severely impaired LV\nfunction despite full heart failure medication and complete left bundle\nbranch block. Please refer to previous medical records for a detailed\nhistory. On 07/05/2016, a CRT-ICD system was successfully implanted. The\nperi- and post-interventional course was uncomplicated. Pneumothorax was\nruled out post-interventionally. The wound conditions are\nirritation-free. The ICD card was given to the patient. We request\noutpatient follow-up on the above-mentioned date for wound inspection\nand CRT follow-up. Please adjust the known cardiovascular risk factors.\n\n**Findings:**\n\n**ECG upon Admission:** Sinus rhythm 66/min, PQ 176ms, QRS 126ms, QTc\n432ms, Complete left bundle branch block with corresponding excitation\nregression disorder.\n\n**Procedure**: Implantation of a CRT-D with left ventricular multipoint\npacing left pectoral. Smooth triple puncture of the lateral left\nsubclavian vein and implantation of an active single-coil electrode in\nthe RV apex with very good electrical values. Trouble-free probing of\nthe CS and direct venography using a balloon occlusion catheter.\nIdentification of a suitable lateral vein and implantation of a\nquadripolar electrode (Quartet, St. Jude Medical) with very good\nelectrical values. No phrenic stimulation up to 10 volts in all\npolarities. Finally, implantation of an active P/S electrode in the\nright atrial roof with equally very good electrical values. Connection\nto the device and submuscular implantation. Wound irrigation and layered\nwound closure with absorbable suture material. Finally, extensive\ntesting of all polarities of the LV electrode and activation of\nmultipoint pacing. Final setting of the ICD.\n\n**Chest X-ray on 07/05/2016:**\n\n[Clinical status, question, justifying indication:]{.underline} History\nof CRT-D implantation. Question about lead position, pneumothorax?\n\n**Findings**: New CRT-D unit left pectoral with leads projected onto the\nright ventricle, the right atrium, and the sinus coronarius. No\npneumothorax.\n\nNormal heart size. No pulmonary congestion. No diffuse infiltrates. No\npleural effusions.\n\n**ECG at Discharge:** Continuous ventricular PM stimulation, HR: 66/min.\n\n**Current Recommendations:**\n\n- We request a follow-up appointment in our Pacemaker Clinic. Please\n provide a referral slip.\n\n- We ask for the protection of the left arm and avoidance of\n elevations \\> 90 degrees. Self-absorbing sutures have been used.\n\n- We request regular wound checks.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942, who presented to our Cardiological University Outpatient\nClinic on 08/26/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation**: Slightly increasing exertional dyspnea, no\ncoronary heart disease.\n\n**Cardiovascular Risk Factors:**\n\n- Family history: No\n\n- Smoking: No\n\n- Hypertension: No\n\n- Diabetes: Yes\n\n- Dyslipidemia: Yes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Findings**:\n\n**Resting ECG:** Sinus rhythm, 83 bpm. Blood pressure: 120/70 mmHg.\n\n**Echocardiography: M-mode and 2-dimensional**\n\nLeft ventricle dimensions: Approximately 57/45 mm (normal up to 56 mm),\nmoderately dilated\n\n- Right atrium and right ventricle: Normal dimensions\n\n- Normal thickness of left ventricular muscle\n\n- Globally, mild reduction in contractility\n\n- Heart valves: Morphologically normal\n\n- Doppler-Echocardiography: No significant valve regurgitation\n\n**Assessment**: Mildly dilated cardiomyopathy with slightly reduced left\nventricular function. Ejection fraction at 45 - 50%. Mild diastolic\ndysfunction. Mild tricuspid regurgitation, pulmonary artery pressure 22\nmm Hg, and left ventricular filling pressure slightly increased.\n\n**Stress Echocardiography: Stress echocardiography with exercise test**\n\n- Stress test protocol: Treadmill exercise test\n\n- Reason for stress test: Exertional dyspnea\n\n- Quality of the ultrasound: Good\n\n- Initial workload: 50 watts\n\n- Maximum workload achieved: 150 Watt\n\n- Blood pressure response: Systolic BP increased from 112/80 mmHg to\n 175/90 mmHg\n\n- Heart rate response: Increased from 71bpm to 124bpm\n\n- Exercise terminated due to leg pain\n\n**Resting ECG:** Sinus rhythm**.** No significant changes during\nexercise\n\n**Echocardiography at rest:** Normokinesis of all left ventricular\nsegments EF: 45 - 50%\n\n**Echocardiography during exercise:** Increased contractility and wall\nthickening of all segments\n\n[Summary]{.underline}: No dynamic wall motion abnormalities. No evidence\nof exercise-induced myocardial ischemia\n\n**Carotid Doppler Ultrasound:** Both common carotid arteries are\nsmooth-walled**.** Intima-media thickness: 0.8 mm**.** Small plaque in\nthe carotid bulb on both sides**.** Normal flow in the internal and\nexternal carotid arteries**.** Normal dimensions and flow in the\nvertebral arteries\n\n**Summary:** Non-obstructive carotid plaques**.** Indicated to lower LDL\nto below 1.8 mmol/L\n\n**Summary:**\n\n- Stress echocardiography shows no evidence of ischemia, EF \\>45-50%\n\n- Carotid duplex shows minimal non-obstructive plaques\n\n- Increase Simvastatin to 20 mg, target LDL-C \\< 1.8 mmol/L\n\n\n\n### text_7\n**Dear colleague, **\n\nWe would like to inform you about the results of the cardiac\ncatheterization of Mr. David Romero, born on 02/16/1942 performed by us\non 08/10/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Procedure:** Right femoral artery puncture. Left ventriculography with\na 5F pigtail catheter in the right anterior oblique projection. Coronary\nangiography with 5F JL4.0 and 5F JR 4.0 catheters. End-diastolic\npressure in the left ventricle within the normal range, measured in\nmmHg. No pathological pressure gradient across the aortic valve.\n\n**Coronary angiography:**\n\n- Unremarkable left main stem.\n\n- The left anterior descending (LAD) artery shows mild wall changes,\n with a maximum stenosis of 20-\\<30%.\n\n- The robust right coronary artery (RCA) is stenosed proximally by\n 30-40%, subsequently ectatic and then stenosed to 40-\\<50% distally.\n Slow contrast clearance. The right coronary artery is also stenosed\n up to 30%.\n\n- Left-dominant coronary circulation.\n\n**Assessment**: Diffuse coronary atherosclerosis with less than 50%\nstenosis in the RCA and evidence of endothelial dysfunction.\n\n**Current Recommendations:**\n\n- Initiation of Ranolazine\n\n- Additional stress myocardial perfusion scintigraphy\n\n\n\n### text_8\n**Dear colleague, **\n\nWe would like to inform you about the results of the Myocardial\nPerfusion Scintigraphy performed on our patient, Mr. David Romero, born\non 02/16/1942, on 09/23/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Myocardial Perfusion Scintigraphy:**\n\nThe myocardial perfusion scintigraphy was conducted using 365 MBq of\n99m-Technetium MIBI during pharmacological stress and 383 MBq of\n99m-Technetium MIBI at rest.\n\n[Technique]{.underline}: Initially, the patient was pharmacologically\nstressed with the intravenous administration of 400 µg of Regadenoson\nover 20 seconds, accompanied by ergometer exercise at 50 W.\nSubsequently, the intravenous injection of the radiopharmaceutical was\nperformed. The maximum blood pressure achieved during the stress phase\nwas 143/84 mm Hg, and the maximum heart rate reached was 102 beats per\nminute.\n\nApproximately 60 minutes later, ECG-triggered acquisition of a\n360-degree SPECT study was conducted with reconstructions of short and\nlong-axis slices.\n\nDue to inhomogeneities in the myocardial wall segments during stress,\nrest images were acquired on another examination day. Following the\nintravenous injection of the radiopharmaceutical, ECG-triggered\nacquisition of a 360-degree SPECT study was performed, including\nshort-axis and long-axis slices, approximately 60 minutes later.\n\n[Clinical Information:]{.underline} Known coronary heart disease (RCA\n50%). ICD/CRT pacemaker.\n\n[Findings]{.underline}: No clear perfusion defects are seen in the\nscintigraphic images acquired after pharmacologic exposure to\nRegadenoson. This finding remains unchanged in the scintigraphic images\nacquired at rest.\n\nQuantitative analysis shows a normal-sized ventricle with a normal left\nventricular ejection fraction (LVEF) of 53% under exercise conditions\nand 47% at rest (EDV 81 mL). There are no clear wall motion\nabnormalities. In the gated SPECT analysis, there are no definite wall\nmotion abnormalities observed in both stress and rest conditions.\n\n**Quantitative Scoring:**\n\n- SSS (Summed Stress Score): 3 (4.4%)\n\n- SRS (Summed Rest Score): 0 (0.0%)\n\n- SDS (Summed Difference Score): 3 (4.4%)\n\n**Assessment**: No evidence of myocardial perfusion defects with\nRegadenoson stress or at rest. Normal ventricular size and function with\nno significant wall motion abnormalities.\n\n\n\n### text_9\n**Dear colleague, **\n\nWe would like to report on our patient, Mr. David Romero, born on\n02/16/1942, who was under our inpatient care from 05/20/2023 to\n05/21/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medical History:** The patient was admitted for device replacement due\nand upgrading to a CRT-P pacemaker. At admission, the patient reported\nno complaints of fever, cough, dyspnea, chest pain, or melena.\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Medication upon Admission**\n\n **Medication** **Dosage** **Frequency**\n --------------------------- -------------- ----------------------\n Insulin glargine (Lantus) 450 E/1.5 ml 0-0-0-6-8 IU\n Insulin lispro (Humalog) 300 E/3 ml 5-8 IU-5-8 IU-5-8 IU\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Colecalciferol 12.5 mcg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n\n**Therapy and Progression:** The patient\\'s current admission was\nelective for the implantation of a 3-chamber CRT-D device due to device\ndepletion. The procedure was performed without complications on\n05/20/2023. The post-interventional course was uneventful. The\nimplantation site showed no irritation or significant hematoma at the\ntime of discharge, and no pneumothorax was detected on X-ray.\n\nTo protect the surgical wound, we request dry wound dressing for the\nnext 10 days and clinical wound checks. Suture removal is not necessary\nwith absorbable suture material. We advise against arm elevation for the\nnext 4 weeks, avoiding heavy lifting on the side of the device pocket\nand gradual, pain-adapted full range of motion after 4 weeks.\n\n**Current Recommendations:** We kindly request an outpatient follow-up\nappointment in our Pacemaker Clinic.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage ** **Frequency**\n ----------------------------- --------------- -----------------------\n Insulin glargine (Lantus) 450 E./1.5 ml 0-0-0-/6-8 IU\n Insulin lispro (Humalog) 300 E./3 ml 5-8 IU/-5-8 IU/5-8 IU\n Levothyroxine (Synthroid) 100 µg 1-0-0-0\n Colecalciferol (Vitamin D3) 12.5 µg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Colecalciferol 12.5 µg 2-0-0-0\n\n**Addition: Findings:**\n\n**ECG at Discharge:** Sinus rhythm, ventricular pacing, QRS 122ms, QTc\n472ms\n\n**Rhythm Examination on 05/20/2023:**\n\n[Results:]{.underline} Replacement of a 3-chamber CRT-D device (new:\nSJM/Abbott Quadra Assura) due to impending battery depletion:\nUncomplicated replacement. Tedious freeing of the submuscular device and\nproximal lead portions using a plasma blade. Extraction of the old\ndevice. Connection to the new device. Avoidance of device fixation in\nthe submuscular position. Hemostasis by electrocauterization. Layered\nwound closure. Skin closure with absorbable intracutaneous sutures. End\nadjustment of the CRT-D device is complete. [Procedure]{.underline}:\nCompression of the wound with a sandbag and local cooling. First\noutpatient follow-up in 8 weeks through our pacemaker clinic (please\nschedule an appointment before discharge). Postoperative chest X-ray is\nnot necessary. Cefuroxime 1.5 mg again tonight.\n\n**Transthoracic Echocardiography on 05/18/2023**\n\n**Results:** Globally mildly impaired systolic LV function. Diastolic\ndysfunction Grade 1 (LV relaxation disorder).\n\n- Right Ventricle: Normal-sized right ventricle. Normal RV function.\n Pulmonary arterial pressure is normal.\n\n- Left Atrium: Slightly dilated left atrium.\n\n- Right Atrium: Normal-sized right atrium.\n\n- Mitral Valve: Morphologically unremarkable. Minimal mitral valve\n regurgitation.\n\n- Aortic Valve: Mildly sclerotic aortic valve cusps. No aortic valve\n insufficiency. No aortic valve stenosis (AV PGmax 7 mmHg).\n\n- Tricuspid Valve: Delicate tricuspid valve leaflets. Minimal\n tricuspid valve regurgitation (TR Pmax 26 mmHg).\n\n- Pulmonary Valve: No pulmonary valve insufficiency. Pericardium: No\n pericardial effusion.\n\n**Assessment**: Examination in sinus rhythm with bundle branch block.\nModerate ultrasound windows. Normal-sized left ventricle (LVED 54 mm)\nwith mildly reduced systolic LV function (EF biplan 55%) with mildly\nreduced contractility without regional emphasis. Mild LV hypertrophy,\npredominantly septal, without obstruction. Diastolic dysfunction Grade 1\n(E/A 0.47) with a normal LV filling index (E/E\\' mean 3.5). Slightly\nsclerotic aortic valve without stenosis, no AI. Slightly dilated left\natrium (LAVI 31 ml/m²). Minimal MI. Normal-sized right ventricle with\nnormal function. Normal-sized right atrium (RAVI 21 ml/m²). Minimal TI.\nAs far as assessable, systolic PA pressure is within the normal range.\nThe IVC cannot be viewed from the subcostal angle. No thrombi are\nvisible. As far as assessable, no pericardial effusion is visible.\n\n**Chest X-ray in two planes on 05/20/2023: **\n\n[Clinical Information, Question, Justification:]{.underline} Post CRT\ndevice replacement. Inquiry about position, pneumothorax.\n\n[Findings]{.underline}: No pneumothorax following CRT device\nreplacement.\n\n\n\n### text_10\n**Dear colleague, **\n\nWe are writing to provide an update on Mr. David Romero, born on\n02/16/1942, who presented at our Rhythm Clinic on 09/29/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ------------------ ---------------\n Lantus (Insulin glargine) 450 Units/1.5 mL 0-0-0-/6-8\n Humalog (Insulin lispro) 300 Units/3 mL 5-8/0/5-8/5-8\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n Lipitor (Atorvastatin) 21.7 mg 0-0-1-0\n Norvasc (Amlodipine) 6.94 mg 1-0-0-0\n Altace (Ramipril) 5 mg 1-0-0-0\n Demadex (Torasemide) 5 mg 0-0-0.5-0\n Coreg (Carvedilol) 25 mg 0.5-0-0.5-0\n Zocor (Simvastatin) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n\n**Measurement Results:**\n\nBattery/Capacitor: Status: OK, Voltage: 8.4V\n\n- Right Atrial: 375 Ohms 3.80 mV 0.375 V 0.50 ms\n\n- Right Ventricular: 388 Ohms 11.80 mV 0.750 V 0.50 ms\n\n- Left Ventricular: 350 Ohms 0.625 V 0.50 ms\n\n- Defibrillation Impedance: Right Ventricular: 48 Ohms\n\n**Implant Settings:**\n\n- Bradycardia Setting: Mode: DDD\n\n- Tachycardia Settings: Zone Detection Interval (ms) Detection Beats\n ATP Shocks Details Status\n\n - VFVF 260 ms 30 /\n\n - VTVT1 330 ms 55 /\n\n<!-- -->\n\n- Probe Settings: Lead Sensitivity Sensing Polarity/Vector\n Amplification/Pulse Width Stimulation Polarity/Vector Auto Amplitude\n Control\n\n - Right Atrial: 0.30 mV Bipolar/ 1.375 V/0.50 ms Bipolar/\n\n - Right Ventricular: Bipolar/ 2.000 V/0.50 ms Bipolar/\n\n - Left Ventricular: 2.000 V/0.50 ms tip 1 - RV Coil\n\n**Assessment:**\n\n- Routine visit with normal device function.\n\n- Normal sinus rhythm with a heart rate of 65/min.\n\n- Balanced heart rate histogram with a plateau at 60-70 bpm.\n\n- Wound conditions are unremarkable.\n\n- Battery status: OK.\n\n- Atrial probe: Intact\n\n- Right ventricular probe: Intact\n\n- Left ventricular probe: Intact\n\n- A follow-up appointment for the patient is requested in 6 months.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.8 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 5.9 mg/L \\< 5.0 mg/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n MCV 92.7 fL 80.0-99.0 fL\n MCH 31.8 pg 27.0-33.5 pg\n MCHC 33.9 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.2% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n\n\n\nHere is the query:\nWhat was Mr. David Romero's left ventricular ejection fraction (LVEF) measured in myocardial perfusion scintigraphy in September 2022?\n\nChoose the correct answer from the following options:\nA. 40%\nB. 28%\nC. 30%\nD. 45%\nE. 53%\n\n\nYour response:\n", "role": "user" }, { "content": "53%", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was under our inpatient care from 03/25/2016 to\n03/30/2016.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- Uncomplicated biopsy, pending results\n\n- LifeVest has been adjusted\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Medical History:** The patient was admitted with suspected myocarditis\ndue to a significantly impaired pump function noticed during outpatient\nvisits. Anamnestically, the patient reported experiencing fatigue and\nexertional dyspnea since mid-December, with no recollection of a\npreceding infection. Antiviral therapy with Interferon/Ribavirin for\nchronic Hepatitis C had been ongoing since November. An outpatient\nevaluation had excluded relevant coronary artery disease.\n\n**Current Presentation:** Suspected inflammatory/dilated cardiomyopathy,\nIndication for biopsy\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Coronary Angiography**: Globally significantly impaired left\nventricular function (EF: 28%)\n\n[Myocardial biopsy:]{.underline} Uncomplicated retrieval of LV\nendomyocardial biopsies\n\n[Recommendation]{.underline}: A conservative medical approach is\nrecommended, and further therapeutic decisions will depend on the\nhistological, immunohistological, and molecular biological examination\nresults of the now-retrieved myocardial biopsies.\n\n[Procedure]{.underline}: Femoral closure system is applied, 6 hours of\nbed rest, administration of 100 mg/day of Aspirin for 4 weeks following\nleft ventricular heart biopsy.\n\n**Echocardiography before Heart Catheterization**:\n\nPerformed in sinus rhythm. Satisfactory ultrasound condition.\n\n[Findings]{.underline}: Moderately dilated left ventricle (LVDd 64mm).\nMarkedly reduced systolic LV function (EF 28%). Global longitudinal\nstrain (2D speckle tracking): -8.6%.\n\nRegional wall motion abnormalities: despite global hypokinesia, the\nposterolateral wall (basal) contracts best. Diastolic dysfunction Grade\n1 (LV relaxation disorder) (E/A 0.7) (E/E\\' mean 13.8). No LV\nhypertrophy. Morphologically age-appropriate heart valves. Moderately\ndilated left atrium (LA Vol. 71ml). Mild mitral valve insufficiency\n(Grade 1 on a 3-grade scale). Normal-sized right ventricle. Moderately\nreduced RV function Normal-sized right atrium. Minimal tricuspid valve\ninsufficiency (Grade 0-1 on a 3-grade scale). Systolic pulmonary artery\npressure in the normal range (systolic PAP 27mmHg).\n\nNo thrombus detected. Minimal pericardial effusion, circular, maximum\n2mm, no hemodynamic relevance.\n\n**Echocardiography after Heart Catheterization:**\n\n[Indication]{.underline}: Follow-up on pericardial effusion.\n\n[Examination]{.underline}: TTE at rest, including duplex and\nquantitative determination of parameters. [Echocardiographic\nFinding:]{.underline} Regarding pericardial effusion, the status is the\nsame. Circular effusion, maximum 2mm.\n\n**ECG after Heart Catheterization:**\n\n76/min, sinus rhythm, complete left bundle branch block.\n\n**Summary:** On 03/26/2016, biopsy and left heart catheterization were\nsuccessfully performed without complications. Here, too, the patient\nexhibited a significantly impaired pump function, currently at 28%.\n\n**Therapy and Progression:**\n\nThroughout the inpatient stay, the patient remained cardiorespiratorily\nstable at all times. Malignant arrhythmias were ruled out via telemetry.\nAfter the intervention, echocardiography showed no pericardial effusion.\nThe results of the endomyocardial biopsies are still pending. An\nappointment for results discussion and evaluation of further procedures\nat our facility should be scheduled in 3 weeks. Following the biopsy,\nAspirin 100 as specified should be given for 4 weeks. We intensified the\nongoing heart failure therapy and added Spironolactone to the\nmedication, recommending further escalation based on hemodynamic\ntolerability.\n\n**Current Recommendations:** Close cardiological follow-up examinations,\nelectrolyte monitoring, and echocardiography are advised. Depending on\nthe left ventricular ejection fraction\\'s course, the implantation of an\nICD or ICD/CRT system should be considered after 3 months. On the day of\ndischarge, we initiated the adjustment of a Life Vest, allowing the\npatient to return home in good general condition.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------ ------------- ---------------------\n Absolute Erythroblasts 0.01/nL \\< 0.01/nL\n Sodium 134 mEq/L 136-145 mEq/L\n Potassium 4.5 mEq/L 3.5-4.5 mEq/L\n Creatinine (Jaffé) 1.25 mg/dL 0.70-1.20 mg/dL\n Urea 50 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n CRP 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine 14.2 ng/L 9.30-17.00 ng/L\n TSH 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Erythrocytes 3.7 /pL 4.3-5.8/pL\n Leukocytes 9.56/nL 3.90-10.50/nL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n PTT Actin-FS 25.3 sec. 22.0-29.0 sec.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the pending findings of the myocardial biopsies\ntaken from Mr. David Romero, born on 02/16/1942 on 03/26/2016 due to the\ndeterioration of LV function from 40% to 28% after interferon therapy\nfor HCV infection.\n\n**Diagnoses:**\n\n- Suspected myocarditis\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic hepatitis C\n\n- Status post hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Myocardial Biopsy on 01/27/2014:**\n\n[Molecular Biology:]{.underline}\n\nPCR examinations performed under the question of myocardial infection\nwith cardiotropic pathogens yielded a positive detection of HCV-specific\nRNA in myocardial tissue without quantification possibility\n(methodically determined). Otherwise, there was no evidence of\nmyocardial infection with enteroviruses, adenoviruses, Epstein-Barr\nvirus, Human Herpes Virus Type 6 A/B, or Erythrovirus genotypes 1/2 in\nthe myocardium.\n\n[Assessment]{.underline}: Positive HCV-mRNA detection in myocardial\ntissue. This positive test result does not unequivocally prove an\ninfection of myocardial cells, as contamination of the tissue sample\nwith HCV-infected peripheral blood cells cannot be ruled out in chronic\nhepatitis.\n\n**Histology and Immunohistochemistry**:\n\nUnremarkable endocardium, normal cell content of the interstitium with\nonly isolated lymphocytes and histiocytes in the histologically examined\nsamples. Quantitatively, immunohistochemically examined native\npreparations showed borderline high CD3-positive lymphocytes with a\ndiffuse distribution pattern at 10.2 cells/mm2. No increased\nperforin-positive cytotoxic T cells. The expression of cell adhesion\nmolecules is discreetly elevated. Otherwise, only slight perivascular\nbut no interstitial fibrosis. Cardiomyocytes are properly arranged and\nslightly hypertrophied (average diameter around 23 µm), the surrounding\ncapillaries are unremarkable. No evidence of acute\ninflammation-associated myocardial cell necrosis (no active myocarditis)\nand no interstitial scars from previous myocyte loss. No lipomatosis.\n\n[Assessment:]{.underline} Based on the myocardial biopsy findings, there\nis positive detection of HCV-RNA in the myocardial tissue samples, with\nthe possibility of tissue contamination with HCV-infected peripheral\nblood cells. Significant myocardial inflammatory reaction cannot be\ndocumented histologically and immunohistochemically. In the endocardial\nsamples, apart from mild hypertrophy of properly arranged\ncardiomyocytes, there are no significant signs of myocardial damage\n(interstitial fibrosis or scars from previous myocyte loss). Therefore,\nthe present findings do not indicate the need for specific further\nantiviral or anti-inflammatory therapy, and the existing heart failure\nmedication can be continued unchanged. If LV function impairment\npersists for an extended period, there is an indication for\nantiarrhythmic protection of the patient using an ICD.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient Mr. David Romero, born on\n02/16/1942, to us for echocardiographic follow-up on 05/04/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Echocardiography: M-mode and 2-dimensional.**\n\nThe left ventricle measures approximately 65/56 mm (normal up to 56 mm).\n\nThe right atrium and right ventricle are of normal dimensions.\n\nGlobal progressive reduction in contractility, morphologically\nunremarkable.\n\nIn Doppler echocardiography, normal heart valves are observed.\n\nMitral valve insufficiency Grade I.\n\n[Assessment]{.underline}: Dilated cardiomyopathy with slightly reduced\nleft ventricular function. MI I TII °, PAP 23 mm Hg + CVP. No more\npulmonary embolism detectable.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942 to us for echocardiographic follow-up on 06/15/2016.\n\n**Diagnoses:**\n\n- Dilatated cardiomyopathy\n\n- LifeVest\n\n- Left ventricular ejection fraction of 28%\n\n- Chronic Hepatitis C\n\n- Status post Hepatitis A\n\n- Post-antiviral therapy\n\n- Exclusion of relevant coronary artery disease\n\n- Type 2 diabetes mellitus\n\n- Hypothyroidism\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torasemide (Torem) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Echocardiography from 06/15/2016**: Good ultrasound conditions.\n\nThe left ventricle is dilated to approximately 65/57 mm (normal up to 56\nmm). The left atrium is dilated to 48 mm. Normal thickness of the left\nventricular myocardium. Ejection fraction is around 28%. Heart valves\nshow normal flow velocities.\n\n**Summary:**\n\nCurrently, the cardiac situation is stable, LVEDD slightly decreasing,\npotassium and creatinine levels were obtained. If EF remains this low,\nan ICD may be indicated.\n\n**Lab results from 06/15/2016:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.8 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.9 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 78 ng/L \\< 14 ng/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n Platelet Count 280 K/µL 150-370 K/µL\n MC 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about Mr. David Romero, born on 02/16/1942, who\npresented himself at our Cardiology University Outpatient Clinic on\n06/30/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ---------------- ---------------\n Aspirin 100 mg/tablet 1-0-0\n Ramipril (Altace) 2.5 mg/tablet 1-0-1\n Carvedilol (Coreg) 12.5 mg/tablet 1-0-1\n Torasemide (Torem) 5 mg/tablet 1-0-0\n Spironolactone (Aldactone) 25 mg/tablet 1-0-0\n L-Thyroxine (Synthroid) 50 µg/tablet 1-0-0\n\n**Echocardiography on 06/30/2016:** In sinus rhythm. Adequate ultrasound\nwindow.\n\nModerately dilated left ventricle (LVDd 63mm). Significantly reduced\nsystolic LV function (EF biplane 29%). No LV hypertrophy.\n\n**ECG on 06/30/2016:** Sinus rhythm, regular tracing, heart rate 69/min,\ncomplete left bundle branch block, QRS 135 ms, ERBS with left bundle\nbranch block.\n\n**Assessment**: Mr. Romero presents himself for the follow-up assessment\nof known dilated cardiomyopathy. He currently reports minimal dyspnea.\nCoronary heart disease has been ruled out. No virus was detected\nbioptically. However, the recent echocardiography still shows severely\nimpaired LV function.\n\n**Current Recommendations:** Given the presence of left bundle branch\nblock, there is an indication for CRT-D implantation. For this purpose,\nwe have scheduled a pre-admission appointment, with the implantation\nplanned for 07/04/2016. We kindly request a referral letter. The\nLifeVest should continue to be worn until the implantation, despite the\npressure sores on the thorax.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to report to you about our patient, Mr. David Romero, born\non 02/16/1942, who was in our inpatient care from 07/04/2016 to\n07/06/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- Planned CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation:** The current admission was elective for CRT-D\nimplantation in dilated cardiomyopathy with severely impaired LV\nfunction despite full heart failure medication and complete left bundle\nbranch block. Please refer to previous medical records for a detailed\nhistory. On 07/05/2016, a CRT-ICD system was successfully implanted. The\nperi- and post-interventional course was uncomplicated. Pneumothorax was\nruled out post-interventionally. The wound conditions are\nirritation-free. The ICD card was given to the patient. We request\noutpatient follow-up on the above-mentioned date for wound inspection\nand CRT follow-up. Please adjust the known cardiovascular risk factors.\n\n**Findings:**\n\n**ECG upon Admission:** Sinus rhythm 66/min, PQ 176ms, QRS 126ms, QTc\n432ms, Complete left bundle branch block with corresponding excitation\nregression disorder.\n\n**Procedure**: Implantation of a CRT-D with left ventricular multipoint\npacing left pectoral. Smooth triple puncture of the lateral left\nsubclavian vein and implantation of an active single-coil electrode in\nthe RV apex with very good electrical values. Trouble-free probing of\nthe CS and direct venography using a balloon occlusion catheter.\nIdentification of a suitable lateral vein and implantation of a\nquadripolar electrode (Quartet, St. Jude Medical) with very good\nelectrical values. No phrenic stimulation up to 10 volts in all\npolarities. Finally, implantation of an active P/S electrode in the\nright atrial roof with equally very good electrical values. Connection\nto the device and submuscular implantation. Wound irrigation and layered\nwound closure with absorbable suture material. Finally, extensive\ntesting of all polarities of the LV electrode and activation of\nmultipoint pacing. Final setting of the ICD.\n\n**Chest X-ray on 07/05/2016:**\n\n[Clinical status, question, justifying indication:]{.underline} History\nof CRT-D implantation. Question about lead position, pneumothorax?\n\n**Findings**: New CRT-D unit left pectoral with leads projected onto the\nright ventricle, the right atrium, and the sinus coronarius. No\npneumothorax.\n\nNormal heart size. No pulmonary congestion. No diffuse infiltrates. No\npleural effusions.\n\n**ECG at Discharge:** Continuous ventricular PM stimulation, HR: 66/min.\n\n**Current Recommendations:**\n\n- We request a follow-up appointment in our Pacemaker Clinic. Please\n provide a referral slip.\n\n- We ask for the protection of the left arm and avoidance of\n elevations \\> 90 degrees. Self-absorbing sutures have been used.\n\n- We request regular wound checks.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient, Mr. David Romero, born on\n02/16/1942, who presented to our Cardiological University Outpatient\nClinic on 08/26/2016.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication ** **Dosage ** **Frequency**\n ---------------------------- ------------- ---------------\n Aspirin 100 mg 1-0-0\n Ramipril (Altace) 2.5 mg 1-0-1\n Carvedilol (Coreg) 12.5 mg 1-0-1\n Torem (Torasemide) 5 mg 1-0-0\n Spironolactone (Aldactone) 25 mg 1-0-0\n L-Thyroxine (Synthroid) 50 µg 1-0-0\n Sitagliptin (Januvia) 100 mg 1-0-0\n Insulin glargine (Lantus) 0-0-20IE\n\n**Current Presentation**: Slightly increasing exertional dyspnea, no\ncoronary heart disease.\n\n**Cardiovascular Risk Factors:**\n\n- Family history: No\n\n- Smoking: No\n\n- Hypertension: No\n\n- Diabetes: Yes\n\n- Dyslipidemia: Yes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without pressure pain,\nspleen and liver not palpable. Normal bowel sounds.\n\n**Findings**:\n\n**Resting ECG:** Sinus rhythm, 83 bpm. Blood pressure: 120/70 mmHg.\n\n**Echocardiography: M-mode and 2-dimensional**\n\nLeft ventricle dimensions: Approximately 57/45 mm (normal up to 56 mm),\nmoderately dilated\n\n- Right atrium and right ventricle: Normal dimensions\n\n- Normal thickness of left ventricular muscle\n\n- Globally, mild reduction in contractility\n\n- Heart valves: Morphologically normal\n\n- Doppler-Echocardiography: No significant valve regurgitation\n\n**Assessment**: Mildly dilated cardiomyopathy with slightly reduced left\nventricular function. Ejection fraction at 45 - 50%. Mild diastolic\ndysfunction. Mild tricuspid regurgitation, pulmonary artery pressure 22\nmm Hg, and left ventricular filling pressure slightly increased.\n\n**Stress Echocardiography: Stress echocardiography with exercise test**\n\n- Stress test protocol: Treadmill exercise test\n\n- Reason for stress test: Exertional dyspnea\n\n- Quality of the ultrasound: Good\n\n- Initial workload: 50 watts\n\n- Maximum workload achieved: 150 Watt\n\n- Blood pressure response: Systolic BP increased from 112/80 mmHg to\n 175/90 mmHg\n\n- Heart rate response: Increased from 71bpm to 124bpm\n\n- Exercise terminated due to leg pain\n\n**Resting ECG:** Sinus rhythm**.** No significant changes during\nexercise\n\n**Echocardiography at rest:** Normokinesis of all left ventricular\nsegments EF: 45 - 50%\n\n**Echocardiography during exercise:** Increased contractility and wall\nthickening of all segments\n\n[Summary]{.underline}: No dynamic wall motion abnormalities. No evidence\nof exercise-induced myocardial ischemia\n\n**Carotid Doppler Ultrasound:** Both common carotid arteries are\nsmooth-walled**.** Intima-media thickness: 0.8 mm**.** Small plaque in\nthe carotid bulb on both sides**.** Normal flow in the internal and\nexternal carotid arteries**.** Normal dimensions and flow in the\nvertebral arteries\n\n**Summary:** Non-obstructive carotid plaques**.** Indicated to lower LDL\nto below 1.8 mmol/L\n\n**Summary:**\n\n- Stress echocardiography shows no evidence of ischemia, EF \\>45-50%\n\n- Carotid duplex shows minimal non-obstructive plaques\n\n- Increase Simvastatin to 20 mg, target LDL-C \\< 1.8 mmol/L\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about the results of the cardiac\ncatheterization of Mr. David Romero, born on 02/16/1942 performed by us\non 08/10/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Procedure:** Right femoral artery puncture. Left ventriculography with\na 5F pigtail catheter in the right anterior oblique projection. Coronary\nangiography with 5F JL4.0 and 5F JR 4.0 catheters. End-diastolic\npressure in the left ventricle within the normal range, measured in\nmmHg. No pathological pressure gradient across the aortic valve.\n\n**Coronary angiography:**\n\n- Unremarkable left main stem.\n\n- The left anterior descending (LAD) artery shows mild wall changes,\n with a maximum stenosis of 20-\\<30%.\n\n- The robust right coronary artery (RCA) is stenosed proximally by\n 30-40%, subsequently ectatic and then stenosed to 40-\\<50% distally.\n Slow contrast clearance. The right coronary artery is also stenosed\n up to 30%.\n\n- Left-dominant coronary circulation.\n\n**Assessment**: Diffuse coronary atherosclerosis with less than 50%\nstenosis in the RCA and evidence of endothelial dysfunction.\n\n**Current Recommendations:**\n\n- Initiation of Ranolazine\n\n- Additional stress myocardial perfusion scintigraphy\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about the results of the Myocardial\nPerfusion Scintigraphy performed on our patient, Mr. David Romero, born\non 02/16/1942, on 09/23/2022.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function (ejection fraction\n around 30%)\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Myocardial Perfusion Scintigraphy:**\n\nThe myocardial perfusion scintigraphy was conducted using 365 MBq of\n99m-Technetium MIBI during pharmacological stress and 383 MBq of\n99m-Technetium MIBI at rest.\n\n[Technique]{.underline}: Initially, the patient was pharmacologically\nstressed with the intravenous administration of 400 µg of Regadenoson\nover 20 seconds, accompanied by ergometer exercise at 50 W.\nSubsequently, the intravenous injection of the radiopharmaceutical was\nperformed. The maximum blood pressure achieved during the stress phase\nwas 143/84 mm Hg, and the maximum heart rate reached was 102 beats per\nminute.\n\nApproximately 60 minutes later, ECG-triggered acquisition of a\n360-degree SPECT study was conducted with reconstructions of short and\nlong-axis slices.\n\nDue to inhomogeneities in the myocardial wall segments during stress,\nrest images were acquired on another examination day. Following the\nintravenous injection of the radiopharmaceutical, ECG-triggered\nacquisition of a 360-degree SPECT study was performed, including\nshort-axis and long-axis slices, approximately 60 minutes later.\n\n[Clinical Information:]{.underline} Known coronary heart disease (RCA\n50%). ICD/CRT pacemaker.\n\n[Findings]{.underline}: No clear perfusion defects are seen in the\nscintigraphic images acquired after pharmacologic exposure to\nRegadenoson. This finding remains unchanged in the scintigraphic images\nacquired at rest.\n\nQuantitative analysis shows a normal-sized ventricle with a normal left\nventricular ejection fraction (LVEF) of 53% under exercise conditions\nand 47% at rest (EDV 81 mL). There are no clear wall motion\nabnormalities. In the gated SPECT analysis, there are no definite wall\nmotion abnormalities observed in both stress and rest conditions.\n\n**Quantitative Scoring:**\n\n- SSS (Summed Stress Score): 3 (4.4%)\n\n- SRS (Summed Rest Score): 0 (0.0%)\n\n- SDS (Summed Difference Score): 3 (4.4%)\n\n**Assessment**: No evidence of myocardial perfusion defects with\nRegadenoson stress or at rest. Normal ventricular size and function with\nno significant wall motion abnormalities.\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nWe would like to report on our patient, Mr. David Romero, born on\n02/16/1942, who was under our inpatient care from 05/20/2023 to\n05/21/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Medical History:** The patient was admitted for device replacement due\nand upgrading to a CRT-P pacemaker. At admission, the patient reported\nno complaints of fever, cough, dyspnea, chest pain, or melena.\n\n**Physical Examination:** The patient is fully oriented with good\ngeneral condition and normal mental state. Dry skin and mucous\nmembranes, normal breathing, no cyanosis. Cranial nerves are grossly\nintact, no focal neurological deficits, good muscle strength and\nsensitivity all around. Clear, rhythmic heart sounds, with a 2/6\nsystolic murmur at the apex. Lungs are evenly ventilated without rales.\nResonant percussion. Soft and supple abdomen without guarding, spleen\nand liver not palpable. Normal bowel sounds.\n\n**Medication upon Admission**\n\n **Medication** **Dosage** **Frequency**\n --------------------------- -------------- ----------------------\n Insulin glargine (Lantus) 450 E/1.5 ml 0-0-0-6-8 IU\n Insulin lispro (Humalog) 300 E/3 ml 5-8 IU-5-8 IU-5-8 IU\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Colecalciferol 12.5 mcg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n\n**Therapy and Progression:** The patient\\'s current admission was\nelective for the implantation of a 3-chamber CRT-D device due to device\ndepletion. The procedure was performed without complications on\n05/20/2023. The post-interventional course was uneventful. The\nimplantation site showed no irritation or significant hematoma at the\ntime of discharge, and no pneumothorax was detected on X-ray.\n\nTo protect the surgical wound, we request dry wound dressing for the\nnext 10 days and clinical wound checks. Suture removal is not necessary\nwith absorbable suture material. We advise against arm elevation for the\nnext 4 weeks, avoiding heavy lifting on the side of the device pocket\nand gradual, pain-adapted full range of motion after 4 weeks.\n\n**Current Recommendations:** We kindly request an outpatient follow-up\nappointment in our Pacemaker Clinic.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage ** **Frequency**\n ----------------------------- --------------- -----------------------\n Insulin glargine (Lantus) 450 E./1.5 ml 0-0-0-/6-8 IU\n Insulin lispro (Humalog) 300 E./3 ml 5-8 IU/-5-8 IU/5-8 IU\n Levothyroxine (Synthroid) 100 µg 1-0-0-0\n Colecalciferol (Vitamin D3) 12.5 µg 2-0-0-0\n Atorvastatin (Lipitor) 21.7 mg 0-0-1-0\n Amlodipine (Norvasc) 6.94 mg 1-0-0-0\n Ramipril (Altace) 5 mg 1-0-0-0\n Torasemide (Torem) 5 mg 0-0-0.5-0\n Carvedilol (Coreg) 25 mg 0.5-0-0.5-0\n Simvastatin (Zocor) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Colecalciferol 12.5 µg 2-0-0-0\n\n**Addition: Findings:**\n\n**ECG at Discharge:** Sinus rhythm, ventricular pacing, QRS 122ms, QTc\n472ms\n\n**Rhythm Examination on 05/20/2023:**\n\n[Results:]{.underline} Replacement of a 3-chamber CRT-D device (new:\nSJM/Abbott Quadra Assura) due to impending battery depletion:\nUncomplicated replacement. Tedious freeing of the submuscular device and\nproximal lead portions using a plasma blade. Extraction of the old\ndevice. Connection to the new device. Avoidance of device fixation in\nthe submuscular position. Hemostasis by electrocauterization. Layered\nwound closure. Skin closure with absorbable intracutaneous sutures. End\nadjustment of the CRT-D device is complete. [Procedure]{.underline}:\nCompression of the wound with a sandbag and local cooling. First\noutpatient follow-up in 8 weeks through our pacemaker clinic (please\nschedule an appointment before discharge). Postoperative chest X-ray is\nnot necessary. Cefuroxime 1.5 mg again tonight.\n\n**Transthoracic Echocardiography on 05/18/2023**\n\n**Results:** Globally mildly impaired systolic LV function. Diastolic\ndysfunction Grade 1 (LV relaxation disorder).\n\n- Right Ventricle: Normal-sized right ventricle. Normal RV function.\n Pulmonary arterial pressure is normal.\n\n- Left Atrium: Slightly dilated left atrium.\n\n- Right Atrium: Normal-sized right atrium.\n\n- Mitral Valve: Morphologically unremarkable. Minimal mitral valve\n regurgitation.\n\n- Aortic Valve: Mildly sclerotic aortic valve cusps. No aortic valve\n insufficiency. No aortic valve stenosis (AV PGmax 7 mmHg).\n\n- Tricuspid Valve: Delicate tricuspid valve leaflets. Minimal\n tricuspid valve regurgitation (TR Pmax 26 mmHg).\n\n- Pulmonary Valve: No pulmonary valve insufficiency. Pericardium: No\n pericardial effusion.\n\n**Assessment**: Examination in sinus rhythm with bundle branch block.\nModerate ultrasound windows. Normal-sized left ventricle (LVED 54 mm)\nwith mildly reduced systolic LV function (EF biplan 55%) with mildly\nreduced contractility without regional emphasis. Mild LV hypertrophy,\npredominantly septal, without obstruction. Diastolic dysfunction Grade 1\n(E/A 0.47) with a normal LV filling index (E/E\\' mean 3.5). Slightly\nsclerotic aortic valve without stenosis, no AI. Slightly dilated left\natrium (LAVI 31 ml/m²). Minimal MI. Normal-sized right ventricle with\nnormal function. Normal-sized right atrium (RAVI 21 ml/m²). Minimal TI.\nAs far as assessable, systolic PA pressure is within the normal range.\nThe IVC cannot be viewed from the subcostal angle. No thrombi are\nvisible. As far as assessable, no pericardial effusion is visible.\n\n**Chest X-ray in two planes on 05/20/2023: **\n\n[Clinical Information, Question, Justification:]{.underline} Post CRT\ndevice replacement. Inquiry about position, pneumothorax.\n\n[Findings]{.underline}: No pneumothorax following CRT device\nreplacement.\n\n", "title": "text_9" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mr. David Romero, born on\n02/16/1942, who presented at our Rhythm Clinic on 09/29/2023.\n\n**Diagnoses:**\n\n- Dilated cardiomyopathy\n\n- Exclusion of coronary heart diseases\n\n- Myocardial biopsy showed no inflammation\n\n- Left bundle branch block\n\n- Severely impaired left ventricular (LV) function\n\n- LifeVest\n\n- CRT-D implantation\n\n- Chronic Hepatitis C\n\n- Type 2 diabetes\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ------------------ ---------------\n Lantus (Insulin glargine) 450 Units/1.5 mL 0-0-0-/6-8\n Humalog (Insulin lispro) 300 Units/3 mL 5-8/0/5-8/5-8\n Levothyroxine (Synthroid) 100 mcg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n Lipitor (Atorvastatin) 21.7 mg 0-0-1-0\n Norvasc (Amlodipine) 6.94 mg 1-0-0-0\n Altace (Ramipril) 5 mg 1-0-0-0\n Demadex (Torasemide) 5 mg 0-0-0.5-0\n Coreg (Carvedilol) 25 mg 0.5-0-0.5-0\n Zocor (Simvastatin) 40 mg 0-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Vitamin D3 (Colecalciferol) 12.5 mcg 2-0-0-0\n\n**Measurement Results:**\n\nBattery/Capacitor: Status: OK, Voltage: 8.4V\n\n- Right Atrial: 375 Ohms 3.80 mV 0.375 V 0.50 ms\n\n- Right Ventricular: 388 Ohms 11.80 mV 0.750 V 0.50 ms\n\n- Left Ventricular: 350 Ohms 0.625 V 0.50 ms\n\n- Defibrillation Impedance: Right Ventricular: 48 Ohms\n\n**Implant Settings:**\n\n- Bradycardia Setting: Mode: DDD\n\n- Tachycardia Settings: Zone Detection Interval (ms) Detection Beats\n ATP Shocks Details Status\n\n - VFVF 260 ms 30 /\n\n - VTVT1 330 ms 55 /\n\n<!-- -->\n\n- Probe Settings: Lead Sensitivity Sensing Polarity/Vector\n Amplification/Pulse Width Stimulation Polarity/Vector Auto Amplitude\n Control\n\n - Right Atrial: 0.30 mV Bipolar/ 1.375 V/0.50 ms Bipolar/\n\n - Right Ventricular: Bipolar/ 2.000 V/0.50 ms Bipolar/\n\n - Left Ventricular: 2.000 V/0.50 ms tip 1 - RV Coil\n\n**Assessment:**\n\n- Routine visit with normal device function.\n\n- Normal sinus rhythm with a heart rate of 65/min.\n\n- Balanced heart rate histogram with a plateau at 60-70 bpm.\n\n- Wound conditions are unremarkable.\n\n- Battery status: OK.\n\n- Atrial probe: Intact\n\n- Right ventricular probe: Intact\n\n- Left ventricular probe: Intact\n\n- A follow-up appointment for the patient is requested in 6 months.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ----------------------------------- ------------ ---------------------\n Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Creatinine 1.34 mg/dL 0.70-1.20 mg/dL\n BUN 49 mg/dL 17-48 mg/dL\n Total Bilirubin 1.8 mg/dL \\< 1.20 mg/dL\n C-reactive Protein 5.9 mg/L \\< 5.0 mg/L\n ALT 67 U/L \\< 41 U/L\n AST 78 U/L \\< 50 U/L\n Alkaline Phosphatase 151 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mU/L 0.27-4.20 mU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cell Count 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cell Count 9.56 K/µL 3.90-10.50 K/µL\n MCV 92.7 fL 80.0-99.0 fL\n MCH 31.8 pg 27.0-33.5 pg\n MCHC 33.9 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.2% 11.5-15.0%\n Quick 89% 78-123%\n INR 1.09 0.90-1.25\n Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n", "title": "text_10" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. Brian Carter, born on\n04/24/1956, who was under our inpatient care from 09/28/2021 to\n09/30/2021.\n\n**Diagnosis**: ARDS in the context of a COVID-19 infection\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Mr. Carter presented to our facility on foot\non 09/28/2021 with a five-day history of slowly progressive dyspnea, dry\ncough, and non-apoplectic, holocentral headache. His initial room air\nsaturation was 78%, which improved to 86% with 10 liters of oxygen.\nArterial blood gas analysis revealed an oxygenation disorder with a paO2\nof 50 mmHg, prompting the initiation of NIV therapy, under which Mr.\nCarter remained hemodynamically stable. CT imaging showed bilateral\ninterstitial pneumonia with COVID-typical infiltrates. Both a rapid test\nin the initial care unit and one from his primary care physician were\nnegative for COVID-19. Therefore, we admitted Mr. Carter to our\nintensive care unit for further evaluation.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Alert and cooperative\n\n[Cardiovascular/Abdominal Examination]{.underline}: Severely impaired\noxygenation improved with NIV; Sinus rhythm at 80 beats per minute\n\n[Abdomen]{.underline}: Surgical abdomen\n\n[Renal System:]{.underline} Urination initially scant, then polyuria\nOthers.\n\n**Therapy and Progression:** Upon admission, Mr. Carter was alert,\ncooperative, and hemodynamically stable despite significant oxygenation\nimpairment. Temporary improvement was achieved with differentiated NIV\nmask ventilation. On 09/30, there was a further deterioration in\noxygenation with an increase in respiratory rate and escalation of\nventilator settings, leading to the decision to intubate. A tolerable\nventilation situation was achieved with an oxygenation index of 125. Due\nto radiological suspicion of atypical pneumonia, we initiated empirical\nanti-infective therapy with Piperacillin/Tazobactam, Clarithromycin, and\nCotrimoxazole. Microbiological test results were pending at the time of\ntransfer. We also initiated mucolytic therapy with Ambroxol. The\npre-existing immunosuppressive therapy with Prednisolone was\ndiscontinued and switched to Dexamethasone 10 mg. At the time of\ntransfer, Mr. Carter was hemodynamically stable with low catecholamine\ndoses (0.07 µg/kg/min). A central venous catheter was placed, and\nenteral or parenteral nutrition had not yet been initiated. Diuresis was\nsufficient after a single dose of 20 mg furosemide, with retention\nparameters within the normal range. Prophylactic anticoagulation with\nheparin 500 U/h was initiated.\n\n**Status at Transfer**:\n\n[Neurology]{.underline}: RASS -5 under Propofol and Sufentanil sedation\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline (NA)\n0.07; Hemoglobin 12.8 g/dL\n\n[Lungs]{.underline}: Adequate decarboxylation with borderline\noxygenation: paO2 87.6 under FiO2 0.7; PEEP 16; PEAK 27\n\n[Abdomen]{.underline}: Soft abdomen, no nutrition initiated\n\n[Renal System]{.underline}: Normal urine output without stimulation.\nRetention values within normal range. Clear urine.\n\n[Access]{.underline}: CVC placed on 09/30, left radial artery catheter\nplaced on 09/30.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under our inpatient care from 09/30/2021 to 10/13/2021.\n\n**Diagnosis:** ARDS due to COVID-19 pneumonia with superinfection by\nAspergillus fumigatus\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The patient was admitted from the emergency\ndepartment, presenting with dyspnea and confirmed SARS-CoV-2 infection.\nAfter initial management in the intensive care unit, a non-invasive\nventilation (NIV) trial was attempted, followed by successful\nintubation. The patient was then transferred to the Intensive Care Unit.\n\n**Therapy and Progression:** Upon admission, the patient was sedated,\nintubated, and controlled on mechanical ventilation with mild\ncatecholamine support. Due to oxygenation impairment despite\nlung-protective ventilation and inhaled supportive NO therapy,\nconservative ARDS therapy was initiated, including positioning therapy\n(a total of 9 prone positions). After stabilization of gas exchange with\npositioning therapy, sedation and ventilation weaning were performed.\nGas exchange and oxygenation are currently stable under BIPAP\nventilation (PiP 25 mbar, PEEP 13 mbar, breathing rate 18/min). The\npatient, under reduced analgosedation with Sufentanil and Clonidine,\nexhibits a sufficient awakening response, is adequately responsive, and\nfollows commands with reduced muscle strength.\n\nThe home medication of Methotrexate and Prednisolone for uveitis was\ndiscontinued upon admission. The patient received Dexamethasone for 10\ndays initially and, starting from 11/10, prednisolone with prophylactic\nCotrimoxazole therapy.\n\nUpon detection of Aspergillus in tracheobronchial secretions, antifungal\ntherapy with Voriconazole and Caspofungin (until target Voriconazole\nlevels were achieved) was initiated. The initially started antimicrobial\ntherapy with Piperacillin + Tazobactam was escalated to Meropenem on\n10/05/2021 due to worsening infection parameters and progression of\ninfiltrates on X-ray. Infection parameters have been fluctuating, and\nfever is not currently observed. Diuresis is qualitatively and\nquantitatively within normal limits, and retention parameters are within\nthe normal range.\n\nAnticoagulation was administered in therapeutic doses using\nlow-molecular-weight heparin.\n\nEnteral nutrition is provided through a nasogastric tube, and the\npatient has regular bowel movements.\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Analgosedated, GCS 10, pupils equal and\nreactive, limb movement prompt, follows commands with reduced strength\n\n[Lungs]{.underline}: Intubated with BIPAP 25/13, FiO2 0.4\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline 0.05\n\n[Abdomen]{.underline}: Obese, no tenderness, abdomen soft, oral intake\nvia a nasogastric tube, regular bowel movements\n\n[Diuresis]{.underline}: Normal urine output, retention parameters within\nnormal limits\n\nSkin/Wounds: Some pressure sores from positioning (see nursing handover\nsheet)\n\n[Mobilization]{.underline}: Not conducted\n\n**Imaging:**\n\n**Bedside Chest X-ray from 10/11/2021:**\n\n[Clinical information, question, justifying indication:]{.underline}\nCOVID pneumonia, insertion of a central venous catheter (CVC)\n\n**Assessment**: Comparison with 10/05/21: Endotracheal tube identical,\ngastric tube seen extending well into the abdomen, left CVC currently\npositioned in the brachiocephalic vein region, right CVC via internal\njugular vein with tip in superior vena cava. No pneumothorax, no\neffusions, increasing consolidation of infiltrates in the right lower\nlobe and retrocardially on the left without significant cavitation as\nfar as can be assessed. Left heart without significant central\ncongestion.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under intensive care treatment from 09/28/2021 to 10/12/2021 and\nin our intensive care unit from 10/13/2021 to 10/21/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The initial hospital admission of the patient was\nthrough our emergency department due to severe respiratory insufficiency\nin the context of COVID-19 pneumonia.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Skin/Mucous Membranes]{.underline}: Warm, Skin Perfusion: Good\nperfusion, Edema: Lower legs\n\n[Head]{.underline}: Mobility: Active and passive free movement, Tongue:\nMoist\n\n[Thorax]{.underline}: Auscultation: Clear bilaterally\n\n[Abdomen]{.underline}: Soft, no guarding, Bowel Sounds: Sparse\nperistalsis, Tenderness: None\n\n[Neurology]{.underline}: Pupil Shape: Round, Pupil Size: Moderate, Light\nReaction: Both sides +++\n\nAlertness: Awake\n\n**ECG on admission:** Tachycardic sinus rhythm with 107/min, Left type,\nP-wave normally configured, normal PQ interval, no pathological Q as in\nPardee-Q, narrow QRS, regular R progression, R/S transition in V3/4, no\nS persistence, no ST segment changes, no discordant T-negatives.\n\n**Therapy and Progression:** Despite intensified oxygen therapy with\nnasal high-flow and mask CPAP, adequate oxygenation could not be\nachieved, and the patient was intubated on 09/29/21. Leading oxygenation\nimpairment led to lung-protective ventilation with inhaled supportive NO\ntherapy and conservative ARDS therapy, including positioning therapy (a\ntotal of 9 prone positions, 16 hours each, from 09/29/21 to 10/8/21).\n\nDue to elevated procalcitonin, the patient received empirical antibiotic\ntreatment with Piperacillin/Tazobactam starting from 10/2/21, which was\nescalated to Meropenem on 10/5/21 and continued until 10/14/21.\n\nAfter the detection of Aspergillus in tracheobronchial secretions and\nBAL, the patient received Voriconazole since 10/7/2021 (treatment\nduration formally 4-6 weeks). Most recently, the level was\nsubtherapeutic, so the dose was adjusted to 2 x 400 mg daily.\n\nThe immunosuppressive therapy with Methotrexate and Prednisolone for\nrheumatoid arthritis was switched to Dexamethasone (09/29 to 10/8) and,\nsince 10/09, Prednisolone monotherapy. After controlling the fungal\ninfection, a rheumatology re-consultation was planned. Furthermore,\nsubtherapeutic anticoagulation with Fraxiparine was initiated for the\nprevention of thrombotic complications in the context of COVID-19.\n\nUnder this treatment regimen, gas exchange continuously improved, and on\n10/12/21, the patient was transferred with low catecholamine\nrequirements for ventilation and sedation weaning. Mr. Carter was\nextubated on 12/13/21 and now maintains good oxygenation with less than\n3L oxygen via nasal cannula. Delirium symptoms after extubation\ncompletely regressed within a few days.\n\nSevere dysphagia was observed after invasive ventilation, leading to a\nspeech therapy consultation. Oral feeding is currently not possible, so\nMr. Carter is receiving parenteral nutrition. As a result, there was a\nparavasate in the upper right extremity with painful erythema. Adequate\npain control was achieved with local cooling and Piritramide as needed.\nDue to continued dietary restrictions, a central venous catheter was\nplaced on 10/20/2021 for parenteral nutrition.\n\nWe request continued speech therapy treatment.\n\nOn 10/21/21, Staphylococcus aureus was detected in blood culture, so we\ninitiated the administration of Flucloxacillin. The MRSA rapid test was\nnegative.\n\nWe are transferring Mr. Carter on 10/21/21 in stable condition, awake,\nand appropriately responsive for further treatment. We appreciate the\ntransfer of our patient and are available for any further questions.\n\n**Current Recommendations:**\n\n- Continuation of antifungal therapy for a total of at least 4-6 weeks\n\n- Voriconazole level measurement\n\n- Speech therapy consultation\n\n- Rheumatology re-consultation\n\n- Follow-up blood cultures upon detection of Staph. aureus\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Mr. Brian Carter, born on 04/24/1956, who was under\nour inpatient care from 10/21/2021 to 11/08/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Transfer for continuation of antimicrobial\ntherapy for MSSA bacteremia. Transesophageal echocardiogram planned for\ntomorrow. Cleared for full diet by speech therapy today. Patient\nmobilized to standing position for the first time today. Overall,\nmobility is significantly limited, but the patient can mobilize to the\nedge of the bed independently. No pain, no fever, mild cough without\nsputum. No shortness of breath. Mood is significantly depressed, but\nthis is a known issue. Before COVID-19, he was heavily affected by\nrheumatoid arthritis.\n\n**Medical History:** The patient was transferred to our COVID ward after\na positive SARS-CoV-2 RNA PCR test in the naso-oropharyngeal swab and\nrespiratory failure. On physical examination, he had a reduced general\ncondition. Respiratory rate was 24/min, and oxygen saturation was 97% on\n4 L/min of O2 via nasal cannula. Oxygen supply of 4 L via nasal cannula\ncould not be reduced during the course. A chest X-ray performed on 11/21\nshowed increasingly loosened infiltrates in the left basal region and a\nminimal effusion at the base.\n\nA SARS-CoV-2 RNA PCR test from 11/10/2020 was negative, so Mr. Carter\nwas no longer in isolation.\n\nDue to the detection of Aspergillus fumigatus in bronchoalveolar lavage,\nintravenous Voriconazole therapy initiated on 10/07/2021 was continued\nand was planned to be adjusted according to drug level monitoring.\nAdditionally, Staph. aureus was identified in a blood culture, and\nStaph. epidermidis. Antibiotic therapy with Cefazolin was started on\n10/22 and was to be continued for a total of 14 days after the first\nnegative blood culture. The central venous catheter, likely the source\nof infection, was removed on 10/22, and microbiological examination of\nthe catheter tip indicated suspicion of Staphylococci. To rule out\nendocarditis, a transesophageal echocardiogram was scheduled for 10/24.\nMr. Carter has already been informed about this intervention, and\nFraxiparine was to be paused on the evening of 10/24 and the morning of\n10/27, with the patient kept fasting.\n\nThere is also a known history of rheumatoid arthritis, which was treated\non an outpatient basis with Methotrexate and Prednisolone. Due to the\ncurrent infection, Methotrexate was paused, and after consultation with\nthe rheumatologists, it was decided to continue with prednisolone 5mg.\nAfter complete pulmonary recovery, a rheumatology re-consultation was\nplanned, and the resumption of methotrexate was considered.\n\nUpon admission, the patient had significant dysphagia, which improved\nduring the course. A flexible endoscopic swallowing examination\nperformed on 10/24/2021 by speech therapists and phoniatrics revealed a\nnormal swallow reflex. Mr. Carter can now resume a regular diet.\n\n**Physical Examination:** Weight: 83 kg, Height: 182 cm. Temperature:\n36.5°C, Heart rate: 80/min, Respiratory rate: 25/min, Blood pressure:\n130/80 mmHg, Oxygen saturation: 98% with 2 L/min O2\n\n[Skin/mucous membranes:]{.underline} No edema, no skin abnormalities.\nCentral venous catheter exit site on the neck is unremarkable.\n\n[Head/neck:]{.underline} Own teeth, intact mucous membranes\n\n[Heart]{.underline}: Rhythmic, tachycardic up to 100/min, clear heart\nsounds, no murmurs\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no adventitious\nsounds\n\n[Abdomen]{.underline}: Soft, active bowel sounds, no tenderness, no\nresistance\n\n[Lymph nodes:]{.underline} Cervical, axillary nodes not palpable\n\n[Vessels]{.underline}: Foot pulses palpable\n\n[Musculoskeletal:]{.underline} Muscle strength reduced due to CIP/CIM.\nCan mobilize to the bedside independently\n\n[Basic neurological examination:]{.underline} Alert, oriented, friendly\n\n[Psychological state]{.underline}: Depressed mood\n\n**Therapy and Progression:** The emergency presentation of Mr. Carter\nwas on 09/28/2021 due to severe dyspnea and respiratory insufficiency.\nAfter direct transfer to Intensive Care Unit, despite intensified oxygen\ntherapy with nasal high flow and mask CPAP, adequate oxygenation could\nnot be achieved, leading to intubation on 10/29/21.\n\nLung-protective ventilation was initiated due to leading oxygenation\nimpairment, with inhalational supportive NO therapy and conservative\nARDS therapy, including positional changes (a total of 9 sessions of 16\nhours each from 09/29/21 to 10/08/21). Due to elevated PCT levels, the\npatient received empiric antibiotic therapy with\nPiperacillin/Tazobactam, escalated to Meropenem. Voriconazole was\ninitiated on 10/07/2021 after the detection of Aspergillus in\ntracheobronchial secretions and BAL (intended treatment duration 4-6\nweeks).\n\nSubtherapeutic anticoagulation with Fraxiparine was administered for the\nprevention of thrombotic complications in the context of COVID-19. Under\nthis treatment regimen, gas exchange steadily improved, and on 10/12/21,\nthe patient was transferred with low catecholamine requirements for\nweaning from mechanical ventilation and sedation. There, he was\nextubated on 10/13/21.\n\nAfter extubation, severe dysphagia was observed, and speech therapy was\nconsulted. Oral diet is currently not possible, so Mr. Carter is on\nparenteral nutrition. This led to a paravasate in the right upper\nextremity with painful erythema. Adequate pain control was achieved with\nlocal cooling and subcutaneous Piritramide, as needed.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- ------------ ---------------------\n Absolute Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.3 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.61 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\>90 \\>90\n BUN 23 mg/dL 17-48 mg/dL\n Total Bilirubin 0.18 mg/dL \\< 1.20 mg/dL\n C-Reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 6.1 ng/L \\< 14 ng/L\n ALT 50 U/L \\< 41 U/L\n AST 40 U/L \\< 50 U/L\n Alkaline Phosphatase 111 U/L 40-130 U/L\n Gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cells 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.56 K/µL 3.90-10.50 K/µL\n Platelets 280 K/µL 150-370 K/µL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Prothrombin Time 89% 78-123%\n INR 1.09 0.90-1.25\n Activated Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n**Imaging:**\n\n**Chest X-ray bedside on 09/29/2021:** CT scan of the chest from\n9/28/2021 is available for comparison. Tracheal tube tip supracarinal.\nCentral venous catheter (CVC) via right internal jugular vein, tip in\nthe confluence of veins. Gastric tube tip infradiaphragmatic. Patchy\nconfluent bilateral lung infiltrates, mainly perihilar, left and right\nupper and lower fields. No significant changes compared to the previous\nday. Small bilateral pleural effusions. No pneumothorax in the lying\nposition. Left-sided heart prominence with mild stasis/capillary leak.\n\n**Chest X-ray bedside on 10/3/2021:**\n\n[Findings]{.underline}: Compared to 09/29/2021. Tracheal tube with tip\napproximately 4 cm above the carina. Gastric tube slightly retracted,\ntip located just below the diaphragm. Central venous catheter via the\nright internal jugular vein, currently with the tip in the superior vena\ncava. Regression and loosening of infiltrates (mainly in the lower\nfields on both sides). No significant effusion or pneumothorax. No\nsubstantial volume overload.\n\n**Chest X-ray bedside on 10/6/2021:**\n\n[Findings]{.underline}: Compared to the previous examination on\n11/4/2020. New central venous catheter (CVC) from the left internal\njugular vein with tip in the confluence. No pneumothorax in the lying\nposition, no large pleural effusions. Progressive infiltrates in the\nright lower field, perihilar regions on both sides. No significant\ncentral stasis. Heart not enlarged, mediastinum slim.\n\n**Chest X-ray bedside on 10/11/2021:**\n\n[Findings]{.underline}: Compared to 10/5/2021. Tracheal tube and gastric\ntube as before. Left CVC with the tip currently in the region of the\nbrachiocephalic vein, right CVC via the internal jugular vein with the\ntip in the superior vena cava. No pneumothorax, no effusions, increasing\nconsolidation of infiltrates in the right lower field and retrocardial\nleft with no significant cavitation. Left-biased heart without\nsignificant central congestion.\n\n**Chest X-ray bedside on 10/16/2021:**\n\n[Findings]{.underline}: Compared to previous examinations on 10/11/2021.\nHeart borderline enlarged. Mediastinum, as far as can be assessed from\nslightly rotated images, appears central and slim. Increasing\nconsolidation in the right lower lobe and left lower lobe, which is well\ncompatible with pneumonic infiltrates. At most, a small pleural effusion\non the left. No pneumothorax in the lying position. No signs of\nsignificant congestion. Right jugular catheter projecting into the\nsuperior vena cava. Tracheal tube and left jugular catheter have been\nremoved since the last examination.\n\n**Chest X-ray bedside on 10/20/2021:**\n\n[Findings]{.underline}: Compared to the examination on 10/16/2021. In\nthe course of known COVID pneumonia, there is an increasingly loosened\nappearance of infiltrates in the left basal region. A small effusion\ncontinues to drain basally. Otherwise, no significant changes in the\nshort-term follow-up. Right jugular catheter projecting into the\nsuperior vena cava, as before.\n\n**EKG on 10/27/2021:** Normal sinus rhythm, 86/min. Indeterminate axis.\nPQ interval: 108ms QRS duration: 108ms. QTc interval: 484ms. Peripheral\nlow voltage. Delayed R progression up to and including V3. RS transition\nin V4. No significant ST-T wave changes.\n\n**Ultrasound Abdomen on 11/01/2021:**\n\n[Reason for referral:]{.underline} History of COVID, Aspergillosis\n\n[Liver]{.underline}: Vertical diameter in the midclavicular line on the\nright is 120 mm.\n\n[Biliary tract]{.underline}: Well visualized. No abnormalities in the\nintrahepatic and extrahepatic bile ducts. Maximum width of the common\nbile duct is 3 mm.\n\n[Gallbladder]{.underline}: Well visualized. Normal findings.\n\n[Pancreas]{.underline}: Maximum diameters - Head: 17 mm, Body: 12 mm,\nTail: 15 mm. Well visualized. Normal findings.\n\n[Spleen]{.underline}: Normal size, normal homogeneous internal echo\npattern, no focal changes, hilum is free. Organ size: 120 mm x 38 mm.\n\n[Right kidney:]{.underline} Partially assessable, as far as\nrecognizable, parenchymal edge is age-appropriate, smooth organ contour,\nno urinary obstruction, no stones. Size: 120 mm x 45 mm, parenchymal\nthickness 21 mm.\n\n[Left kidney:]{.underline} Partially assessable, as far as recognizable,\nparenchymal edge is age-appropriate, smooth organ contour, no urinary\nobstruction, no stones. Size: 115 mm x 61 mm, parenchymal thickness 19\nmm.\n\n[Bladder:]{.underline} Well visualized, orthotopically located, normal\nwall proportions, no pathological echo structures in the lumen, normal\norgan size.\n\n[Abdominal vessels:]{.underline} Normal findings.\n\n[Abdominal lymph nodes:]{.underline} No evidence of enlarged lymph nodes\nin the subphrenic region.\n\n[Peritoneum]{.underline}: No free fluid.\n\n[Color duplex sonography of the portal vein:]{.underline} Orthograde\nflow, no evidence of thrombosis.\n\n[Assessment]{.underline}: In the right lower lobe cranial-lateral\n(segment VII), there is an entirely echo-free cystic structure with a\nslightly lobulated contour. There is no \\\"double wall,\\\" and there are\nno features suggestive of Echinococcus. This is most likely a congenital\ncyst. The overall structure, architecture, and texture of the liver are\nnormal, with no other focal abnormalities. In the rest of the abdomen,\nthere are no other pathological findings.\n\n**Cardiology Consultation on 10/29/2021:**\n\n**Medical History:** The patient reports thoracic complaints following\nthe intensive care unit stay post-COVID. These pains have been noticed\nwith mild exertion and are described as retrosternal with radiation to\nthe left chest. This last occurred on Sunday afternoon, lasting for\napproximately 1 hour and then spontaneously resolving at rest. This pain\ncannot be induced by a change in position, coughing, or deep\ninspiration. Dyspnea is continuously present, and the patient still\nrequires oxygen. Dyspnea worsens when lying down.\n\n**Cardiovascular risk factors**: Mildly elevated blood pressure\n(hypertension) since May of this year, managed with half a tablet\naccording to self-measurements (averaging 120/80 mmHg, rarely in the\n130s). Lipid profile checked by the general practitioner earlier this\nyear, presumably with good results. No known diabetes. Former smoker\nuntil 2007, but it is difficult to estimate the pack-years, as smoking\noccurred on occasions and during stressful times, less than 15\npack-years. No family history of cardiovascular diseases.\nUveitis/scleritis/episcleritis managed with 10mg MTX per week and 5 mg p\n\nPrednisolone orally daily, well-controlled without recurrence.\n\n**Physical Examination**: Lungs with moist rales bilaterally. Cardiac\nexamination with faint heart sounds. Regular heart rate of 80/min. No\npericardial rub. Pale-gray skin color. Respiratory rate of 15/min while\nsitting. Radial pulses palpable bilaterally. Groin pulses not examined.\nAllen\\'s test operable on the right, borderline on the left.\n\n**ECG**: tachycardic sinus rhythm with a heart rate of 109/min, left\naxis deviation, regular R-wave progression in chest leads, mild\nS-persistence in V6, no significant ST-T wave changes.\n\n**Transthoracic and transesophageal echocardiography on 11/27/2020**:\n\n[Kinetics]{.underline}: Hypokinesia of the lateral and anterior walls,\notherwise normokinetic and synergistic. Systolic function (right\nventricle): TAPSE 18 mm (\\> 16 mm), RV-S\\' 17.6 cm/s (\\> 10 cm/s).\n\n[Valves]{.underline}: Mitral valve - Delicate leaflets, good opening\nmotion, no significant insufficiency. Lambl\\'s excrescences on the\natrial side. Small fluttering structure at the subvalvular apparatus,\ncompatible with chordae tendineae. Aortic valve - Tricuspid, delicate\nvalve. Functionally intact (AV Vmax 1.0 m/s). Tricuspid valve -\nMorphologically normal. Mild insufficiency. TR Vmax 1.9 m/s, sPAP 15\nmmHg + CVP. Pulmonic valve - Morphologically and functionally normal.\n\n[Other Findings:]{.underline} No pericardial effusion. Small Persistent\nForamen Ovale. Left atrial appendage free of intracavitary thrombi at\n60°/90°/150°. Thoracic aorta with smooth-walled plaques, no dissections\nor thrombi.\n\n[Assessment]{.underline}: No structures suggestive of endocarditis. No\nrelevant valvular abnormalities. Incidentally, there is a moderately\nreduced LVEF with wall motion abnormalities in the RIVA (right\nventricular anterior) region. We request a cardiology consultation and\nfurther diagnostics.\n\n**Phoniatric Consultation on 10/24/2021:**\n\n[Medical History:]{.underline} Patient with a history of COVID\npneumonia, twice tested negative. Currently, the patient has Aspergillus\nand pneumonia. Previously, the patient was in the ICU and intubated for\ntwo weeks due to COVID. Following speech therapy for dysphagia, a\nflexible endoscopic evaluation of swallowing (FEES) is requested.\n\n[Findings]{.underline}: FEES reveals a normal configuration of the\nlarynx with good mobility of the tongue and lips. Normal gross mobility\nof the vocal cords during phonation and respiration transitions. Full\nglottic closure appears complete. Flexible transnasal swallow evaluation\n(FEES) with blue dye: Sufficient oral bolus control for liquids, purees,\nand solids. No drooling or leakage. Swallow reflex present. Voluntary\ninitiation of the swallow act is possible. Side-by-side swallowing of\ntest substances over the valleculae without evidence of\npre-/intra-/post-deglutitive penetration or aspiration for all test\nconsistencies. Rosenbeck\\'s Penetration-Aspiration Scale score: 1\n(Minimal retention in the valleculae with puree, which can be completely\ncleared by swallowing). Normal sensitivity, strong cough reflex. No\nnasal regurgitation.\n\n[Assessment]{.underline}: Normal swallowing function.\n\n[Current Recommendations:]{.underline} Able to consume regular diet and\nthin liquids, as well as medications with water.\n\n**Therapy and Progression:** The patient was admitted for further\ntreatment. Upon admission, the patient was in a reduced general\ncondition with significant mobility limitations.\n\nStaphylococcus aureus was detected in a blood culture, leading to a\ntransesophageal echocardiogram (TEE) on 11/26/2020. No vegetations were\nfound, but a moderate hypokinesia of the left ventricle in the RIVA area\nwas observed. Cardiac enzymes were within normal limits. This was\ninterpreted as post-COVID myocarditis, differential diagnosis myocardial\ninjury in severe ARDS, coronary artery disease, or mixed picture.\n\nIn consultation with the cardiology colleagues, a cautious heart failure\nmedication regimen with beta-blockers and ACE inhibitors was initiated.\nWe recommend an elective coronary angiography in the future. Currently,\nthe patient was symptom-free with low cardiac markers and a normal ECG,\nso acute diagnostic procedures were not indicated.\n\nThe antibiotic therapy with Cefazolin was continued until 11/05/2021\n(last sterile blood cultures from 10/24/2021). Staphylococcus\nepidermidis detected in the blood culture on 10/20/21 and at the tip of\nthe central venous catheter on 10/22/21 were considered\ncatheter-associated. The catheter was immediately removed. The patient\ndid not develop a fever during the hospital stay. Inflammatory markers\nimproved over time.\n\nAn abdominal ultrasound was performed due to an unclear liver lesion,\nwhich was found to be a congenital cyst. Echinococcus serology was\nnegative.\n\nIn consultation with the psychiatric colleagues, Quetiapine medication\nwas cautiously resumed for known depression, but it had to be\ndiscontinued later due to significant QTc prolongation. Long-term oxygen\ntherapy of 2 liters was indicated.\n\nOur ophthalmology colleagues recommended the resumption of MTX therapy\ngiven the patient\\'s stable vision. We request this therapy be initiated\nand an outpatient follow-up appointment in ophthalmology arranged after\nthe patient completes rehabilitation.\n\nWith physiotherapy, the patient achieved mobilization up to walking.\nSwallowing and articulation difficulties also significantly improved.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency** **Route**\n ---------------------------------- --------------- ------------------------------ ------------\n Metoprolol Succinate (Toprol XL) 23.8 mg 1-0-1-0 Oral\n Dicloxacillin Sodium (Dynapen) 2176 mg 1-1-1-0 Oral\n Voriconazole (Vfend) 200 mg 2-0-2-0 Oral\n Acetaminophen (Tylenol) 500 mg As needed Oral\n Ipratropium Bromide (Atrovent) 0.26 mg/2 ml 6-0-0-0 Inhalation\n Albuterol Sulfate (ProAir) 1.5 mg/2.5 ml 6-0-0-0 Inhalation\n Amitriptyline (Elavil) 28.3 mg 0-0-1-0 Oral\n Citalopram (Celexa) 50 mg 1-0-0-0 Oral\n Melatonin 2 mg 0-0-2-0 Oral\n Montelukast (Singulair) 10 mg 1-0-0-0 Oral\n Pantoprazole (Protonix) 45 mg 0-0-1-0 Oral\n Eplerenone (Inspra) 25 mg 1-0-0-0 Oral\n Ramipril (Altace) 2.5 mg 0-0-1-0 Oral\n Folic Acid 5 mg 0-0-1-0 48h after MTX intake Oral\n Methotrexate (Trexall) 15 mg 1-0-0-0 Once a Week Oral\n\n\n\n### text_4\n**Dear colleague, **\n\nWe thank you for referring your patient, Mr. Brian Carter, born on\n04/24/1956 to our outpatient care on 02/03/2022.\n\n**Diagnoses**: Suspected Post-Intensive-Care Syndrome with:\n\n- Dysphagia\n\n- ICU-acquired weakness\n\n- Depressive mood, anxiety\n\n**Other Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n<!-- -->\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** Mr. Carter was treated in the intensive care unit\nfor a total of 24 days in September and October 2021 due to COVID-19.\nFollowing intensive care treatment, he underwent neurological\nrehabilitation from 11/08/2021 to 01/18/2022, with the following\nrehabilitation results: \\\"Mr. I. benefited well from the therapies.\nParticularly, physiotherapy helped regain confidence in walking. During\ntreatment, breathing difficulties improved, and oxygen supplementation\nwas no longer necessary.\\\" An antidepressant therapy with Mirtazapine\nwas initiated for sleep disorders and mood swings, resulting in a\nreduction in sleep disturbances.\n\n**Assessment**: Since the illness, Mr. Carter reports general fatigue,\nquick fatigue, and weakness, especially in the lower extremities. He is\ncurrently not undergoing physiotherapy or any other treatments.\nRegarding psychopharmacological therapy, the patient has been seeing a\npsychiatrist once a month based on anamnesis. After a short exertion, he\nexperiences dyspnea and regularly needs to take breaks. Room air\nsaturation was at 94%. Physical examination revealed significant\nexpiratory wheezing and prolonged expiration bilaterally. Furthermore,\nthe patient reports cognitive impairments with marked forgetfulness and\ndifficulty concentrating. This is evident in the reduced results of the\nMiniCog (2/3 words, normal clock, 4 points) and animal naming tests\n(correct single naming of 10 animals, 3 points). Additionally, the\npatient reports an exacerbation of symptoms of depression known since\n2011, including sadness, fatigue, sleep disturbances, and anxiety. These\nworsened during the ICU stay. The current medication includes Citalopram\n40 mg and Mirtazapine 7.5 mg, which have somewhat improved previously\nworsened sleep disturbances. Psychotherapy is not currently taking place\nbut is strongly recommended.\n\nDysphagia diagnosed during the intensive care unit stay has slightly\nimproved, allowing Mr. Carter to consume regular food again. However, he\nstill experiences dysphagia and coughing during each meal. An\nappointment at the swallowing clinic has been scheduled by us (see\nbelow).\n\n**Current Recommendations:**\n\nAs swallowing difficulties persist, an appointment has been scheduled at\nour local swallowing clinic. We also recommend a pulmonary evaluation.\nContact has already been made, and the colleagues from Pulmonology will\nget in touch with Mr. Carter. Furthermore, due to a previously existing\ndepressive mood with currently exacerbated symptoms, we recommend\nconnecting the patient with an outpatient psychotherapist. Some\ntherapists have already been suggested by the patient\\'s general\npractitioner, and we strongly recommend further contact. A prescription\nfor physiotherapy has been issued for pronounced muscle weakness and\nsuspected ICU-acquired weakness. Further physiotherapeutic engagement\nwith the general practitioner\\'s assistance is urgently required.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------- ------------- ---------------------\n Neutrophils 49.0 % 42.0-77.0 %\n Lymphocytes 31.9 % 20.0-44.0 %\n Monocytes 7.2 % 2.0-9.5 %\n Basophils 0.7 % 0.0-1.8 %\n Eosinophils 10.8 % 0.5-5.5 %\n Immature Granulocytes 0.4 % 0.0-1.0 %\n Sodium 139 mEq/L 136-145 mEq/L\n Potassium 3.5 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.99 mg/dL 0.70-1.20 mg/dL\n BUN 25 mg/dL 17-48 mg/dL\n Total Bilirubin 0.45 mg/dL \\< 1.20 mg/dL\n CRP 3.9 mg/dL \\< 5.0 mg/dL\n ALT 21 U/L \\< 41 U/L\n AST 20 U/L \\< 50 U/L\n Alkaline Phosphatase 65 U/L 40-130 U/L\n Gamma-GT 38 U/L 8-61 U/L\n LDH 160 U/L 135-250 U/L\n Lipase 20 U/L 13-60 U/L\n Procalcitonin 0.03 µg/L \\< 0.50 µg/L\n Hemoglobin 13.2 g/dL 13.5-17.0 g/dL\n Hematocrit 44.2 % 39.5-50.5 %\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 7.62 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n\n\n\n\nHere is the query:\nHow was Mr. Carter's thyroid-stimulating hormone (TSH) level characterized?\n\nChoose the correct answer from the following options:\nA. Elevated\nB. Decreased\nC. Subtherapeutic\nD. Within normal range\nE. Not measured\n\n\nYour response:\n", "role": "user" }, { "content": "Within normal range", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. Brian Carter, born on\n04/24/1956, who was under our inpatient care from 09/28/2021 to\n09/30/2021.\n\n**Diagnosis**: ARDS in the context of a COVID-19 infection\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Mr. Carter presented to our facility on foot\non 09/28/2021 with a five-day history of slowly progressive dyspnea, dry\ncough, and non-apoplectic, holocentral headache. His initial room air\nsaturation was 78%, which improved to 86% with 10 liters of oxygen.\nArterial blood gas analysis revealed an oxygenation disorder with a paO2\nof 50 mmHg, prompting the initiation of NIV therapy, under which Mr.\nCarter remained hemodynamically stable. CT imaging showed bilateral\ninterstitial pneumonia with COVID-typical infiltrates. Both a rapid test\nin the initial care unit and one from his primary care physician were\nnegative for COVID-19. Therefore, we admitted Mr. Carter to our\nintensive care unit for further evaluation.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Alert and cooperative\n\n[Cardiovascular/Abdominal Examination]{.underline}: Severely impaired\noxygenation improved with NIV; Sinus rhythm at 80 beats per minute\n\n[Abdomen]{.underline}: Surgical abdomen\n\n[Renal System:]{.underline} Urination initially scant, then polyuria\nOthers.\n\n**Therapy and Progression:** Upon admission, Mr. Carter was alert,\ncooperative, and hemodynamically stable despite significant oxygenation\nimpairment. Temporary improvement was achieved with differentiated NIV\nmask ventilation. On 09/30, there was a further deterioration in\noxygenation with an increase in respiratory rate and escalation of\nventilator settings, leading to the decision to intubate. A tolerable\nventilation situation was achieved with an oxygenation index of 125. Due\nto radiological suspicion of atypical pneumonia, we initiated empirical\nanti-infective therapy with Piperacillin/Tazobactam, Clarithromycin, and\nCotrimoxazole. Microbiological test results were pending at the time of\ntransfer. We also initiated mucolytic therapy with Ambroxol. The\npre-existing immunosuppressive therapy with Prednisolone was\ndiscontinued and switched to Dexamethasone 10 mg. At the time of\ntransfer, Mr. Carter was hemodynamically stable with low catecholamine\ndoses (0.07 µg/kg/min). A central venous catheter was placed, and\nenteral or parenteral nutrition had not yet been initiated. Diuresis was\nsufficient after a single dose of 20 mg furosemide, with retention\nparameters within the normal range. Prophylactic anticoagulation with\nheparin 500 U/h was initiated.\n\n**Status at Transfer**:\n\n[Neurology]{.underline}: RASS -5 under Propofol and Sufentanil sedation\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline (NA)\n0.07; Hemoglobin 12.8 g/dL\n\n[Lungs]{.underline}: Adequate decarboxylation with borderline\noxygenation: paO2 87.6 under FiO2 0.7; PEEP 16; PEAK 27\n\n[Abdomen]{.underline}: Soft abdomen, no nutrition initiated\n\n[Renal System]{.underline}: Normal urine output without stimulation.\nRetention values within normal range. Clear urine.\n\n[Access]{.underline}: CVC placed on 09/30, left radial artery catheter\nplaced on 09/30.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under our inpatient care from 09/30/2021 to 10/13/2021.\n\n**Diagnosis:** ARDS due to COVID-19 pneumonia with superinfection by\nAspergillus fumigatus\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The patient was admitted from the emergency\ndepartment, presenting with dyspnea and confirmed SARS-CoV-2 infection.\nAfter initial management in the intensive care unit, a non-invasive\nventilation (NIV) trial was attempted, followed by successful\nintubation. The patient was then transferred to the Intensive Care Unit.\n\n**Therapy and Progression:** Upon admission, the patient was sedated,\nintubated, and controlled on mechanical ventilation with mild\ncatecholamine support. Due to oxygenation impairment despite\nlung-protective ventilation and inhaled supportive NO therapy,\nconservative ARDS therapy was initiated, including positioning therapy\n(a total of 9 prone positions). After stabilization of gas exchange with\npositioning therapy, sedation and ventilation weaning were performed.\nGas exchange and oxygenation are currently stable under BIPAP\nventilation (PiP 25 mbar, PEEP 13 mbar, breathing rate 18/min). The\npatient, under reduced analgosedation with Sufentanil and Clonidine,\nexhibits a sufficient awakening response, is adequately responsive, and\nfollows commands with reduced muscle strength.\n\nThe home medication of Methotrexate and Prednisolone for uveitis was\ndiscontinued upon admission. The patient received Dexamethasone for 10\ndays initially and, starting from 11/10, prednisolone with prophylactic\nCotrimoxazole therapy.\n\nUpon detection of Aspergillus in tracheobronchial secretions, antifungal\ntherapy with Voriconazole and Caspofungin (until target Voriconazole\nlevels were achieved) was initiated. The initially started antimicrobial\ntherapy with Piperacillin + Tazobactam was escalated to Meropenem on\n10/05/2021 due to worsening infection parameters and progression of\ninfiltrates on X-ray. Infection parameters have been fluctuating, and\nfever is not currently observed. Diuresis is qualitatively and\nquantitatively within normal limits, and retention parameters are within\nthe normal range.\n\nAnticoagulation was administered in therapeutic doses using\nlow-molecular-weight heparin.\n\nEnteral nutrition is provided through a nasogastric tube, and the\npatient has regular bowel movements.\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Analgosedated, GCS 10, pupils equal and\nreactive, limb movement prompt, follows commands with reduced strength\n\n[Lungs]{.underline}: Intubated with BIPAP 25/13, FiO2 0.4\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline 0.05\n\n[Abdomen]{.underline}: Obese, no tenderness, abdomen soft, oral intake\nvia a nasogastric tube, regular bowel movements\n\n[Diuresis]{.underline}: Normal urine output, retention parameters within\nnormal limits\n\nSkin/Wounds: Some pressure sores from positioning (see nursing handover\nsheet)\n\n[Mobilization]{.underline}: Not conducted\n\n**Imaging:**\n\n**Bedside Chest X-ray from 10/11/2021:**\n\n[Clinical information, question, justifying indication:]{.underline}\nCOVID pneumonia, insertion of a central venous catheter (CVC)\n\n**Assessment**: Comparison with 10/05/21: Endotracheal tube identical,\ngastric tube seen extending well into the abdomen, left CVC currently\npositioned in the brachiocephalic vein region, right CVC via internal\njugular vein with tip in superior vena cava. No pneumothorax, no\neffusions, increasing consolidation of infiltrates in the right lower\nlobe and retrocardially on the left without significant cavitation as\nfar as can be assessed. Left heart without significant central\ncongestion.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under intensive care treatment from 09/28/2021 to 10/12/2021 and\nin our intensive care unit from 10/13/2021 to 10/21/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The initial hospital admission of the patient was\nthrough our emergency department due to severe respiratory insufficiency\nin the context of COVID-19 pneumonia.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Skin/Mucous Membranes]{.underline}: Warm, Skin Perfusion: Good\nperfusion, Edema: Lower legs\n\n[Head]{.underline}: Mobility: Active and passive free movement, Tongue:\nMoist\n\n[Thorax]{.underline}: Auscultation: Clear bilaterally\n\n[Abdomen]{.underline}: Soft, no guarding, Bowel Sounds: Sparse\nperistalsis, Tenderness: None\n\n[Neurology]{.underline}: Pupil Shape: Round, Pupil Size: Moderate, Light\nReaction: Both sides +++\n\nAlertness: Awake\n\n**ECG on admission:** Tachycardic sinus rhythm with 107/min, Left type,\nP-wave normally configured, normal PQ interval, no pathological Q as in\nPardee-Q, narrow QRS, regular R progression, R/S transition in V3/4, no\nS persistence, no ST segment changes, no discordant T-negatives.\n\n**Therapy and Progression:** Despite intensified oxygen therapy with\nnasal high-flow and mask CPAP, adequate oxygenation could not be\nachieved, and the patient was intubated on 09/29/21. Leading oxygenation\nimpairment led to lung-protective ventilation with inhaled supportive NO\ntherapy and conservative ARDS therapy, including positioning therapy (a\ntotal of 9 prone positions, 16 hours each, from 09/29/21 to 10/8/21).\n\nDue to elevated procalcitonin, the patient received empirical antibiotic\ntreatment with Piperacillin/Tazobactam starting from 10/2/21, which was\nescalated to Meropenem on 10/5/21 and continued until 10/14/21.\n\nAfter the detection of Aspergillus in tracheobronchial secretions and\nBAL, the patient received Voriconazole since 10/7/2021 (treatment\nduration formally 4-6 weeks). Most recently, the level was\nsubtherapeutic, so the dose was adjusted to 2 x 400 mg daily.\n\nThe immunosuppressive therapy with Methotrexate and Prednisolone for\nrheumatoid arthritis was switched to Dexamethasone (09/29 to 10/8) and,\nsince 10/09, Prednisolone monotherapy. After controlling the fungal\ninfection, a rheumatology re-consultation was planned. Furthermore,\nsubtherapeutic anticoagulation with Fraxiparine was initiated for the\nprevention of thrombotic complications in the context of COVID-19.\n\nUnder this treatment regimen, gas exchange continuously improved, and on\n10/12/21, the patient was transferred with low catecholamine\nrequirements for ventilation and sedation weaning. Mr. Carter was\nextubated on 12/13/21 and now maintains good oxygenation with less than\n3L oxygen via nasal cannula. Delirium symptoms after extubation\ncompletely regressed within a few days.\n\nSevere dysphagia was observed after invasive ventilation, leading to a\nspeech therapy consultation. Oral feeding is currently not possible, so\nMr. Carter is receiving parenteral nutrition. As a result, there was a\nparavasate in the upper right extremity with painful erythema. Adequate\npain control was achieved with local cooling and Piritramide as needed.\nDue to continued dietary restrictions, a central venous catheter was\nplaced on 10/20/2021 for parenteral nutrition.\n\nWe request continued speech therapy treatment.\n\nOn 10/21/21, Staphylococcus aureus was detected in blood culture, so we\ninitiated the administration of Flucloxacillin. The MRSA rapid test was\nnegative.\n\nWe are transferring Mr. Carter on 10/21/21 in stable condition, awake,\nand appropriately responsive for further treatment. We appreciate the\ntransfer of our patient and are available for any further questions.\n\n**Current Recommendations:**\n\n- Continuation of antifungal therapy for a total of at least 4-6 weeks\n\n- Voriconazole level measurement\n\n- Speech therapy consultation\n\n- Rheumatology re-consultation\n\n- Follow-up blood cultures upon detection of Staph. aureus\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Brian Carter, born on 04/24/1956, who was under\nour inpatient care from 10/21/2021 to 11/08/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Transfer for continuation of antimicrobial\ntherapy for MSSA bacteremia. Transesophageal echocardiogram planned for\ntomorrow. Cleared for full diet by speech therapy today. Patient\nmobilized to standing position for the first time today. Overall,\nmobility is significantly limited, but the patient can mobilize to the\nedge of the bed independently. No pain, no fever, mild cough without\nsputum. No shortness of breath. Mood is significantly depressed, but\nthis is a known issue. Before COVID-19, he was heavily affected by\nrheumatoid arthritis.\n\n**Medical History:** The patient was transferred to our COVID ward after\na positive SARS-CoV-2 RNA PCR test in the naso-oropharyngeal swab and\nrespiratory failure. On physical examination, he had a reduced general\ncondition. Respiratory rate was 24/min, and oxygen saturation was 97% on\n4 L/min of O2 via nasal cannula. Oxygen supply of 4 L via nasal cannula\ncould not be reduced during the course. A chest X-ray performed on 11/21\nshowed increasingly loosened infiltrates in the left basal region and a\nminimal effusion at the base.\n\nA SARS-CoV-2 RNA PCR test from 11/10/2020 was negative, so Mr. Carter\nwas no longer in isolation.\n\nDue to the detection of Aspergillus fumigatus in bronchoalveolar lavage,\nintravenous Voriconazole therapy initiated on 10/07/2021 was continued\nand was planned to be adjusted according to drug level monitoring.\nAdditionally, Staph. aureus was identified in a blood culture, and\nStaph. epidermidis. Antibiotic therapy with Cefazolin was started on\n10/22 and was to be continued for a total of 14 days after the first\nnegative blood culture. The central venous catheter, likely the source\nof infection, was removed on 10/22, and microbiological examination of\nthe catheter tip indicated suspicion of Staphylococci. To rule out\nendocarditis, a transesophageal echocardiogram was scheduled for 10/24.\nMr. Carter has already been informed about this intervention, and\nFraxiparine was to be paused on the evening of 10/24 and the morning of\n10/27, with the patient kept fasting.\n\nThere is also a known history of rheumatoid arthritis, which was treated\non an outpatient basis with Methotrexate and Prednisolone. Due to the\ncurrent infection, Methotrexate was paused, and after consultation with\nthe rheumatologists, it was decided to continue with prednisolone 5mg.\nAfter complete pulmonary recovery, a rheumatology re-consultation was\nplanned, and the resumption of methotrexate was considered.\n\nUpon admission, the patient had significant dysphagia, which improved\nduring the course. A flexible endoscopic swallowing examination\nperformed on 10/24/2021 by speech therapists and phoniatrics revealed a\nnormal swallow reflex. Mr. Carter can now resume a regular diet.\n\n**Physical Examination:** Weight: 83 kg, Height: 182 cm. Temperature:\n36.5°C, Heart rate: 80/min, Respiratory rate: 25/min, Blood pressure:\n130/80 mmHg, Oxygen saturation: 98% with 2 L/min O2\n\n[Skin/mucous membranes:]{.underline} No edema, no skin abnormalities.\nCentral venous catheter exit site on the neck is unremarkable.\n\n[Head/neck:]{.underline} Own teeth, intact mucous membranes\n\n[Heart]{.underline}: Rhythmic, tachycardic up to 100/min, clear heart\nsounds, no murmurs\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no adventitious\nsounds\n\n[Abdomen]{.underline}: Soft, active bowel sounds, no tenderness, no\nresistance\n\n[Lymph nodes:]{.underline} Cervical, axillary nodes not palpable\n\n[Vessels]{.underline}: Foot pulses palpable\n\n[Musculoskeletal:]{.underline} Muscle strength reduced due to CIP/CIM.\nCan mobilize to the bedside independently\n\n[Basic neurological examination:]{.underline} Alert, oriented, friendly\n\n[Psychological state]{.underline}: Depressed mood\n\n**Therapy and Progression:** The emergency presentation of Mr. Carter\nwas on 09/28/2021 due to severe dyspnea and respiratory insufficiency.\nAfter direct transfer to Intensive Care Unit, despite intensified oxygen\ntherapy with nasal high flow and mask CPAP, adequate oxygenation could\nnot be achieved, leading to intubation on 10/29/21.\n\nLung-protective ventilation was initiated due to leading oxygenation\nimpairment, with inhalational supportive NO therapy and conservative\nARDS therapy, including positional changes (a total of 9 sessions of 16\nhours each from 09/29/21 to 10/08/21). Due to elevated PCT levels, the\npatient received empiric antibiotic therapy with\nPiperacillin/Tazobactam, escalated to Meropenem. Voriconazole was\ninitiated on 10/07/2021 after the detection of Aspergillus in\ntracheobronchial secretions and BAL (intended treatment duration 4-6\nweeks).\n\nSubtherapeutic anticoagulation with Fraxiparine was administered for the\nprevention of thrombotic complications in the context of COVID-19. Under\nthis treatment regimen, gas exchange steadily improved, and on 10/12/21,\nthe patient was transferred with low catecholamine requirements for\nweaning from mechanical ventilation and sedation. There, he was\nextubated on 10/13/21.\n\nAfter extubation, severe dysphagia was observed, and speech therapy was\nconsulted. Oral diet is currently not possible, so Mr. Carter is on\nparenteral nutrition. This led to a paravasate in the right upper\nextremity with painful erythema. Adequate pain control was achieved with\nlocal cooling and subcutaneous Piritramide, as needed.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- ------------ ---------------------\n Absolute Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.3 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.61 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\>90 \\>90\n BUN 23 mg/dL 17-48 mg/dL\n Total Bilirubin 0.18 mg/dL \\< 1.20 mg/dL\n C-Reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 6.1 ng/L \\< 14 ng/L\n ALT 50 U/L \\< 41 U/L\n AST 40 U/L \\< 50 U/L\n Alkaline Phosphatase 111 U/L 40-130 U/L\n Gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cells 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.56 K/µL 3.90-10.50 K/µL\n Platelets 280 K/µL 150-370 K/µL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Prothrombin Time 89% 78-123%\n INR 1.09 0.90-1.25\n Activated Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n**Imaging:**\n\n**Chest X-ray bedside on 09/29/2021:** CT scan of the chest from\n9/28/2021 is available for comparison. Tracheal tube tip supracarinal.\nCentral venous catheter (CVC) via right internal jugular vein, tip in\nthe confluence of veins. Gastric tube tip infradiaphragmatic. Patchy\nconfluent bilateral lung infiltrates, mainly perihilar, left and right\nupper and lower fields. No significant changes compared to the previous\nday. Small bilateral pleural effusions. No pneumothorax in the lying\nposition. Left-sided heart prominence with mild stasis/capillary leak.\n\n**Chest X-ray bedside on 10/3/2021:**\n\n[Findings]{.underline}: Compared to 09/29/2021. Tracheal tube with tip\napproximately 4 cm above the carina. Gastric tube slightly retracted,\ntip located just below the diaphragm. Central venous catheter via the\nright internal jugular vein, currently with the tip in the superior vena\ncava. Regression and loosening of infiltrates (mainly in the lower\nfields on both sides). No significant effusion or pneumothorax. No\nsubstantial volume overload.\n\n**Chest X-ray bedside on 10/6/2021:**\n\n[Findings]{.underline}: Compared to the previous examination on\n11/4/2020. New central venous catheter (CVC) from the left internal\njugular vein with tip in the confluence. No pneumothorax in the lying\nposition, no large pleural effusions. Progressive infiltrates in the\nright lower field, perihilar regions on both sides. No significant\ncentral stasis. Heart not enlarged, mediastinum slim.\n\n**Chest X-ray bedside on 10/11/2021:**\n\n[Findings]{.underline}: Compared to 10/5/2021. Tracheal tube and gastric\ntube as before. Left CVC with the tip currently in the region of the\nbrachiocephalic vein, right CVC via the internal jugular vein with the\ntip in the superior vena cava. No pneumothorax, no effusions, increasing\nconsolidation of infiltrates in the right lower field and retrocardial\nleft with no significant cavitation. Left-biased heart without\nsignificant central congestion.\n\n**Chest X-ray bedside on 10/16/2021:**\n\n[Findings]{.underline}: Compared to previous examinations on 10/11/2021.\nHeart borderline enlarged. Mediastinum, as far as can be assessed from\nslightly rotated images, appears central and slim. Increasing\nconsolidation in the right lower lobe and left lower lobe, which is well\ncompatible with pneumonic infiltrates. At most, a small pleural effusion\non the left. No pneumothorax in the lying position. No signs of\nsignificant congestion. Right jugular catheter projecting into the\nsuperior vena cava. Tracheal tube and left jugular catheter have been\nremoved since the last examination.\n\n**Chest X-ray bedside on 10/20/2021:**\n\n[Findings]{.underline}: Compared to the examination on 10/16/2021. In\nthe course of known COVID pneumonia, there is an increasingly loosened\nappearance of infiltrates in the left basal region. A small effusion\ncontinues to drain basally. Otherwise, no significant changes in the\nshort-term follow-up. Right jugular catheter projecting into the\nsuperior vena cava, as before.\n\n**EKG on 10/27/2021:** Normal sinus rhythm, 86/min. Indeterminate axis.\nPQ interval: 108ms QRS duration: 108ms. QTc interval: 484ms. Peripheral\nlow voltage. Delayed R progression up to and including V3. RS transition\nin V4. No significant ST-T wave changes.\n\n**Ultrasound Abdomen on 11/01/2021:**\n\n[Reason for referral:]{.underline} History of COVID, Aspergillosis\n\n[Liver]{.underline}: Vertical diameter in the midclavicular line on the\nright is 120 mm.\n\n[Biliary tract]{.underline}: Well visualized. No abnormalities in the\nintrahepatic and extrahepatic bile ducts. Maximum width of the common\nbile duct is 3 mm.\n\n[Gallbladder]{.underline}: Well visualized. Normal findings.\n\n[Pancreas]{.underline}: Maximum diameters - Head: 17 mm, Body: 12 mm,\nTail: 15 mm. Well visualized. Normal findings.\n\n[Spleen]{.underline}: Normal size, normal homogeneous internal echo\npattern, no focal changes, hilum is free. Organ size: 120 mm x 38 mm.\n\n[Right kidney:]{.underline} Partially assessable, as far as\nrecognizable, parenchymal edge is age-appropriate, smooth organ contour,\nno urinary obstruction, no stones. Size: 120 mm x 45 mm, parenchymal\nthickness 21 mm.\n\n[Left kidney:]{.underline} Partially assessable, as far as recognizable,\nparenchymal edge is age-appropriate, smooth organ contour, no urinary\nobstruction, no stones. Size: 115 mm x 61 mm, parenchymal thickness 19\nmm.\n\n[Bladder:]{.underline} Well visualized, orthotopically located, normal\nwall proportions, no pathological echo structures in the lumen, normal\norgan size.\n\n[Abdominal vessels:]{.underline} Normal findings.\n\n[Abdominal lymph nodes:]{.underline} No evidence of enlarged lymph nodes\nin the subphrenic region.\n\n[Peritoneum]{.underline}: No free fluid.\n\n[Color duplex sonography of the portal vein:]{.underline} Orthograde\nflow, no evidence of thrombosis.\n\n[Assessment]{.underline}: In the right lower lobe cranial-lateral\n(segment VII), there is an entirely echo-free cystic structure with a\nslightly lobulated contour. There is no \\\"double wall,\\\" and there are\nno features suggestive of Echinococcus. This is most likely a congenital\ncyst. The overall structure, architecture, and texture of the liver are\nnormal, with no other focal abnormalities. In the rest of the abdomen,\nthere are no other pathological findings.\n\n**Cardiology Consultation on 10/29/2021:**\n\n**Medical History:** The patient reports thoracic complaints following\nthe intensive care unit stay post-COVID. These pains have been noticed\nwith mild exertion and are described as retrosternal with radiation to\nthe left chest. This last occurred on Sunday afternoon, lasting for\napproximately 1 hour and then spontaneously resolving at rest. This pain\ncannot be induced by a change in position, coughing, or deep\ninspiration. Dyspnea is continuously present, and the patient still\nrequires oxygen. Dyspnea worsens when lying down.\n\n**Cardiovascular risk factors**: Mildly elevated blood pressure\n(hypertension) since May of this year, managed with half a tablet\naccording to self-measurements (averaging 120/80 mmHg, rarely in the\n130s). Lipid profile checked by the general practitioner earlier this\nyear, presumably with good results. No known diabetes. Former smoker\nuntil 2007, but it is difficult to estimate the pack-years, as smoking\noccurred on occasions and during stressful times, less than 15\npack-years. No family history of cardiovascular diseases.\nUveitis/scleritis/episcleritis managed with 10mg MTX per week and 5 mg p\n\nPrednisolone orally daily, well-controlled without recurrence.\n\n**Physical Examination**: Lungs with moist rales bilaterally. Cardiac\nexamination with faint heart sounds. Regular heart rate of 80/min. No\npericardial rub. Pale-gray skin color. Respiratory rate of 15/min while\nsitting. Radial pulses palpable bilaterally. Groin pulses not examined.\nAllen\\'s test operable on the right, borderline on the left.\n\n**ECG**: tachycardic sinus rhythm with a heart rate of 109/min, left\naxis deviation, regular R-wave progression in chest leads, mild\nS-persistence in V6, no significant ST-T wave changes.\n\n**Transthoracic and transesophageal echocardiography on 11/27/2020**:\n\n[Kinetics]{.underline}: Hypokinesia of the lateral and anterior walls,\notherwise normokinetic and synergistic. Systolic function (right\nventricle): TAPSE 18 mm (\\> 16 mm), RV-S\\' 17.6 cm/s (\\> 10 cm/s).\n\n[Valves]{.underline}: Mitral valve - Delicate leaflets, good opening\nmotion, no significant insufficiency. Lambl\\'s excrescences on the\natrial side. Small fluttering structure at the subvalvular apparatus,\ncompatible with chordae tendineae. Aortic valve - Tricuspid, delicate\nvalve. Functionally intact (AV Vmax 1.0 m/s). Tricuspid valve -\nMorphologically normal. Mild insufficiency. TR Vmax 1.9 m/s, sPAP 15\nmmHg + CVP. Pulmonic valve - Morphologically and functionally normal.\n\n[Other Findings:]{.underline} No pericardial effusion. Small Persistent\nForamen Ovale. Left atrial appendage free of intracavitary thrombi at\n60°/90°/150°. Thoracic aorta with smooth-walled plaques, no dissections\nor thrombi.\n\n[Assessment]{.underline}: No structures suggestive of endocarditis. No\nrelevant valvular abnormalities. Incidentally, there is a moderately\nreduced LVEF with wall motion abnormalities in the RIVA (right\nventricular anterior) region. We request a cardiology consultation and\nfurther diagnostics.\n\n**Phoniatric Consultation on 10/24/2021:**\n\n[Medical History:]{.underline} Patient with a history of COVID\npneumonia, twice tested negative. Currently, the patient has Aspergillus\nand pneumonia. Previously, the patient was in the ICU and intubated for\ntwo weeks due to COVID. Following speech therapy for dysphagia, a\nflexible endoscopic evaluation of swallowing (FEES) is requested.\n\n[Findings]{.underline}: FEES reveals a normal configuration of the\nlarynx with good mobility of the tongue and lips. Normal gross mobility\nof the vocal cords during phonation and respiration transitions. Full\nglottic closure appears complete. Flexible transnasal swallow evaluation\n(FEES) with blue dye: Sufficient oral bolus control for liquids, purees,\nand solids. No drooling or leakage. Swallow reflex present. Voluntary\ninitiation of the swallow act is possible. Side-by-side swallowing of\ntest substances over the valleculae without evidence of\npre-/intra-/post-deglutitive penetration or aspiration for all test\nconsistencies. Rosenbeck\\'s Penetration-Aspiration Scale score: 1\n(Minimal retention in the valleculae with puree, which can be completely\ncleared by swallowing). Normal sensitivity, strong cough reflex. No\nnasal regurgitation.\n\n[Assessment]{.underline}: Normal swallowing function.\n\n[Current Recommendations:]{.underline} Able to consume regular diet and\nthin liquids, as well as medications with water.\n\n**Therapy and Progression:** The patient was admitted for further\ntreatment. Upon admission, the patient was in a reduced general\ncondition with significant mobility limitations.\n\nStaphylococcus aureus was detected in a blood culture, leading to a\ntransesophageal echocardiogram (TEE) on 11/26/2020. No vegetations were\nfound, but a moderate hypokinesia of the left ventricle in the RIVA area\nwas observed. Cardiac enzymes were within normal limits. This was\ninterpreted as post-COVID myocarditis, differential diagnosis myocardial\ninjury in severe ARDS, coronary artery disease, or mixed picture.\n\nIn consultation with the cardiology colleagues, a cautious heart failure\nmedication regimen with beta-blockers and ACE inhibitors was initiated.\nWe recommend an elective coronary angiography in the future. Currently,\nthe patient was symptom-free with low cardiac markers and a normal ECG,\nso acute diagnostic procedures were not indicated.\n\nThe antibiotic therapy with Cefazolin was continued until 11/05/2021\n(last sterile blood cultures from 10/24/2021). Staphylococcus\nepidermidis detected in the blood culture on 10/20/21 and at the tip of\nthe central venous catheter on 10/22/21 were considered\ncatheter-associated. The catheter was immediately removed. The patient\ndid not develop a fever during the hospital stay. Inflammatory markers\nimproved over time.\n\nAn abdominal ultrasound was performed due to an unclear liver lesion,\nwhich was found to be a congenital cyst. Echinococcus serology was\nnegative.\n\nIn consultation with the psychiatric colleagues, Quetiapine medication\nwas cautiously resumed for known depression, but it had to be\ndiscontinued later due to significant QTc prolongation. Long-term oxygen\ntherapy of 2 liters was indicated.\n\nOur ophthalmology colleagues recommended the resumption of MTX therapy\ngiven the patient\\'s stable vision. We request this therapy be initiated\nand an outpatient follow-up appointment in ophthalmology arranged after\nthe patient completes rehabilitation.\n\nWith physiotherapy, the patient achieved mobilization up to walking.\nSwallowing and articulation difficulties also significantly improved.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency** **Route**\n ---------------------------------- --------------- ------------------------------ ------------\n Metoprolol Succinate (Toprol XL) 23.8 mg 1-0-1-0 Oral\n Dicloxacillin Sodium (Dynapen) 2176 mg 1-1-1-0 Oral\n Voriconazole (Vfend) 200 mg 2-0-2-0 Oral\n Acetaminophen (Tylenol) 500 mg As needed Oral\n Ipratropium Bromide (Atrovent) 0.26 mg/2 ml 6-0-0-0 Inhalation\n Albuterol Sulfate (ProAir) 1.5 mg/2.5 ml 6-0-0-0 Inhalation\n Amitriptyline (Elavil) 28.3 mg 0-0-1-0 Oral\n Citalopram (Celexa) 50 mg 1-0-0-0 Oral\n Melatonin 2 mg 0-0-2-0 Oral\n Montelukast (Singulair) 10 mg 1-0-0-0 Oral\n Pantoprazole (Protonix) 45 mg 0-0-1-0 Oral\n Eplerenone (Inspra) 25 mg 1-0-0-0 Oral\n Ramipril (Altace) 2.5 mg 0-0-1-0 Oral\n Folic Acid 5 mg 0-0-1-0 48h after MTX intake Oral\n Methotrexate (Trexall) 15 mg 1-0-0-0 Once a Week Oral\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient, Mr. Brian Carter, born on\n04/24/1956 to our outpatient care on 02/03/2022.\n\n**Diagnoses**: Suspected Post-Intensive-Care Syndrome with:\n\n- Dysphagia\n\n- ICU-acquired weakness\n\n- Depressive mood, anxiety\n\n**Other Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n<!-- -->\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** Mr. Carter was treated in the intensive care unit\nfor a total of 24 days in September and October 2021 due to COVID-19.\nFollowing intensive care treatment, he underwent neurological\nrehabilitation from 11/08/2021 to 01/18/2022, with the following\nrehabilitation results: \\\"Mr. I. benefited well from the therapies.\nParticularly, physiotherapy helped regain confidence in walking. During\ntreatment, breathing difficulties improved, and oxygen supplementation\nwas no longer necessary.\\\" An antidepressant therapy with Mirtazapine\nwas initiated for sleep disorders and mood swings, resulting in a\nreduction in sleep disturbances.\n\n**Assessment**: Since the illness, Mr. Carter reports general fatigue,\nquick fatigue, and weakness, especially in the lower extremities. He is\ncurrently not undergoing physiotherapy or any other treatments.\nRegarding psychopharmacological therapy, the patient has been seeing a\npsychiatrist once a month based on anamnesis. After a short exertion, he\nexperiences dyspnea and regularly needs to take breaks. Room air\nsaturation was at 94%. Physical examination revealed significant\nexpiratory wheezing and prolonged expiration bilaterally. Furthermore,\nthe patient reports cognitive impairments with marked forgetfulness and\ndifficulty concentrating. This is evident in the reduced results of the\nMiniCog (2/3 words, normal clock, 4 points) and animal naming tests\n(correct single naming of 10 animals, 3 points). Additionally, the\npatient reports an exacerbation of symptoms of depression known since\n2011, including sadness, fatigue, sleep disturbances, and anxiety. These\nworsened during the ICU stay. The current medication includes Citalopram\n40 mg and Mirtazapine 7.5 mg, which have somewhat improved previously\nworsened sleep disturbances. Psychotherapy is not currently taking place\nbut is strongly recommended.\n\nDysphagia diagnosed during the intensive care unit stay has slightly\nimproved, allowing Mr. Carter to consume regular food again. However, he\nstill experiences dysphagia and coughing during each meal. An\nappointment at the swallowing clinic has been scheduled by us (see\nbelow).\n\n**Current Recommendations:**\n\nAs swallowing difficulties persist, an appointment has been scheduled at\nour local swallowing clinic. We also recommend a pulmonary evaluation.\nContact has already been made, and the colleagues from Pulmonology will\nget in touch with Mr. Carter. Furthermore, due to a previously existing\ndepressive mood with currently exacerbated symptoms, we recommend\nconnecting the patient with an outpatient psychotherapist. Some\ntherapists have already been suggested by the patient\\'s general\npractitioner, and we strongly recommend further contact. A prescription\nfor physiotherapy has been issued for pronounced muscle weakness and\nsuspected ICU-acquired weakness. Further physiotherapeutic engagement\nwith the general practitioner\\'s assistance is urgently required.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------- ------------- ---------------------\n Neutrophils 49.0 % 42.0-77.0 %\n Lymphocytes 31.9 % 20.0-44.0 %\n Monocytes 7.2 % 2.0-9.5 %\n Basophils 0.7 % 0.0-1.8 %\n Eosinophils 10.8 % 0.5-5.5 %\n Immature Granulocytes 0.4 % 0.0-1.0 %\n Sodium 139 mEq/L 136-145 mEq/L\n Potassium 3.5 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.99 mg/dL 0.70-1.20 mg/dL\n BUN 25 mg/dL 17-48 mg/dL\n Total Bilirubin 0.45 mg/dL \\< 1.20 mg/dL\n CRP 3.9 mg/dL \\< 5.0 mg/dL\n ALT 21 U/L \\< 41 U/L\n AST 20 U/L \\< 50 U/L\n Alkaline Phosphatase 65 U/L 40-130 U/L\n Gamma-GT 38 U/L 8-61 U/L\n LDH 160 U/L 135-250 U/L\n Lipase 20 U/L 13-60 U/L\n Procalcitonin 0.03 µg/L \\< 0.50 µg/L\n Hemoglobin 13.2 g/dL 13.5-17.0 g/dL\n Hematocrit 44.2 % 39.5-50.5 %\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 7.62 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are writing to provide an update on the examination results of our\npatient Mrs. Hilary Sanders, born on 08/24/1976, who presented to our\noutpatient clinic on 10/09/2016.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n human immunoglobulin\n\n**Medical History:** Mrs. Sanders presented with suspected previously\nundiagnosed immunodeficiency. There were no reports of frequent\ninfections during childhood and adolescence. No increased herpes\ninfections. No history of pneumonia, meningitis, or other serious\ninfections.\n\n**Current Presentation:** Mrs. Sanders has experienced recurrent\nrespiratory infections (bronchitis, pharyngitis) for about 3 years.\n\n**Physical Examination:** She reported joint pain in the left knee and\nnumbness below the shoulder blade. A tendency to bruise easily. No\nmucosal lesions, recurrent axillary lymph node swelling. No recurrent\nfevers. No B-symptoms. No resting dyspnea, no subjective heart rhythm\ndisturbances, no syncope, no peripheral edema, or other signs of\ncardiopulmonary decompensation.\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all IgG\n subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and NK-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B-cells.\n\n- Monocytic HLA-DR expression (immune competence marker) within the\n normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n- T-cell function after 24h polyvalent ConA stimulation: TNF-alpha,\n IFN-gamma, IL-2, IL-4 unremarkable\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells.\n\nFurther cellular immune status, including the complement system and\nsoluble mediators, showed no significant abnormalities except for an\nelevated soluble IL-2 receptor. Given the unremarkable monocytic\nTNF-alpha secretion after LPS stimulation, a significant Toll-like\nReceptor 4 defect is unlikely. An antibody response to Tetanus Toxoid\nwas demonstrated in a vaccine titer test. Protective\npneumococcal-specific antibodies could not be detected. There were no\nabnormalities in autoimmune diagnostics.\n\nImmunofixation showed no evidence of monoclonal gammopathy.\nHypogammaglobulinemia due to enteral or renal protein loss is unlikely\nin the presence of normal albumin.\n\nOverall, the picture is consistent with Common Variable\nImmunodeficiency. Formally, CVID is defined by a reduction in the major\nimmunoglobulin class IgG, with accompanying reduction in IgA and/or IgM,\nin the absence of normal or impaired vaccine response. Due to very low\nimmunoglobulin levels and planned travel, determination of vaccine\nresponse was currently omitted in the absence of therapeutic\nconsequence. After stable substitution, specific vaccine antibody levels\ncan be determined before or after vaccination, with the assumption that\nstable antibody concentrations exist due to continuous immunoglobulin\nsubstitution.\n\nAccording to B-cell differentiation, it corresponds to Type Ib according\nto the Freiburg Classification and Type B+smB-CD21lo according to the\nEuro Classification. The classification is clinically relevant, as Type\nIa is associated with increased immunocytopenias (especially ITP and\nAIH) and splenomegaly. In CVID with a high proportion (\\>10%) of CD-21\nlow B-cells, increased granulomatous diseases and splenomegaly have also\nbeen observed.\n\nThe indication for immunoglobulin substitution therapy exists because of\nrecurrent infections. The form of substitution therapy (intravenous. vs.\nsubcutaneous) is primarily based on patient preferences, but also on\nmedical conditions (concomitant diseases such as thrombocytopenia,\nconvenience, insurance, etc.).\n\n**Current Recommendations:**\n\nWe propose to initiate immunoglobulin substitution therapy with Hizentra\n20% (subcutaneous) at a dose of 200 ml once a week on Tuesdays. Further\ninformation and training on subcutaneous immunoglobulin substitution\ntherapy will be provided by a home care nursing service.\n\nMrs. Sanders will remain under regular medical supervision with close\nmonitoring of clinical symptoms, laboratory parameters, and the\neffectiveness of immunoglobulin substitution therapy. Any unexpected\nside effects or changes in her condition should be reported immediately.\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n --------------------------------------- --------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Calcium 2.41 mg/dL 2.15-2.50 mg/dL\n Inorganic Phosphate 1.00 mg/dL 0.87-1.45 mg/dL\n Selenium 0.79 µmol/L 0.60-1.50 µmol/L\n Zinc 10.1 µmol/L 9.0-22.0 µmol/L\n Creatinine 0.75 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 mL/min \\>90 mL/min\n Total Bilirubin 0.37 mg/dL \\< 1.20 mg/dL\n Albumin 4.55 g/dL 3.50-5.20 g/dL\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n A2-Globulin in Serum 10.7% 7.1-11.8%\n ß-Globulin in Serum 9.2% 8.4-13.1%\n Gamma-Globulin in Serum 3.2% 11.1-18.8%\n Immunoglobulin G 514 mg/dL 700-1600 mg/dL\n Immunoglobulin A 14 mg/dL 70-400 mg/dL\n Immunoglobulin M 19 mg/dL 40-230 mg/dL\n Immunoglobulin E 90 kU/L 0.0-100.0 kU/L\n IgG 1 299.5 mg/dL 280-800 mg/dL\n IgG 2 162.7 mg/dL 115-570 mg/dL\n IgG 3 49.1 mg/dL 24-125 mg/dL\n IgG 4 4.0 mg/dL 5.2-125 mg/dL\n Serum Immunofixation \n CRP 4.8 mg/L \\< 5.0 mg/L\n C3 Complement 980 mg/L 900-1800 mg/L\n C4 Complement 120 mg/L 100-400 mg/L\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n HBs Antigen Negative \n HBc Antibody Negative \n HBs Antibody Negative \n Ferritin 56 µg/L 13-140 µg/L\n ALT (GPT) 33 U/L \\< 31 U/L\n AST (GOT) 29 U/L \\< 35 U/L\n Alkaline Phosphatase 84 U/L 35-105 U/L\n Creatine Kinase 90 U/L \\< 167 U/L\n CK-MB 8.3 U/L \\< 24.0 U/L\n Gamma-GT 40 U/L 5-36 U/L\n LDH 204 U/L 135-214 U/L\n Lipase 50 U/L 13-60 U/L\n Cortisol 306.6 nmol/L 64.0-327.0 nmol/L\n 25-OH-Vitamin D3 65.3 nmol/L 50.0-150.0 nmol/L\n 1.25-OH-Vitamin D3 134 pmol/L 18.0-155.0 pmol/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Vitamin B12 770 pg/mL 191-663 pg/mL\n Folic Acid 14.6 ng/mL 4.6-18.7 ng/mL\n Hemoglobin 13.9 g/dL 12.0-15.6 g/dL\n Hematocrit 41.0% 35.5-45.5%\n Erythrocytes 5.2 M/uL 3.9-5.2 M/uL\n Leukocytes 4.13 K/uL 3.90-10.50 K/uL\n Platelets 174 K/uL 150-370 K/uL\n MCV 80.0 fL 80.0-99.0 fL\n MCH 26.7 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n RDW-CV 13.7% 11.5-15.0%\n Absolute Neutrophils 2.87 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.010 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.71 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.42 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.03 K/uL 0.00-0.20 K/uL\n HbA1c 4.9% \\< 6.0%\n HbA1c (IFCC) 30.1 mmol/mol \\< 42.0\n HBV Serology Result Negative \n HIV1/2 Antibodies, P24 Antigen Negative \n Hepatitis C Virus Antibodies in Serum Negative \n\n**Dear colleague,**\n\nWe report the examination results of Mrs. Hilary Sanders, born on\n08/24/1976 who presented at our outpatient clinic on 03/04/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all\n IgG-Subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and natural killer-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B cells.\n\n- Monocytic HLA-DR expression within the normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells. The further cellular immune\nstatus, including the complement system and soluble mediators, showed no\nsignificant abnormalities except for an elevated soluble IL-2 receptor.\n\n**Current Presentation:** Mrs. Sanders was again provided with detailed\ninformation about her condition and the planned course of action. We\nscheduled an appointment to initiate regular subcutaneous immunoglobulin\ntherapy.\n\n**Medical History:** Mrs. Sanders received her first dose of Hizentra\n20% subcutaneously as immunoglobulin substitution therapy for CVID. The\nadministration was well-tolerated initially, with no evidence of\nsignificant local or systemic side effects. Mrs. Sanders was once again\ninformed about possible risks (especially hypersensitivity reactions)\nand advised to contact us immediately in case of questions,\nuncertainties, or any abnormalities. The dosing for the first four weeks\nwas 3x20mL Hizentra 20% subcutaneously, and from the fifth week onward,\nit was changed to either 1x40mL or 2x20mL Hizentra 20% subcutaneously\nper week.\n\nIn the past days, Mrs. Sanders has been experiencing a cold: runny nose,\ncough (green-yellow), difficulty clearing mucus, slight fever, sinus\ninflammation, sore throat, difficulty speaking, and swallowing problems.\nThere was no improvement.\n\n**Physical Examination:** Reddened throat, no exudates, non-swollen\ncervical lymph nodes, lung examination showed bronchitis-like breathing\nsounds, no rales.\n\n**Therapy and Progression**: Today\\'s CRP is not elevated. IgGs are\nstill below normal. We recommended increasing immunoglobulin\nsubstitution during the infection. The patient had difficulty finding a\nsuitable injection site on her abdomen. However, she reported that the\nsecretions were gradually becoming lighter, so she decided to wait with\nthe antibiotic and only use it if there was no improvement.\n\nThe patient has been receiving 3x20mL Hizentra 20% per week since her\nlast visit. She complained of developing skin hardening at the injection\nsites, so a slower infusion time was discussed. She has been\nexperiencing a strong cough for several weeks without fever. No rales or\nsigns of pleuritis were detected on auscultation. No abnormalities were\nobserved on the chest X-ray. Laboratory results now show normal IgG\nlevels, so the dose was reduced to 2x20mL per week. A CT scan of the\nthorax and abdominal ultrasound were requested.\n\n**Chest X-ray in two planes from 03/04/2017:**\n\n[Findings/Assessment:]{.underline} No previous images are available for\ncomparison. Upper mediastinum and heart appear normal, with no central\ncongestion. No pneumothorax, effusions, confluent infiltrates, or\nsignificant focal lesions.\n\n**Abdominal ultrasound on 03/04/2017:**\n\nHepatosplenomegaly and retroperitoneal lymphadenopathy up to 26mm.\n\n**CT Chest/Abdomen/ from 03/04/2017:**\n\n[Methodology]{.underline}: Digital overview radiographs. After\nintravenous injection of contrast agent a 16-row CT scan of the thorax\nand entire abdomen was performed in the venous contrast phase, with\nprimary data set reconstruction at a thickness of 1.25 mm. Multiplanar\nreconstructions were created.\n\n[Findings]{.underline}: A conventional radiographic pre-image from\n11/18/2014 is available for comparison.\n\n[Thorax]{.underline}: Normal lung parenchyma with normal vascular\nmarkings. Small, sometimes hazy, sometimes nodular densities measuring\nup to 4mm in both lower lobes and the left upper lobe. Small\npleura-adjacent density in the right lower lobe. No evidence of\nconfluent infiltrates. No pleural effusion or pneumothorax. Normal heart\nsize and configuration. Normal diameter of the thoracic aorta and\npulmonary trunk. Increased number and enlarged retroclavicular lymph\nnodes on the right and left, axillary on both sides measuring up to 30mm\nin diameter. Trachea and esophagus displayed normally. No hiatus hernia.\nThyroid and neck soft tissues were unremarkable, as far as depicted.\nNormal thoracic soft tissue mantle. No soft tissue emphysema.\n\n[Abdomen]{.underline}: Hepatomegaly with morphologically normal liver\nparenchyma. No portal vein thrombosis. Gallbladder is unremarkable with\nno calculi. Intrahepatic and extrahepatic bile ducts are not dilated.\nPancreas is normally lobulated and structured, with no dilation of the\npancreatic duct. Splenomegaly. Accessory spleen measuring approximately\n20 mm in diameter. Splenic parenchyma is homogeneously contrasted in the\nvenous phase. Kidneys are orthotopically positioned, normal size with no\nside differences, and contrasted equally on both sides. Two regularly\nconfigured hypodense lesions in the left kidney, suggestive of\nuncomplicated renal cysts. No dilation of the urinary tract, and no\nevidence of stones. Adrenal glands are not visualized. Increased and\nenlarged mesenteric, pararaortic, parailiacal, and inguinal lymph nodes\nup to 30 mm in size. Gastrointestinal tract is displayed normally, as\nfar as assessable. Normal representation of major abdominal vessels. No\nfree intraperitoneal fluid or air.\n\n[Osseous structures:]{.underline} No evidence of suspicious osseous\ndestruction. Normal soft tissue mantle.\n\n[Assessment:]{.underline} Intrapulmonary multifocal, sometimes hazy,\nsometimes nodular densities, differential diagnosis includes atypical\npneumonia. Thoracoabdominal lymphadenopathy. Hepatosplenomegaly without\nsuspicious lesions.\n\n**Current Recommendations:**\n\n- Outpatient follow-up for discussion of findings\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% 2x20mL/week\n\n- Lung function test\n\n- Gastroscopy\n\n- In case of acute infection: increase immunoglobulin administration\n\n- Abdominal ultrasound: annually\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually Seasonal influenza vaccination: annually\n\n**Lab results upon discharge:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n Gamma-Globulin 3.2% 11.1-18.8%\n Immunoglobulin G 188 mg/dL 700-1600 mg/dL\n Immunoglobulin A 11 mg/dL 70-400 mg/dL\n Immunoglobulin M 12 mg/dL 40-230 mg/dL\n IgG Subclass 1 113 mg/dL 280-800 mg/dL\n IgG Subclass 2 49.1 mg/dL 115-570 mg/dL\n IgG Subclass 4 \\<0.0 mg/dL 5.2-125 mg/dL\n aPCP-IgG 7.32 mg/dL 10.00-191.20 mg/dL\n aPCP-IgG2 2.74 mg/dL 4.70-89.40 mg/dL\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n LDH 224 U/L 135-214 U/L\n Vitamin B12 708 pg/mL 191-663 pg/mL\n Erythrocytes 5.3 M/uL 3.9-5.2 M/uL\n Platelets 129 K/uL 150-370 K/uL\n MCV 78.0 fL 80.0-99.0 fL\n MCH 25.1 pg 27.0-33.5 pg\n Absolute Lymphocytes 0.91 K/uL 1.10-4.50 K/uL\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on Mrs. Hilary Sanders, born on 08/24/1976, who\npresented to our Immunodeficiency Clinic on 10/06/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Hepatosplenomegaly\n\n- Thoracoabdominal, inguinal, and axillary lymphadenopathy\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** Mrs. Sanders first presented herself to our clinic,\nwith suspected undiagnosed immunodeficiency. Regular subcutaneous\nimmunoglobulin therapy with Hizentra 20% (2x20mL/week) has been\nwell-tolerated. Initially, there were frequent upper respiratory tract\ninfections with sore throat and cough. In the absence of fever, a\none-time course of Cotrim was prescribed for 7 days due to sinusitis. We\ndiscussed Mrs. Sanders' medical history in detail, including the recent\nCT findings. She has been informed about the necessity of vigilance in\ncase of unclear and especially persistent lymph node swellings.\nRegarding the inguinal and axillary lymph nodes measuring up to 30mm in\ndiameter found on CT, we recommend an observational approach with\nregular sonographic monitoring. There have been no significant changes\nin laboratory parameters, with good IgG levels during ongoing\nsubstitution therapy and known moderate leukopenia and lymphopenia.\nDuring the next appointment, an additional lung function test, including\ndiffusion measurement, will be conducted\n\n**Current Recommendations:**\n\n- Outpatient follow-up, including lung function test\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% (2x20mL/week).\n\n- Current gastroscopy.\n\n<!-- -->\n\n- In case of acute infection: increase immunoglobulin administration.\n\n- Administer targeted, sufficiently long, and high-dose antibiotic\n therapy if bacterial infections require treatment.\n\n- Ideally, obtain material for microbiological diagnostics.\n\n- In case of increasing diarrhea, consider outpatient stool\n examinations, including Giardia lamblia and Cryptosporidium.\n\n- Abdominal ultrasound: annually.\n\n- Lung function test, including diffusion measurement: annually.\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually.\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings or H. pylori testing\n\n- Chest X-ray or CT thorax: if clinical symptoms or lung function\n abnormalities are observed.\n\n- Seasonal influenza vaccination: annually.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.1 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffé) 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n Immunoglobulin G 1025 mg/dL 700-1600 mg/dL\n Immunoglobulin A 16 mg/dL 70-400 mg/dL\n Immunoglobulin M 28 mg/dL 40-230 mg/dL\n Free Lambda Light Chains 5.86 5.70-26.30\n Free Kappa Light Chains 6.05 3.30-19.40\n Kappa/Lambda Ratio 1.03 0.26-1.65\n IgG Subclass 1 580.9 mg/dL 280-800 mg/dL\n IgG Subclass 2 340.7 mg/dL 115-570 mg/dL\n IgG Subclass 3 50.9 mg/dL 24-125 mg/dL\n IgG Subclass 4 5.7 mg/dL 5.2-125 mg/dL\n CRP 7.3 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 13.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 5.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n**Abdominal Ultrasound on 10/06/2017:**\n\n[Liver]{.underline}: Measures 19 cm in the MCL, homogeneous parenchyma,\nno focal lesions.\n\n[Gallbladder/Biliary Tract:]{.underline} No evidence of calculi, no\nsigns of inflammation, no congestion.\n\n[Spleen]{.underline}: Measures 14 cm in diameter, homogeneous. Accessory\nspleen measures 16 mm at the hilus.\n\n[Pancreas]{.underline}: Morphologically unremarkable, as far as visible\ndue to intestinal gas overlay, no evidence of space-occupying processes.\n\nRetroperitoneum: No signs of aneurysms. Enlarged retroperitoneal and\niliac lymph nodes, measuring up to approximately 2.5 cm in diameter.\n\n[Kidneys]{.underline}: Both kidneys are of normal size (right 4.3 x 11.8\ncm, left 4.6 cm x 11.9 cm). No congestion, no evidence of calculi\n(stones), no evidence of space-occupying processes.\n\n[Bladder]{.underline}: Smoothly defined and normally configured.\nMinimally filled.\n\n[Uterus]{.underline}: Size within the normal range, homogeneous.\n\nNo ascites.\n\n[Assessment:]{.underline} Evidence of enlarged lymph nodes up to 2.5 cm\nretroperitoneal and iliac. Compared to previous findings, a slight\ndecrease in splenomegaly.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on the examination results of our patient, Mrs. Hilary\nSanders, born on 08/24/1976, who presented herself in our\nImmunodeficiency Clinic on 02/10/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Ongoing diarrhea in the morning, often\nrecurring in the afternoon. No melena, no fresh blood. Resolving\nrespiratory infection, positive influenza.\n\nCurrently, IgG levels remain within the target range. An increased need\nfor immunoglobulins is expected, especially in the third trimester of\npregnancy. Therefore, we recommend close monitoring with us during\npregnancy. Ferritin levels have further declined, indicating the need\nfor iron substitution. Anamnestically, there is an intolerance to oral\niron preparations.\n\n**Recommendations:**\n\n- Outpatient follow-up\n\n- Early follow-up in case of infections or persistent diarrhea\n\n- Continue regular subcutaneous immunoglobulin therapy, currently with\n Hizentra 20% 2x20mL/week\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n04/12/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infection with symptoms for 3-4\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance.\n\nIgG levels remain within the target range; therefore, we recommend\ncontinuing the current treatment unchanged.\n\nSince the last visit, mild upper respiratory tract infections. No fever\n(except for one episode of sinusitis), no antibiotics. SCIG treatment\nunchanged with 3x20mL/week of Hizentra ®.\n\nMrs. Sanders continues to experience watery diarrhea about 5-7 times\ndaily. No blood in stools, no pain, no vomiting, no nausea. There has\nbeen no clear association with specific foods observed. Current weight:\n69kg.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori testing: e.g., breath test or Helicobacter\n pylori antigen in stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and Helicobacter pylori testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n02/18/2019.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infections with symptoms for 7\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance. Continued diarrhea, approximately 6 times a\nday, without weight loss. IgG levels remain within the target range;\ntherefore, we recommend continuing the current treatment unchanged.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue treatment as is\n\n- External upper gastrointestinal endoscopy (and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are writing to provide summary on the clinical course of Mrs. Hilary\nSanders, born on 08/24/1976, who presented at our outpatient\nImmunodeficiency Clinic.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n- Iron-deficiency anemia\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Overall stable condition. No longer\nexperiencing cough. Persistent fatigue. Upcoming appointment with the\nGastroenterology department next week. There is again an indication for\niron substitution.\n\n**Update on 11/15/2019: Laboratory results from 11/15/2019:**\nTransaminase elevation, Protein 18, markedly elevated BNP. However, IgA\nis at 0.5 (otherwise not detectable), IgG subclasses within normal\nrange. Findings do not align. Patient informed by phone, returning for\nfurther evaluation today; also screening for Hepatitis A, B, C, and E,\nEBV, CMV, TSH, coagulation. No shortness of breath, no edema, no\nabdominal enlargement, stable weight at 69 kg. In case of worsening\nsymptoms, shortness of breath, or fever, immediate referral to the\nemergency department recommended.\n\n**02/12/2020:** The patient is doing reasonably well. She has had a mild\ncold for about 2 weeks, no fever, but nasal congestion and\nyellowish-green sputum. No other infections. No antibiotics prescribed.\nShe has adapted to her gastrointestinal issues. An appointment with the\nGastroenterology department. She is currently working from home.\nMedication: no new medications, only Cuvitru 20mL 3x weekly. Weight\nremains stable at 67 kg. The last lung function test was in the summer\nof this year and was within normal limits. Imaging has not been\nperformed recently. Gastroscopy and colonoscopy have not been conducted\nfor some time.\n\n**04/14/2020:** Referral to Gastroenterology at is recommended for\npersistent abdominal symptoms.\n\n**10/24/2020:** The patient has mostly avoided social contacts due to\nthe pandemic. She continues to experience digestive problems (food\nintolerances, diarrhea, flatulence). She has less stamina. Few\ninfections in the past year, at most a minor cold. No significant\ninfections. Hizentra injections remain unchanged at 20 mL 3 times a\nweek.\n\n**03/22/2021:** Constant colds since December 2020. One-time antibiotic\ntreatment in October 2019. Subcutaneous Immunoglobulin therapy remains\nunchanged at 20 mL 3 times weekly.\n\n**09/19/2021:** She feels disoriented and very tired, more so than\nusual. Difficulty maintaining a steady gaze. No steroid therapy was\nadministered. CT showed enlarged lymph nodes. Diarrhea, especially in\nthe morning, 3-4 times a day, additional bowel movements with meals,\nsometimes watery. No fever, no infections. Hizentra injections continued\nunchanged.\n\n**Summary**: IgG levels are currently within the target range, so we\nrecommend continuing immunoglobulin substitution therapy without\nchanges. The antibody response (SARS-CoV-2 (S-Ag) IgG ELISA) to the\nCovid-19 vaccination is, as expected, negative. However, there is a\npositive detection of SARS-CoV-2 (N-Ag) IgG ELISA, as expected in the\ncase of viral contact (not vaccination). We consider this to be an\nunspecific reaction and recommend further monitoring at the next\nfollow-up appointment. With a platelet count currently at 55 K/uL, we\nrecommend a short-term blood count check with us or your primary care\nphysician.\n\nDue to the immunodeficiency, a lack of antibody response to vaccination\nwas expected. In the medium term, passive protection through\nimmunoglobulin substitution therapy will play a role. This is contingent\non a significant portion of plasma donors having antibodies against\nSARS-CoV2. There is a multi-month delay from the time of donation to the\nrelease of the preparations, so we anticipate that meaningful protection\nthrough immunoglobulin products will not be expected. An exact prognosis\nin this regard is not possible.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Consultation with Gastroenterology\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are providing you with an update regarding our patient Mrs. Hilary\nSanders, born on 08/24/1976. She was under our inpatient care from\n03/29/2023 to 04/05/2023.\n\n**Diagnoses:**\n\n- Suspected CVID-Associated enteropathy\n\n- Known hepatosplenomegaly with a borderline enlarged portal vein, no\n significant portocaval shunts. Multiple liver lesions, possibly\n hemangiomas further evaluation if not already done.\n\n- Known retroperitoneal and iliac lymphadenopathy, likely related to\n the underlying condition.\n\n- Known changes in the lower lung bases, likely associated with the\n underlying condition, e.g., ILD. Refer to previous examinations.\n\n- Capsule endoscopy: Incomplete capsule enteroscopy with no evidence\n of inflammatory changes. Some hyperemia and blurry vascular pattern\n observed in the visible colon.\n\n- CVID-Associated Hepatopathy in the Form of Nodular Regenerative\n Hyperplasia\n\n**Other Diagnoses:** Common Variable Immunodeficiency Syndrome (CVID)\nwith:\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n Hizentra 20%\n\n- Infectious manifestations: Frequent respiratory tract infections\n\n- Non-Infectious manifestations:\n\n - ITP (Immune Thrombocytopenia)\n\n - Hepatosplenomegaly\n\n - Lymphadenopathy in supraclavicular, infraclavicular,\n thoracoabdominal, inguinal, and axillary regions\n\n - Suspected Granulomatous-Lymphocytic Interstitial Lung Disease in\n CVID\n\n<!-- -->\n\n- Iron-deficiency anemia\n\n**Pysical Examination:** Patient in normal general condition and\nnutritional status (175 cm, 65.8 kg. No resting dyspnea.\n\n[Neuro (grossly orienting):]{.underline} awake, oriented to\ntime/place/person/situation, No evidence of focal neurological deficit.\nNo meningism.\n\n[Head/neck]{.underline}: pharynx non-irritable. Moist, rosy mucous\nmembranes. Tongue occupied.\n\n[Skin]{.underline}: intact, turgor normal, no icterus, no cyanosis.\n\n[Thorax]{.underline}: normal configuration, no spinal palpitation, renal\nbed clear.\n\n[Lung]{.underline}: vesicular breath sound bds, no accessory sounds,\nsonorous tapping sound bds.\n\n[Cor]{.underline}: Cardiac action pure, rhythmic, no vitia typical\nmurmurs.\n\n[Abdomen]{.underline}: regular bowel sounds, soft abdominal wall, no\ntenderness, no resistances, no hepatosplenomegaly.\n\n[Extremities]{.underline}: no edema. Feet warm. Dorsalis pedis +/+ and\nposterior tibial artery +/+.\n\n**Current Presentation:** The patient was admitted for further\nevaluation of suspected CVID-associated enteropathy, as she had been\nexperiencing chronic diarrhea for the past three years. On admission,\nthe patient reported an overall good general and nutritional condition.\nShe described her current subjective well-being as good but mentioned\nhaving chronic diarrhea for the past three years, with up to 7 bowel\nmovements per day. The stools were watery without any signs of blood.\nThere were no indications of infection, such as fever, chills, dysuria,\nhematuria, cough, sputum, or dyspnea. She also experienced intermittent\nleft-sided upper abdominal pain, primarily postprandially. She had a\ngood appetite.\n\nOn the day of admission, an esophagogastroduodenoscopy was performed,\nwhich revealed erythematous antral gastritis. Additionally, there was an\napproximately 1 cm irregular mucosal area at the corpus-antrum junction\non the greater curvature side. A magnetic resonance imaging scan showed\nno evidence of inflamed bowel loops, ruling out chronic inflammatory\nbowel disease or celiac disease. To further investigate, a capsule\nendoscopy was performed, with results pending at the time of discharge.\nHypovitaminosis B12 and folate deficiency were ruled out. However,\niron-deficiency anemia was confirmed, and the patient had already\nscheduled an outpatient appointment for iron substitution. Serum levels\nof vitamin B6 and zinc were pending at discharge.\n\nDue to a moderate increase in transaminases and evidence of\nhepatosplenomegaly, we decided, after detailed explanation and with the\npatient\\'s consent, to perform a sonographically guided liver biopsy in\naddition to the planned endoscopy. The differential diagnosis included\nCVID-associated hepatopathy. The biopsy was successfully conducted ,\nwithout any post-interventional bleeding. Histology revealed mild acute\nhepatitis and nodular regenerative hyperplasia.This finding could be\nconsistent with changes in CVID-associated hepatopathy. Granulomas were\nnot observed. With only slightly elevated liver values, a trial therapy\nwith budesonide was initiated, and clinical (diarrhea?) and laboratory\n(transaminases?) follow-up will be performed in the outpatient setting.\n\nWe discharged Mrs. Sanders in a cardiopulmonarily stable condition.\n\n[Current Recommendations:]{.underline}\n\n- Follow-up in the gastroenterological outpatient clinic\n\n**Esophagogastroduodenoscopy (EGD) on 04/01/2023:** Introduction of the\ngastroscope in a left lateral position. Visualized up to the descending\npart of the duodenum. Unremarkable upper esophageal sphincter. Normal\nmotility and mucosa in the upper, middle, and distal esophagus. The\nZ-line is sharply demarcated in the hiatus. The cardia closes\nsufficiently. The stomach expands normally in all parts under air\ninsufflation. Multiple glandular cysts \\< 8 mm in size in the fundus and\ncorpus. Approximately 1 cm irregular mucosal area at the corpus-antrum\njunction on the greater curvature side. Streaky redness of the mucosa in\nthe antrum. Unremarkable mucosa in the bulb. Unremarkable mucosa in the\ndescending part of the duodenum. Step biopsies performed.\n\n[Summary]{.underline}: Erythematous antral gastritis. Approximately 1 cm\nirregular mucosal area at the corpus-antrum junction on the greater\ncurvature side, suggestive of inflammation. Multiple glandular cysts\nobserved in the fundus and corpus.\n\n[Abdominal MRI on 04/02/2023:]{.underline}\n\n[Clinical information, questions, and justification for the\nexam]{.underline}: Chronic diarrhea, suspected CVID-associated\nenteropathy, differential diagnosis of celiac disease, and inflammatory\nbowel disease (IBD). Assessment of malignancy.\n\nTechnique: After oral administration of mannitol solution and injection\nof 40 mg Buscopan, a 3-Tesla abdominal MRI was performed.\n\n[Findings]{.underline}: Multiple nodular consolidations and opacities\ndetected in the lower basal lung segments, measuring 7 x 4 mm, for\nexample, in the right lateral lower lobe (Series 18, Image 3).\nAdditionally, streaky-reticular changes observed. Left diaphragmatic\nelevation. Liver globally enlarged and smooth-bordered with several\nlesions showing mild to moderately hyperintense signals in T2-weighted\nimages and hypointense signals in T1-weighted images. These lesions\ndemonstrated increased enhancement in the early contrast phases,\nespecially those at the periphery, and more diffuse enhancement in the\nlate phases. For example, a lesion measuring 12 x 11 mm in Segment 2, a\nlesion measuring 8 mm in Segment 8 and a lesion measuring 21 x 13 mm in\nSegment 7. The portal vein measures borderline wide, up to 15 mm in\ndiameter. Gallbladder is unremarkable without evidence of stones. Intra-\nand extrahepatic bile ducts are not dilated. Spleen significantly\nenlarged, measuring 14 cm in pole-to-pole distance and 7.2 cm in\ntransverse diameter, homogeneous enhancement in native phases and late\ncontrast phase. Large accessory spleen located hilarly. Bilateral\nadrenal glands appear slender. Pancreas displays typical appearance with\nno ductal dilatation. Both kidneys are in orthotopic position, with\nunremarkable cortical cysts on the right side. No signs of urinary\nobstruction. The urinary bladder is moderately filled. No free fluid.\nAdequate dilation of small bowel loops. No evidence of significant bowel\nobstruction. No thickened bowel walls or increased post-contrast signal\nin the bowel loops. Cystic lesion in the right ovary measuring 17 x 11\nmm consistent with a corpus luteum cyst. Multiple enlarged\nretroperitoneal lymph nodes observed, for example, paracaval node with a\nshort-axis diameter of 14 mm and right iliacoexternal node with a\nshort-axis diameter of 14.5 mm No evidence of enlarged mesenteric or\ninguinal lymph nodes.\n\n\n\n\nHere is the query:\nAs of 2016, how long had Mrs. Sanders experienced recurrent respiratory infections?\n\nChoose the correct answer from the following options:\nA. 1 year\nB. 2 years\nC. 3 years\nD. 4 years\nE. 5 years\n\n\nYour response:\n", "role": "user" }, { "content": "3 years", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are writing to provide an update on the examination results of our\npatient Mrs. Hilary Sanders, born on 08/24/1976, who presented to our\noutpatient clinic on 10/09/2016.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n human immunoglobulin\n\n**Medical History:** Mrs. Sanders presented with suspected previously\nundiagnosed immunodeficiency. There were no reports of frequent\ninfections during childhood and adolescence. No increased herpes\ninfections. No history of pneumonia, meningitis, or other serious\ninfections.\n\n**Current Presentation:** Mrs. Sanders has experienced recurrent\nrespiratory infections (bronchitis, pharyngitis) for about 3 years.\n\n**Physical Examination:** She reported joint pain in the left knee and\nnumbness below the shoulder blade. A tendency to bruise easily. No\nmucosal lesions, recurrent axillary lymph node swelling. No recurrent\nfevers. No B-symptoms. No resting dyspnea, no subjective heart rhythm\ndisturbances, no syncope, no peripheral edema, or other signs of\ncardiopulmonary decompensation.\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all IgG\n subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and NK-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B-cells.\n\n- Monocytic HLA-DR expression (immune competence marker) within the\n normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n- T-cell function after 24h polyvalent ConA stimulation: TNF-alpha,\n IFN-gamma, IL-2, IL-4 unremarkable\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells.\n\nFurther cellular immune status, including the complement system and\nsoluble mediators, showed no significant abnormalities except for an\nelevated soluble IL-2 receptor. Given the unremarkable monocytic\nTNF-alpha secretion after LPS stimulation, a significant Toll-like\nReceptor 4 defect is unlikely. An antibody response to Tetanus Toxoid\nwas demonstrated in a vaccine titer test. Protective\npneumococcal-specific antibodies could not be detected. There were no\nabnormalities in autoimmune diagnostics.\n\nImmunofixation showed no evidence of monoclonal gammopathy.\nHypogammaglobulinemia due to enteral or renal protein loss is unlikely\nin the presence of normal albumin.\n\nOverall, the picture is consistent with Common Variable\nImmunodeficiency. Formally, CVID is defined by a reduction in the major\nimmunoglobulin class IgG, with accompanying reduction in IgA and/or IgM,\nin the absence of normal or impaired vaccine response. Due to very low\nimmunoglobulin levels and planned travel, determination of vaccine\nresponse was currently omitted in the absence of therapeutic\nconsequence. After stable substitution, specific vaccine antibody levels\ncan be determined before or after vaccination, with the assumption that\nstable antibody concentrations exist due to continuous immunoglobulin\nsubstitution.\n\nAccording to B-cell differentiation, it corresponds to Type Ib according\nto the Freiburg Classification and Type B+smB-CD21lo according to the\nEuro Classification. The classification is clinically relevant, as Type\nIa is associated with increased immunocytopenias (especially ITP and\nAIH) and splenomegaly. In CVID with a high proportion (\\>10%) of CD-21\nlow B-cells, increased granulomatous diseases and splenomegaly have also\nbeen observed.\n\nThe indication for immunoglobulin substitution therapy exists because of\nrecurrent infections. The form of substitution therapy (intravenous. vs.\nsubcutaneous) is primarily based on patient preferences, but also on\nmedical conditions (concomitant diseases such as thrombocytopenia,\nconvenience, insurance, etc.).\n\n**Current Recommendations:**\n\nWe propose to initiate immunoglobulin substitution therapy with Hizentra\n20% (subcutaneous) at a dose of 200 ml once a week on Tuesdays. Further\ninformation and training on subcutaneous immunoglobulin substitution\ntherapy will be provided by a home care nursing service.\n\nMrs. Sanders will remain under regular medical supervision with close\nmonitoring of clinical symptoms, laboratory parameters, and the\neffectiveness of immunoglobulin substitution therapy. Any unexpected\nside effects or changes in her condition should be reported immediately.\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n --------------------------------------- --------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.2 mEq/L 3.4-4.5 mEq/L\n Calcium 2.41 mg/dL 2.15-2.50 mg/dL\n Inorganic Phosphate 1.00 mg/dL 0.87-1.45 mg/dL\n Selenium 0.79 µmol/L 0.60-1.50 µmol/L\n Zinc 10.1 µmol/L 9.0-22.0 µmol/L\n Creatinine 0.75 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 mL/min \\>90 mL/min\n Total Bilirubin 0.37 mg/dL \\< 1.20 mg/dL\n Albumin 4.55 g/dL 3.50-5.20 g/dL\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n A2-Globulin in Serum 10.7% 7.1-11.8%\n ß-Globulin in Serum 9.2% 8.4-13.1%\n Gamma-Globulin in Serum 3.2% 11.1-18.8%\n Immunoglobulin G 514 mg/dL 700-1600 mg/dL\n Immunoglobulin A 14 mg/dL 70-400 mg/dL\n Immunoglobulin M 19 mg/dL 40-230 mg/dL\n Immunoglobulin E 90 kU/L 0.0-100.0 kU/L\n IgG 1 299.5 mg/dL 280-800 mg/dL\n IgG 2 162.7 mg/dL 115-570 mg/dL\n IgG 3 49.1 mg/dL 24-125 mg/dL\n IgG 4 4.0 mg/dL 5.2-125 mg/dL\n Serum Immunofixation \n CRP 4.8 mg/L \\< 5.0 mg/L\n C3 Complement 980 mg/L 900-1800 mg/L\n C4 Complement 120 mg/L 100-400 mg/L\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n HBs Antigen Negative \n HBc Antibody Negative \n HBs Antibody Negative \n Ferritin 56 µg/L 13-140 µg/L\n ALT (GPT) 33 U/L \\< 31 U/L\n AST (GOT) 29 U/L \\< 35 U/L\n Alkaline Phosphatase 84 U/L 35-105 U/L\n Creatine Kinase 90 U/L \\< 167 U/L\n CK-MB 8.3 U/L \\< 24.0 U/L\n Gamma-GT 40 U/L 5-36 U/L\n LDH 204 U/L 135-214 U/L\n Lipase 50 U/L 13-60 U/L\n Cortisol 306.6 nmol/L 64.0-327.0 nmol/L\n 25-OH-Vitamin D3 65.3 nmol/L 50.0-150.0 nmol/L\n 1.25-OH-Vitamin D3 134 pmol/L 18.0-155.0 pmol/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Vitamin B12 770 pg/mL 191-663 pg/mL\n Folic Acid 14.6 ng/mL 4.6-18.7 ng/mL\n Hemoglobin 13.9 g/dL 12.0-15.6 g/dL\n Hematocrit 41.0% 35.5-45.5%\n Erythrocytes 5.2 M/uL 3.9-5.2 M/uL\n Leukocytes 4.13 K/uL 3.90-10.50 K/uL\n Platelets 174 K/uL 150-370 K/uL\n MCV 80.0 fL 80.0-99.0 fL\n MCH 26.7 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n RDW-CV 13.7% 11.5-15.0%\n Absolute Neutrophils 2.87 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.010 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.71 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.42 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.03 K/uL 0.00-0.20 K/uL\n HbA1c 4.9% \\< 6.0%\n HbA1c (IFCC) 30.1 mmol/mol \\< 42.0\n HBV Serology Result Negative \n HIV1/2 Antibodies, P24 Antigen Negative \n Hepatitis C Virus Antibodies in Serum Negative \n\n**Dear colleague,**\n\nWe report the examination results of Mrs. Hilary Sanders, born on\n08/24/1976 who presented at our outpatient clinic on 03/04/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Immunological Diagnostics:**\n\n- Immunoglobulins including subclasses: IgA, IgG, IgM, and all\n IgG-Subclasses were reduced.\n\n- Numerically unremarkable monocytes and granulocytes, lymphocytopenia\n with reduced B- and natural killer-cells, normal CD4/CD8 ratio.\n\n- B-lymphocyte subpopulation with numerically reduced B cells.\n\n- Monocytic HLA-DR expression within the normal range.\n\n- No evidence of acute or chronic T-cell activation.\n\n- IL-6, LBP (Lipopolysaccharide-Binding Protein), and IL-8\n post-erylysis were unremarkable, elevated s-IL-2.\n\n- Monocytic TNF-alpha secretion after 4h LPS stimulation was\n unremarkable.\n\n**Assessment**: In the immunological diagnostics, as in previous\noutpatient findings, a reduction in all major immunoglobulin classes and\nsubclasses was observed. Cellular immune status revealed lymphocytopenia\nwith reduced B- and natural killer-cells. The further cellular immune\nstatus, including the complement system and soluble mediators, showed no\nsignificant abnormalities except for an elevated soluble IL-2 receptor.\n\n**Current Presentation:** Mrs. Sanders was again provided with detailed\ninformation about her condition and the planned course of action. We\nscheduled an appointment to initiate regular subcutaneous immunoglobulin\ntherapy.\n\n**Medical History:** Mrs. Sanders received her first dose of Hizentra\n20% subcutaneously as immunoglobulin substitution therapy for CVID. The\nadministration was well-tolerated initially, with no evidence of\nsignificant local or systemic side effects. Mrs. Sanders was once again\ninformed about possible risks (especially hypersensitivity reactions)\nand advised to contact us immediately in case of questions,\nuncertainties, or any abnormalities. The dosing for the first four weeks\nwas 3x20mL Hizentra 20% subcutaneously, and from the fifth week onward,\nit was changed to either 1x40mL or 2x20mL Hizentra 20% subcutaneously\nper week.\n\nIn the past days, Mrs. Sanders has been experiencing a cold: runny nose,\ncough (green-yellow), difficulty clearing mucus, slight fever, sinus\ninflammation, sore throat, difficulty speaking, and swallowing problems.\nThere was no improvement.\n\n**Physical Examination:** Reddened throat, no exudates, non-swollen\ncervical lymph nodes, lung examination showed bronchitis-like breathing\nsounds, no rales.\n\n**Therapy and Progression**: Today\\'s CRP is not elevated. IgGs are\nstill below normal. We recommended increasing immunoglobulin\nsubstitution during the infection. The patient had difficulty finding a\nsuitable injection site on her abdomen. However, she reported that the\nsecretions were gradually becoming lighter, so she decided to wait with\nthe antibiotic and only use it if there was no improvement.\n\nThe patient has been receiving 3x20mL Hizentra 20% per week since her\nlast visit. She complained of developing skin hardening at the injection\nsites, so a slower infusion time was discussed. She has been\nexperiencing a strong cough for several weeks without fever. No rales or\nsigns of pleuritis were detected on auscultation. No abnormalities were\nobserved on the chest X-ray. Laboratory results now show normal IgG\nlevels, so the dose was reduced to 2x20mL per week. A CT scan of the\nthorax and abdominal ultrasound were requested.\n\n**Chest X-ray in two planes from 03/04/2017:**\n\n[Findings/Assessment:]{.underline} No previous images are available for\ncomparison. Upper mediastinum and heart appear normal, with no central\ncongestion. No pneumothorax, effusions, confluent infiltrates, or\nsignificant focal lesions.\n\n**Abdominal ultrasound on 03/04/2017:**\n\nHepatosplenomegaly and retroperitoneal lymphadenopathy up to 26mm.\n\n**CT Chest/Abdomen/ from 03/04/2017:**\n\n[Methodology]{.underline}: Digital overview radiographs. After\nintravenous injection of contrast agent a 16-row CT scan of the thorax\nand entire abdomen was performed in the venous contrast phase, with\nprimary data set reconstruction at a thickness of 1.25 mm. Multiplanar\nreconstructions were created.\n\n[Findings]{.underline}: A conventional radiographic pre-image from\n11/18/2014 is available for comparison.\n\n[Thorax]{.underline}: Normal lung parenchyma with normal vascular\nmarkings. Small, sometimes hazy, sometimes nodular densities measuring\nup to 4mm in both lower lobes and the left upper lobe. Small\npleura-adjacent density in the right lower lobe. No evidence of\nconfluent infiltrates. No pleural effusion or pneumothorax. Normal heart\nsize and configuration. Normal diameter of the thoracic aorta and\npulmonary trunk. Increased number and enlarged retroclavicular lymph\nnodes on the right and left, axillary on both sides measuring up to 30mm\nin diameter. Trachea and esophagus displayed normally. No hiatus hernia.\nThyroid and neck soft tissues were unremarkable, as far as depicted.\nNormal thoracic soft tissue mantle. No soft tissue emphysema.\n\n[Abdomen]{.underline}: Hepatomegaly with morphologically normal liver\nparenchyma. No portal vein thrombosis. Gallbladder is unremarkable with\nno calculi. Intrahepatic and extrahepatic bile ducts are not dilated.\nPancreas is normally lobulated and structured, with no dilation of the\npancreatic duct. Splenomegaly. Accessory spleen measuring approximately\n20 mm in diameter. Splenic parenchyma is homogeneously contrasted in the\nvenous phase. Kidneys are orthotopically positioned, normal size with no\nside differences, and contrasted equally on both sides. Two regularly\nconfigured hypodense lesions in the left kidney, suggestive of\nuncomplicated renal cysts. No dilation of the urinary tract, and no\nevidence of stones. Adrenal glands are not visualized. Increased and\nenlarged mesenteric, pararaortic, parailiacal, and inguinal lymph nodes\nup to 30 mm in size. Gastrointestinal tract is displayed normally, as\nfar as assessable. Normal representation of major abdominal vessels. No\nfree intraperitoneal fluid or air.\n\n[Osseous structures:]{.underline} No evidence of suspicious osseous\ndestruction. Normal soft tissue mantle.\n\n[Assessment:]{.underline} Intrapulmonary multifocal, sometimes hazy,\nsometimes nodular densities, differential diagnosis includes atypical\npneumonia. Thoracoabdominal lymphadenopathy. Hepatosplenomegaly without\nsuspicious lesions.\n\n**Current Recommendations:**\n\n- Outpatient follow-up for discussion of findings\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% 2x20mL/week\n\n- Lung function test\n\n- Gastroscopy\n\n- In case of acute infection: increase immunoglobulin administration\n\n- Abdominal ultrasound: annually\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually Seasonal influenza vaccination: annually\n\n**Lab results upon discharge:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Total Protein 6.3 g/dL 6.4-8.3 g/dL\n Albumin Fraction 71.8% 55.8-66.1%\n A1-Globulin 5.1% 2.9-4.9%\n Gamma-Globulin 3.2% 11.1-18.8%\n Immunoglobulin G 188 mg/dL 700-1600 mg/dL\n Immunoglobulin A 11 mg/dL 70-400 mg/dL\n Immunoglobulin M 12 mg/dL 40-230 mg/dL\n IgG Subclass 1 113 mg/dL 280-800 mg/dL\n IgG Subclass 2 49.1 mg/dL 115-570 mg/dL\n IgG Subclass 4 \\<0.0 mg/dL 5.2-125 mg/dL\n aPCP-IgG 7.32 mg/dL 10.00-191.20 mg/dL\n aPCP-IgG2 2.74 mg/dL 4.70-89.40 mg/dL\n ß-2-Microglobulin 3.6 mg/L 0.8-2.2 mg/L\n LDH 224 U/L 135-214 U/L\n Vitamin B12 708 pg/mL 191-663 pg/mL\n Erythrocytes 5.3 M/uL 3.9-5.2 M/uL\n Platelets 129 K/uL 150-370 K/uL\n MCV 78.0 fL 80.0-99.0 fL\n MCH 25.1 pg 27.0-33.5 pg\n Absolute Lymphocytes 0.91 K/uL 1.10-4.50 K/uL\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mrs. Hilary Sanders, born on 08/24/1976, who\npresented to our Immunodeficiency Clinic on 10/06/2017.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Hepatosplenomegaly\n\n- Thoracoabdominal, inguinal, and axillary lymphadenopathy\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** Mrs. Sanders first presented herself to our clinic,\nwith suspected undiagnosed immunodeficiency. Regular subcutaneous\nimmunoglobulin therapy with Hizentra 20% (2x20mL/week) has been\nwell-tolerated. Initially, there were frequent upper respiratory tract\ninfections with sore throat and cough. In the absence of fever, a\none-time course of Cotrim was prescribed for 7 days due to sinusitis. We\ndiscussed Mrs. Sanders' medical history in detail, including the recent\nCT findings. She has been informed about the necessity of vigilance in\ncase of unclear and especially persistent lymph node swellings.\nRegarding the inguinal and axillary lymph nodes measuring up to 30mm in\ndiameter found on CT, we recommend an observational approach with\nregular sonographic monitoring. There have been no significant changes\nin laboratory parameters, with good IgG levels during ongoing\nsubstitution therapy and known moderate leukopenia and lymphopenia.\nDuring the next appointment, an additional lung function test, including\ndiffusion measurement, will be conducted\n\n**Current Recommendations:**\n\n- Outpatient follow-up, including lung function test\n\n- Continue regular subcutaneous immunoglobulin administration with\n current regimen of Hizentra 20% (2x20mL/week).\n\n- Current gastroscopy.\n\n<!-- -->\n\n- In case of acute infection: increase immunoglobulin administration.\n\n- Administer targeted, sufficiently long, and high-dose antibiotic\n therapy if bacterial infections require treatment.\n\n- Ideally, obtain material for microbiological diagnostics.\n\n- In case of increasing diarrhea, consider outpatient stool\n examinations, including Giardia lamblia and Cryptosporidium.\n\n- Abdominal ultrasound: annually.\n\n- Lung function test, including diffusion measurement: annually.\n\n- H. pylori testing, e.g., breath test or H. pylori antigen in stool:\n annually.\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings or H. pylori testing\n\n- Chest X-ray or CT thorax: if clinical symptoms or lung function\n abnormalities are observed.\n\n- Seasonal influenza vaccination: annually.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- ------------- ---------------------\n Sodium 141 mEq/L 132-146 mEq/L\n Potassium 4.1 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffé) 0.82 mg/dL 0.50-0.90 mg/dL\n Estimated GFR (eGFR CKD-EPI) \\>90 \\-\n Total Bilirubin 0.21 mg/dL \\< 1.20 mg/dL\n Albumin 4.09 g/dL 3.5-5.2 g/dL\n Immunoglobulin G 1025 mg/dL 700-1600 mg/dL\n Immunoglobulin A 16 mg/dL 70-400 mg/dL\n Immunoglobulin M 28 mg/dL 40-230 mg/dL\n Free Lambda Light Chains 5.86 5.70-26.30\n Free Kappa Light Chains 6.05 3.30-19.40\n Kappa/Lambda Ratio 1.03 0.26-1.65\n IgG Subclass 1 580.9 mg/dL 280-800 mg/dL\n IgG Subclass 2 340.7 mg/dL 115-570 mg/dL\n IgG Subclass 3 50.9 mg/dL 24-125 mg/dL\n IgG Subclass 4 5.7 mg/dL 5.2-125 mg/dL\n CRP 7.3 mg/L \\< 5.0 mg/L\n Haptoglobin 108 mg/dL 30-200 mg/dL\n Ferritin 24 µg/L 13-140 µg/L\n ALT 24 U/L \\< 31 U/L\n AST 37 U/L \\< 35 U/L\n Gamma-GT 27 U/L 5-36 U/L\n Lactate Dehydrogenase 244 U/L 135-214 U/L\n 25-OH-Vitamin D3 91.7 nmol/L 50.0-150.0 nmol/L\n Hemoglobin 13.1 g/dL 12.0-15.6 g/dL\n Hematocrit 40.0% 35.5-45.5%\n Red Blood Cells 5.5 M/uL 3.9-5.2 M/uL\n White Blood Cells 2.41 K/uL 3.90-10.50 K/uL\n Platelets 142 K/uL 150-370 K/uL\n MCV 73.0 fL 80.0-99.0 fL\n MCH 23.9 pg 27.0-33.5 pg\n MCHC 32.7 g/dL 31.5-36.0 g/dL\n MPV 10.7 fL 7.0-12.0 fL\n RDW-CV 14.8% 11.5-15.0%\n Absolute Neutrophils 1.27 K/uL 1.50-7.70 K/uL\n Absolute Immature Granulocytes 0.000 K/uL \\< 0.050 K/uL\n Absolute Lymphocytes 0.67 K/uL 1.10-4.50 K/uL\n Absolute Monocytes 0.34 K/uL 0.10-0.90 K/uL\n Absolute Eosinophils 0.09 K/uL 0.02-0.50 K/uL\n Absolute Basophils 0.04 K/uL 0.00-0.20 K/uL\n Free Hemoglobin 5.00 mg/dL \\< 20.00 mg/dL\n\n**Abdominal Ultrasound on 10/06/2017:**\n\n[Liver]{.underline}: Measures 19 cm in the MCL, homogeneous parenchyma,\nno focal lesions.\n\n[Gallbladder/Biliary Tract:]{.underline} No evidence of calculi, no\nsigns of inflammation, no congestion.\n\n[Spleen]{.underline}: Measures 14 cm in diameter, homogeneous. Accessory\nspleen measures 16 mm at the hilus.\n\n[Pancreas]{.underline}: Morphologically unremarkable, as far as visible\ndue to intestinal gas overlay, no evidence of space-occupying processes.\n\nRetroperitoneum: No signs of aneurysms. Enlarged retroperitoneal and\niliac lymph nodes, measuring up to approximately 2.5 cm in diameter.\n\n[Kidneys]{.underline}: Both kidneys are of normal size (right 4.3 x 11.8\ncm, left 4.6 cm x 11.9 cm). No congestion, no evidence of calculi\n(stones), no evidence of space-occupying processes.\n\n[Bladder]{.underline}: Smoothly defined and normally configured.\nMinimally filled.\n\n[Uterus]{.underline}: Size within the normal range, homogeneous.\n\nNo ascites.\n\n[Assessment:]{.underline} Evidence of enlarged lymph nodes up to 2.5 cm\nretroperitoneal and iliac. Compared to previous findings, a slight\ndecrease in splenomegaly.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination results of our patient, Mrs. Hilary\nSanders, born on 08/24/1976, who presented herself in our\nImmunodeficiency Clinic on 02/10/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Ongoing diarrhea in the morning, often\nrecurring in the afternoon. No melena, no fresh blood. Resolving\nrespiratory infection, positive influenza.\n\nCurrently, IgG levels remain within the target range. An increased need\nfor immunoglobulins is expected, especially in the third trimester of\npregnancy. Therefore, we recommend close monitoring with us during\npregnancy. Ferritin levels have further declined, indicating the need\nfor iron substitution. Anamnestically, there is an intolerance to oral\niron preparations.\n\n**Recommendations:**\n\n- Outpatient follow-up\n\n- Early follow-up in case of infections or persistent diarrhea\n\n- Continue regular subcutaneous immunoglobulin therapy, currently with\n Hizentra 20% 2x20mL/week\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n04/12/2018.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infection with symptoms for 3-4\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance.\n\nIgG levels remain within the target range; therefore, we recommend\ncontinuing the current treatment unchanged.\n\nSince the last visit, mild upper respiratory tract infections. No fever\n(except for one episode of sinusitis), no antibiotics. SCIG treatment\nunchanged with 3x20mL/week of Hizentra ®.\n\nMrs. Sanders continues to experience watery diarrhea about 5-7 times\ndaily. No blood in stools, no pain, no vomiting, no nausea. There has\nbeen no clear association with specific foods observed. Current weight:\n69kg.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori testing: e.g., breath test or Helicobacter\n pylori antigen in stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and Helicobacter pylori testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mrs. Hilary Sanders, born on\n08/24/1976, who presented to our outpatient Immunodeficiency Clinic on\n02/18/2019.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Respiratory infections with symptoms for 7\nweeks. No antibiotics. No significant infections since then. Hizentra\n3x20 mL with good tolerance. Continued diarrhea, approximately 6 times a\nday, without weight loss. IgG levels remain within the target range;\ntherefore, we recommend continuing the current treatment unchanged.\n\nWe discussed further diagnostic steps. Initially, outpatient endoscopic\ndiagnostics should be performed.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Continue treatment as is\n\n- External upper gastrointestinal endoscopy (and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are writing to provide summary on the clinical course of Mrs. Hilary\nSanders, born on 08/24/1976, who presented at our outpatient\nImmunodeficiency Clinic.\n\n**Diagnoses:**\n\n- Common Variable Immunodeficiency Syndrome (CVID)\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Recurrent respiratory infections\n\n- Idiopathic thombocytopenic purpura\n\n- Arterial hypertension\n\n- Initiation of subcutaneous immunoglobulin substitution therapy human\n immunoglobulin\n\n- Suspected CVID Enteropathy\n\n- Iron-deficiency anemia\n\n**Medical History:** For a detailed medical history, please refer to our\nprevious medical records.\n\n**Therapy and Progression:** Overall stable condition. No longer\nexperiencing cough. Persistent fatigue. Upcoming appointment with the\nGastroenterology department next week. There is again an indication for\niron substitution.\n\n**Update on 11/15/2019: Laboratory results from 11/15/2019:**\nTransaminase elevation, Protein 18, markedly elevated BNP. However, IgA\nis at 0.5 (otherwise not detectable), IgG subclasses within normal\nrange. Findings do not align. Patient informed by phone, returning for\nfurther evaluation today; also screening for Hepatitis A, B, C, and E,\nEBV, CMV, TSH, coagulation. No shortness of breath, no edema, no\nabdominal enlargement, stable weight at 69 kg. In case of worsening\nsymptoms, shortness of breath, or fever, immediate referral to the\nemergency department recommended.\n\n**02/12/2020:** The patient is doing reasonably well. She has had a mild\ncold for about 2 weeks, no fever, but nasal congestion and\nyellowish-green sputum. No other infections. No antibiotics prescribed.\nShe has adapted to her gastrointestinal issues. An appointment with the\nGastroenterology department. She is currently working from home.\nMedication: no new medications, only Cuvitru 20mL 3x weekly. Weight\nremains stable at 67 kg. The last lung function test was in the summer\nof this year and was within normal limits. Imaging has not been\nperformed recently. Gastroscopy and colonoscopy have not been conducted\nfor some time.\n\n**04/14/2020:** Referral to Gastroenterology at is recommended for\npersistent abdominal symptoms.\n\n**10/24/2020:** The patient has mostly avoided social contacts due to\nthe pandemic. She continues to experience digestive problems (food\nintolerances, diarrhea, flatulence). She has less stamina. Few\ninfections in the past year, at most a minor cold. No significant\ninfections. Hizentra injections remain unchanged at 20 mL 3 times a\nweek.\n\n**03/22/2021:** Constant colds since December 2020. One-time antibiotic\ntreatment in October 2019. Subcutaneous Immunoglobulin therapy remains\nunchanged at 20 mL 3 times weekly.\n\n**09/19/2021:** She feels disoriented and very tired, more so than\nusual. Difficulty maintaining a steady gaze. No steroid therapy was\nadministered. CT showed enlarged lymph nodes. Diarrhea, especially in\nthe morning, 3-4 times a day, additional bowel movements with meals,\nsometimes watery. No fever, no infections. Hizentra injections continued\nunchanged.\n\n**Summary**: IgG levels are currently within the target range, so we\nrecommend continuing immunoglobulin substitution therapy without\nchanges. The antibody response (SARS-CoV-2 (S-Ag) IgG ELISA) to the\nCovid-19 vaccination is, as expected, negative. However, there is a\npositive detection of SARS-CoV-2 (N-Ag) IgG ELISA, as expected in the\ncase of viral contact (not vaccination). We consider this to be an\nunspecific reaction and recommend further monitoring at the next\nfollow-up appointment. With a platelet count currently at 55 K/uL, we\nrecommend a short-term blood count check with us or your primary care\nphysician.\n\nDue to the immunodeficiency, a lack of antibody response to vaccination\nwas expected. In the medium term, passive protection through\nimmunoglobulin substitution therapy will play a role. This is contingent\non a significant portion of plasma donors having antibodies against\nSARS-CoV2. There is a multi-month delay from the time of donation to the\nrelease of the preparations, so we anticipate that meaningful protection\nthrough immunoglobulin products will not be expected. An exact prognosis\nin this regard is not possible.\n\n**Current Recommendations:**\n\n- Outpatient follow-up in three months\n\n- Consultation with Gastroenterology\n\n- Continue SCIG treatment as is\n\n- External upper gastrointestinal endoscopy and colonoscopy (please\n return with findings)\n\n- In case of increasing diarrhea, conduct outpatient stool\n examinations, including testing for Giardia lamblia and\n Cryptosporidium\n\n- Abdominal ultrasound: annually\n\n- Pulmonary function tests including diffusion measurement: annually\n\n- Helicobacter pylori (HP) testing: e.g., breath test or HP antigen in\n stool: annually\n\n- Gastroscopy: approximately every 2-3 years, depending on previous\n findings and HP testing\n\n- Chest X-ray or chest CT: in case of abnormal clinical presentation\n or pulmonary function\n\n- Annual seasonal influenza vaccination\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update regarding our patient Mrs. Hilary\nSanders, born on 08/24/1976. She was under our inpatient care from\n03/29/2023 to 04/05/2023.\n\n**Diagnoses:**\n\n- Suspected CVID-Associated enteropathy\n\n- Known hepatosplenomegaly with a borderline enlarged portal vein, no\n significant portocaval shunts. Multiple liver lesions, possibly\n hemangiomas further evaluation if not already done.\n\n- Known retroperitoneal and iliac lymphadenopathy, likely related to\n the underlying condition.\n\n- Known changes in the lower lung bases, likely associated with the\n underlying condition, e.g., ILD. Refer to previous examinations.\n\n- Capsule endoscopy: Incomplete capsule enteroscopy with no evidence\n of inflammatory changes. Some hyperemia and blurry vascular pattern\n observed in the visible colon.\n\n- CVID-Associated Hepatopathy in the Form of Nodular Regenerative\n Hyperplasia\n\n**Other Diagnoses:** Common Variable Immunodeficiency Syndrome (CVID)\nwith:\n\n- Complete IgG deficiency\n\n- Complete IgM deficiency\n\n- Complete IgA deficiency\n\n- Leukopenia and lymphopenia\n\n- Initiation of subcutaneous immunoglobulin substitution therapy with\n Hizentra 20%\n\n- Infectious manifestations: Frequent respiratory tract infections\n\n- Non-Infectious manifestations:\n\n - ITP (Immune Thrombocytopenia)\n\n - Hepatosplenomegaly\n\n - Lymphadenopathy in supraclavicular, infraclavicular,\n thoracoabdominal, inguinal, and axillary regions\n\n - Suspected Granulomatous-Lymphocytic Interstitial Lung Disease in\n CVID\n\n<!-- -->\n\n- Iron-deficiency anemia\n\n**Pysical Examination:** Patient in normal general condition and\nnutritional status (175 cm, 65.8 kg. No resting dyspnea.\n\n[Neuro (grossly orienting):]{.underline} awake, oriented to\ntime/place/person/situation, No evidence of focal neurological deficit.\nNo meningism.\n\n[Head/neck]{.underline}: pharynx non-irritable. Moist, rosy mucous\nmembranes. Tongue occupied.\n\n[Skin]{.underline}: intact, turgor normal, no icterus, no cyanosis.\n\n[Thorax]{.underline}: normal configuration, no spinal palpitation, renal\nbed clear.\n\n[Lung]{.underline}: vesicular breath sound bds, no accessory sounds,\nsonorous tapping sound bds.\n\n[Cor]{.underline}: Cardiac action pure, rhythmic, no vitia typical\nmurmurs.\n\n[Abdomen]{.underline}: regular bowel sounds, soft abdominal wall, no\ntenderness, no resistances, no hepatosplenomegaly.\n\n[Extremities]{.underline}: no edema. Feet warm. Dorsalis pedis +/+ and\nposterior tibial artery +/+.\n\n**Current Presentation:** The patient was admitted for further\nevaluation of suspected CVID-associated enteropathy, as she had been\nexperiencing chronic diarrhea for the past three years. On admission,\nthe patient reported an overall good general and nutritional condition.\nShe described her current subjective well-being as good but mentioned\nhaving chronic diarrhea for the past three years, with up to 7 bowel\nmovements per day. The stools were watery without any signs of blood.\nThere were no indications of infection, such as fever, chills, dysuria,\nhematuria, cough, sputum, or dyspnea. She also experienced intermittent\nleft-sided upper abdominal pain, primarily postprandially. She had a\ngood appetite.\n\nOn the day of admission, an esophagogastroduodenoscopy was performed,\nwhich revealed erythematous antral gastritis. Additionally, there was an\napproximately 1 cm irregular mucosal area at the corpus-antrum junction\non the greater curvature side. A magnetic resonance imaging scan showed\nno evidence of inflamed bowel loops, ruling out chronic inflammatory\nbowel disease or celiac disease. To further investigate, a capsule\nendoscopy was performed, with results pending at the time of discharge.\nHypovitaminosis B12 and folate deficiency were ruled out. However,\niron-deficiency anemia was confirmed, and the patient had already\nscheduled an outpatient appointment for iron substitution. Serum levels\nof vitamin B6 and zinc were pending at discharge.\n\nDue to a moderate increase in transaminases and evidence of\nhepatosplenomegaly, we decided, after detailed explanation and with the\npatient\\'s consent, to perform a sonographically guided liver biopsy in\naddition to the planned endoscopy. The differential diagnosis included\nCVID-associated hepatopathy. The biopsy was successfully conducted ,\nwithout any post-interventional bleeding. Histology revealed mild acute\nhepatitis and nodular regenerative hyperplasia.This finding could be\nconsistent with changes in CVID-associated hepatopathy. Granulomas were\nnot observed. With only slightly elevated liver values, a trial therapy\nwith budesonide was initiated, and clinical (diarrhea?) and laboratory\n(transaminases?) follow-up will be performed in the outpatient setting.\n\nWe discharged Mrs. Sanders in a cardiopulmonarily stable condition.\n\n[Current Recommendations:]{.underline}\n\n- Follow-up in the gastroenterological outpatient clinic\n\n**Esophagogastroduodenoscopy (EGD) on 04/01/2023:** Introduction of the\ngastroscope in a left lateral position. Visualized up to the descending\npart of the duodenum. Unremarkable upper esophageal sphincter. Normal\nmotility and mucosa in the upper, middle, and distal esophagus. The\nZ-line is sharply demarcated in the hiatus. The cardia closes\nsufficiently. The stomach expands normally in all parts under air\ninsufflation. Multiple glandular cysts \\< 8 mm in size in the fundus and\ncorpus. Approximately 1 cm irregular mucosal area at the corpus-antrum\njunction on the greater curvature side. Streaky redness of the mucosa in\nthe antrum. Unremarkable mucosa in the bulb. Unremarkable mucosa in the\ndescending part of the duodenum. Step biopsies performed.\n\n[Summary]{.underline}: Erythematous antral gastritis. Approximately 1 cm\nirregular mucosal area at the corpus-antrum junction on the greater\ncurvature side, suggestive of inflammation. Multiple glandular cysts\nobserved in the fundus and corpus.\n\n[Abdominal MRI on 04/02/2023:]{.underline}\n\n[Clinical information, questions, and justification for the\nexam]{.underline}: Chronic diarrhea, suspected CVID-associated\nenteropathy, differential diagnosis of celiac disease, and inflammatory\nbowel disease (IBD). Assessment of malignancy.\n\nTechnique: After oral administration of mannitol solution and injection\nof 40 mg Buscopan, a 3-Tesla abdominal MRI was performed.\n\n[Findings]{.underline}: Multiple nodular consolidations and opacities\ndetected in the lower basal lung segments, measuring 7 x 4 mm, for\nexample, in the right lateral lower lobe (Series 18, Image 3).\nAdditionally, streaky-reticular changes observed. Left diaphragmatic\nelevation. Liver globally enlarged and smooth-bordered with several\nlesions showing mild to moderately hyperintense signals in T2-weighted\nimages and hypointense signals in T1-weighted images. These lesions\ndemonstrated increased enhancement in the early contrast phases,\nespecially those at the periphery, and more diffuse enhancement in the\nlate phases. For example, a lesion measuring 12 x 11 mm in Segment 2, a\nlesion measuring 8 mm in Segment 8 and a lesion measuring 21 x 13 mm in\nSegment 7. The portal vein measures borderline wide, up to 15 mm in\ndiameter. Gallbladder is unremarkable without evidence of stones. Intra-\nand extrahepatic bile ducts are not dilated. Spleen significantly\nenlarged, measuring 14 cm in pole-to-pole distance and 7.2 cm in\ntransverse diameter, homogeneous enhancement in native phases and late\ncontrast phase. Large accessory spleen located hilarly. Bilateral\nadrenal glands appear slender. Pancreas displays typical appearance with\nno ductal dilatation. Both kidneys are in orthotopic position, with\nunremarkable cortical cysts on the right side. No signs of urinary\nobstruction. The urinary bladder is moderately filled. No free fluid.\nAdequate dilation of small bowel loops. No evidence of significant bowel\nobstruction. No thickened bowel walls or increased post-contrast signal\nin the bowel loops. Cystic lesion in the right ovary measuring 17 x 11\nmm consistent with a corpus luteum cyst. Multiple enlarged\nretroperitoneal lymph nodes observed, for example, paracaval node with a\nshort-axis diameter of 14 mm and right iliacoexternal node with a\nshort-axis diameter of 14.5 mm No evidence of enlarged mesenteric or\ninguinal lymph nodes.\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nHerewith we report on Mr. John Williams, born 08/08/1956, inpatient from\n10/03/2015 to 10/06/2015.\n\n**Diagnosis:**\n\nMultiple Myeloma IgG kappa.\n\n**Staging and Initial Diagnosis:**\n\nDate: 03/2015\n\nStage: IIA based on the Salmon and Durie scale, ISS II.\n\n- CT whole body 03/11/2015: Osteolysis detected in the seventh\n thoracic vertebra (T7); pathologic fracture observed in the first\n lumbar vertebra (L1).\n\n- Bone marrow infiltration: Initial histological evaluation showed\n 22%; cytomorphological assessment revealed 28%.\n\n**Histological Findings:**\n\nDate: 03/2015\n\n**FISH (Fluorescence In Situ Hybridization) Results:** Detected an\nadditional signal for both CCND1 and CCND3. Presence of one trisomy or\ntetrasomy 9. Additional signals observed for 5p15- and 5q31- as well as\n19p13- and 19q13-. 46, XY with a detected ASxL1 mutation.\n\n**Treatment Timeline:**\n\n**01-02/15:** Administered 2 cycles of\nCyclophosphamide-Bortezomib-Dexamethasone (CyBorD). Resulted in stable\ndisease but caused prolonged pancytopenia.\n\n**03/15 - 06/15:** Administered 3 cycles of a combination treatment\nincluding Carfilzomib, Lenalidomide, and Dexamethasone.\n\n**07/15:** Underwent stem cell mobilization using cyclophosphamide.\n\n**07-08/15:** Experienced extended pancytopenia and regeneration. Bone\nmarrow puncture showed progressive disease with a significant increase\nin plasma cell infiltration, reaching 92%.\n\n**09/02/15:** Received the first dosage of daratumumab at 16mg/kg.\nSubsequently developed thrombocytopenia. Treatment did not include\nRevlimid.\n\n**Histopathological report: **\n\nMultiple myeloma, IgG kappa. The evaluation is for myelodysplastic\nsyndrome in the presence of tricytopenia and an ASXL1 mutation.\n\n**Methods:** Hematoxylin and eosin (HE), periodic acid-Schiff (PAS),\niron, Giemsa, Gomori, chloroacetate esterase, step sections,\ndecalcification, and 1 block.\n\n**Microscopic Examination:**\n\nThe sample is a 2 cm long bone marrow biopsy core that contains more\nthan ten medullary canals. The cellularity is around 20-30%, which is\nconsidered normocellular for the patient\\'s age. There is evidence of\nbone marrow edema and heightened hemosiderosis. Recent stromal\nhemorrhages are also observed. There is a relative increase in\nerythropoiesis with a ratio of erythropoiesis to granulopoiesis being\napproximately 2:1. Erythropoiesis is present in well-defined zones with\nregular maturation. Only minimal nuclear rounding is observed.\nGranulopoiesis matures into segmented granulocytes. PAS staining reveals\nsome morphologically normal megakaryocytes. Occasionally there are bare\nnuclei and possible microforms. Scattered mature plasma cells are\nobserved with no signs of atypical proliferation. The argyrophilic\nfibrous network is fine, and no fibrosis is detected.\n\n**Preliminary Findings:**\n\nThe bone marrow biopsy is normocellular for the age with a relative\nincrease in erythropoiesis that shows only minimal cytological atypia.\nGranulopoiesis is slightly reduced, while megakaryopoiesis is\nnormocellular with a few cells that are hypolobulated.There is bone\nmarrow edema and enhanced hemosiderosis. Scattered mature plasma cells\nare also noted.\n\nBased solely on histomorphologic observations, it is not enough to\nconfirm a diagnosis of myelodysplastic syndrome (MDS), which is the\nsuspected clinical diagnosis. For a more thorough evaluation of\npotential atypicalities in the megakaryopoiesis (like\nmicromegakaryocytes), further immunohistochemical examination is\nrecommended. Assessing the blast content is also advised. There is no\nevidence currently of manifest infiltrates from the previously diagnosed\nmultiple myeloma.\n\n**Immunohistochemical Additional Findings (Dated 10/04/2015):**\n\n**Immunohistochemistry Stains Used:** CD3, CD79a, CD34, CD117, MUM-1,\nKappa, lambda, CyclinD1, CD61.\n\nBlast cells positive for CD34 and CD117 are below 5% of the total. CD3\nstains scattered T lymphocytes, and CD79a identifies sporadic B\nlymphocytes and some plasma cells. Plasma cells are also positive for\nMUM-1 and exhibit polytypic expression of kappa and lambda light chains.\nThere is no co-expression with CyclinD1. CD61 highlights the previously\ndescribed megakaryocytes, and no micromegakaryocytes are observed.\n\n**Final Report:**\n\nThe bone marrow biopsy is representative and normocellular for the\npatient\\'s age. There is a relative increase in erythropoiesis that\nshows only minor cytological atypia. Granulopoiesis appears slightly\nreduced, while megakaryopoiesis presents with a few hypolobulated cell\nforms. Evidence of bone marrow edema and increased hemosiderosis is\nnoted, along with scattered mature plasma cells.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe hereby report on Mr. Williams, John, born 08/08/1956, inpatient from\n11/30/2015 to 12/28/2015.\n\n**Oncological Diagnosis**:\n\nMultiple myeloma IgG kappa.\n\nInitial diagnosis 03/15: Stage IIA (Salmon and Durie), ISS II.\n\n**Sites**:\n\nOsteolysis in T7 vertebra, fracture in T1 vertebra.\n\nBone marrow: 22% histological, 28% cytomorphologic infiltration.\n\n**Histology**:\n\nBone marrow biopsy 11/16: FISH: Additional signals for CCND1, CCND3;\nTrisomy 3, 9; Additional signals on chromosomes 5 and 19. Chromosomal\nanalysis: 46, XY with ASxL1 mutation.\n\n**Treatment**:\n\n01-02/15: 2 cycles Cyclophosphamide-Bortezomib-Dexamethasone -\\>\nStable disease, prolonged low blood counts.\n\n03/15 - 06/15: 3 cycles Carfilzomib/Lenolidomide/Dexamethasone.\n\n07/15: Stem cell mobilization with Cyclophosphamide.\n\n07-08/15: Extended low blood count. Bone marrow biopsy: 92% plasma cell\ninfiltration.\n\n09/02/15: Darzalex 16mg/kg initial dose, with platelet count drop. No\nLenalidomide.\n\n09/04/15: 10 cycles of Darzalex, 1 cycle with Lenalidomide due to\nrenewed low platelet and white blood cell counts.\n\n11-12/15: Conditioning chemo with Fludarabine/Treosulfan, then\nallogeneic stem cell transplant from HLA-matched unrelated donor.\nImmunosuppression with ATG, cyclosporine, Mycophenolate Mofetil.\n\n**Complications**:\n\nMucositis, central line infection, gastrointestinal symptoms, urinary\ninfections with E. faecium and E.coli, JC virus bladder infection.\n\n**Secondary Diagnoses**:\n\nDry eye syndrome, Type 2 diabetes managed with oral meds, Hypertension.\n\n**Treatment Plan**:\n\nGradual reduction of immunosuppression based on graft vs. host disease\nsigns.\n\n**Radiology**:\n\nCT Whole Body: 12/01/15: Various areas of bone osteolysis. Degeneration\nof spine.\n\nCT Chest 12/02/15 and 12/03/15: Changes in lungs and some fluid\naccumulation.\n\n**Medication**:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------- ---------------\n Mycophenolic Acid (Myfortic) 360 mg Twice Daily\n Cyclosporine (Sandimmune) 200 mg Daily\n Artificial Tears As directed 3x Daily\n Candesartan (Atacand) 8 mg Daily\n Tamsulosin (Flomax) 0.4 mg Daily\n Pantoprazole (Protonix) 40 mg Daily\n Amlodipine (Norvasc) 5 mg Twice Daily\n Cotrimoxazole (Bactrim) 960 mg Mon/Wed/Fri\n Valacyclovir (Valtrex) 500 mg Twice Daily\n\n**Summary**:\n\nMr. Williams was admitted on 11/30/2015 for treatment related to his\nMultiple Myeloma. He underwent conditioning chemotherapy,\nimmunosuppressive therapy, and stem cell transplantation. He experienced\ncomplications, including infections and symptoms affecting multiple\nsystems. Close monitoring of blood pressure and glucose is recommended.\nHe was discharged on 12/28/2015 in good condition and will be followed\nup in the outpatient clinic. If there are worsening symptoms, he should\nvisit the emergency department immediately.\n\n**Dear Mr. Williams,**\n\nWe report on your outpatient treatment on 02/15/2016.\n\n**Diagnoses:**\n\n1. **Multiple Myeloma** IgG kappa, diagnosed 03/2015.\n\n Stage IIA as per Salmon and Durie, stage II as per ISS.\n\n Osteolysis at T7 vertebra, fracture at T1 vertebra.\n\n Bone marrow infiltration: 22% histologically, 28% cytologically.\n\n FISH: Indications of additional CCND1 and CCND3 signals; Trisomy 3,\n additional signals at various chromosomes.\n\n Chromosome analysis: 46, XY \\[20\\].\n\n**Secondary diagnoses:**\n\nType 2 diabetes mellitus\n\nHypertension\n\nCataract (surgery 06/2018)\n\nNodular goiter\n\nRSV pneumonia (03/2018)\n\n**Summary:**\n\nMr. Williams presents in good general health to our bone marrow\ntransplant (BMT) outpatient clinic. There are no signs of infection or\nchronic graft rejection. He has shown significant improvement in\nresilience and does not have any complaints. Vital signs are stable.\nBlood tests showed ongoing regeneration with normal light chains and\npersistent positive immunofixation. There is no need for\nmyeloma-specific therapy at present, but close monitoring of the\nparaprotein is required.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ---------------------- -------------------------------------------------------\n Tamsulosin (Flomax) 0.4 mg Daily in the morning\n Candesartan (Atacand) 8 mg Twice Daily\n Metformin (Glucophage) 1000 mg 0.5 tablet in the morning, 1.5 tablets in the evening\n Pantoprazole (Protonix) 20 mg Daily in the morning\n Vitamin D3 (various brands) 20,000 IU Once a week\n Allopurinol (Zyloprim) 100 mg Daily in the morning\n Insulin (various types) As per sliding scale As per sliding scale\n\nWith kind regards\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are providing an update on our shared patient, Mr. John Williams, who\nconsulted with us on June 15, 2018.\n\n**Consultation Summary:**\n\n8. **Multiple Myeloma**\n\n **Kidney biopsy scheduled for tomorrow.**\n\n **Prostate cancer**\n\n**Current Status:**\n\nAcute renal failure accompanied by proteinuria due to the recent\ndiagnosis of multiple myeloma.\n\nMultiple osteolytic lesions, including at the T4, T7, L1 vertebra and\nthe ribs.\n\n**Diagnosis:**\n\nMultiple myeloma.\n\nProstate cancer\n\n**Clinical Presentation:**\n\nOsteolytic lesion presenting as thoracic pain.\n\n**Imaging Findings:**\n\nOsteolytic lesion at T4 vertebra with involvement of the posterior edge.\n\n**Planned Procedures:**\n\nRestricted bed rest.\n\nWhole spine MRI with STIR sequences, to be presented in the upcoming\ntumor board meeting for deciding further course of action.\n\n**Previous Diagnoses:**\n\nMay, 2018, Nephrology: Enlarged kidneys noted bilaterally.\n\nJanuary, 2018, Urology: Prostate cancer\n\nDecember, 2015, Internal Medicine: Multiple myeloma without evidence of\ncomplete remission.\n\n**Previous Procedures:**\n\nTransrectal biopsy of the prostate.\n\n**Histology Report, Date: June 13, 2018:**\n\nSuspected plasmacytoma with paraproteinemia.\n\nWBC 6.47; Hb 10.8; Platelets 251,000.\n\nBone marrow biopsy: Cellularity approximated at 48%, indicating slightly\nincreased cellularity. Amidst reduced hematopoiesis, there is\nproliferation of plasmacytoid cells with certain features.\n\n**Preliminary Report:**\n\nThe bone marrow sample indicates possible infiltration due to plasma\ncell myeloma. Additional tests will be conducted to confirm and further\nelucidate this finding.\n\n**Supplementary Findings:**\n\nImmunohistochemical staining: CD138, Kappa, Lambda, CD20.\n\nMicroscopic findings confirm the presence of nodular infiltrates with\ncertain features.\n\n**Final Report:**\n\nBone marrow sample indicates infiltration by a plasma cell myeloma with\nkappa light chain restriction. Additionally, regular trilinear\nhematopoiesis is significantly reduced.\n\n\n\n### text_3\n**Dear colleague, **\n\nI wish to provide an update on our mutual patient, Mr. John Williams,\nborn 08/08/1956, who presented at our clinic at 08/20/2018.\n\n**Diagnosis:**\n\nPresent condition: Multiple Myeloma IgG type, coded under ICD-10.\n\nStage: II B based on Durie and Salmon criteria; determined from Hb 9.1,\nCreatinine 4.5 mg/dL.\n\n**Histology:**\n\nBone marrow biopsy presents a strong indication of interstitial and\nfocal nodular invasion of the marrow space by plasma cell myeloma,\npredominantly of high to intermediate maturity.\n\n**Immunohistochemistry:**\n\nThe nodular infiltrates were found positive for CD138 with a kappa-light\nchain restriction (infiltration rate at 62%).\n\nCytological findings align with high-grade bone marrow infiltration by\nmultiple myeloma.\n\n**Tumor Localization:**\n\nMRI of the entire spine conducted on 06/20/2018 reveals disseminated\nbone lesions throughout the spine without any soft tissue involvement.\nThere is noted anterior vertebral body involvement at T4.\n\n**Secondary Diagnoses:**\n\nCysts in the right kidney.\n\nAs of 01/2018, a diagnosis of Prostate cancer with a Gleason score of 8\nand a PSA reading of 10.02.\n\nPrevious rib fracture, which may be associated with the multiple\nmyeloma.\n\nChronic renal failure, with ongoing dialysis treatment.\n\nDocumented mitral valve surgery in 2015.\n\nHistory of Deep Vein Thrombosis in 1999.\n\n**Prior Treatments:**\n\nInitial diagnosis of multiple myeloma IgG kappa in 2015.\n\nProstate cancer was diagnosed in 01/2018 following spontaneous rib\nfractures, Gleason score of 8.\n\nA PSMA-PET-CT scan in 05/18 showed multiple bone lesions, notably\npronounced at Th4.\n\nTumor board review in 06/2018 concluded treatment strategies for\nurological tumors, encompassing radiation therapy targeting Th4 and\nantiandrogen therapy for the identified prostate cancer, using a GnRH\nanalog.\n\nThe progression of multiple myeloma required the commencement of\nsystemic treatment with Velcade and Dexamethasone.\n\n**Study**: PSMA-PET-CT Scan\n\n**Date of Study**: 05/2018\n\n**Clinical Information**: Prostate cancer diagnosed in 01/2018 following\nspontaneous rib fractures. Gleason score of 8.\n\n**Technique**:\n\nWhole body positron emission tomography/computed tomography (PET/CT) was\nperformed following the intravenous administration of PSMA-radiotracer.\nCoronal, sagittal, and axial images were acquired and reviewed.\n\n**Findings**:\n\nBone: Notably increased PSMA uptake is seen at the level of T4 vertebral\nbody consistent with metastatic involvement. The lesion has caused\ncortical erosion and expansion with potential involvement of the\nanterior spinal canal. Multiple rib lesions are identified,\ncorresponding with the clinical history of spontaneous rib fractures.\nThese lesions exhibit no increased PSMA uptake. No other foci of\nincreased PSMA uptake throughout the axial and appendicular skeleton.\n\n**Prostate**:\n\n12. The prostate gland demonstrates diffusely increased uptake, which is\n consistent with primary prostate malignancy, especially given the\n known clinical history.\n\n**Thorax/Abdomen: **\n\n13. No abnormal PSMA avid soft tissue masses or lymphadenopathies were\n noted in the visualized fields. No pulmonary nodules or masses\n suggestive of metastatic disease were identified. Liver, spleen,\n kidneys, and adrenal glands appear unremarkable with no evidence of\n metastatic lesions.\n\n**Impression**:\n\nOsseous metastasis from prostate cancer with involvement of the T4\nvertebral body. No evidence of soft tissue, lymph node, or pulmonary\nmetastases in the visualized fields. Prostate gland showing evidence\nconsistent with primary malignancy.\n\n**Current Radiation Therapy:**\n\n**Indication:** Radiotherapy became a consideration due to a sizable\nosteolytic lesion at T4, both for pain alleviation and stabilization.\nConcurrent treatment of the aching ribs on the right side (7th-9th) was\nalso performed.\n\n**Technique:** 6 MeV photons from a linear accelerator, administering a\ncumulative dose of 30 Gy to thoracic vertebra 4 and 20 Gy to the ribs\nwith respective daily doses.\n\n1. **Treatment Duration:**\n\n Th4: 08/21/2018 to 08/27/2018\n\n Rib area: 08/21/2018 to 08/27/2018\n\n**Clinical Update:**\n\nThroughout the therapy period, Mr. Williams remained admitted to our\nOncology ward for ongoing reduced dosage chemotherapy using Velcade. He\nhas reported a decline in pain sensations during this timeframe. The\noverall health status appeared satisfactory, with no skin irritation\nobserved at the irradiated sites.\n\n**Subsequent Actions:**\n\nGuidance on skincare and potential adverse effects have been provided to\nMr. Williams. The intensity of the chemotherapy will soon be escalated.\nA radio-oncological assessment has been scheduled in our outpatient\nfacility for 09/05/2018 at 12:00 PM. I kindly request the most recent\ntest results by this date.\n\n**Note:** In compliance with the Radiation Protection Act, we shall\nundertake regular evaluations and request updates on the patient\\'s\ncondition. Mr. Williams has been apprised of the necessity for\nconsistent oncological check-ups.\n\nWarm regards,\n\n\n\n### text_4\n**Dear colleague, **\n\nWe wish to update you on our mutual patient, Mr. John Williams.\n\n**Diagnosis:**\n\nCurrent multiple myeloma IgG type\n\n**Tumor Localization:**\n\nBased on a whole spine MRI dated June 20, 2018:\n\nMultiple intraosseous lesions throughout the spine without soft tissue\ninvolvement.\n\nKnown intrusion of the T4 cover plate.\n\n**Secondary Diagnoses:**\n\nRight kidney cysts\n\nDiagnosed prostate carcinoma in January 2018, Gleason score 8, initial\nPSA at 10.02.\n\nHistory of a spontaneous rib fracture related to the multiple myeloma.\n\nChronic renal insufficiency; he remains on dialysis.\n\nHistory of mitral valve reconstruction in 2015.\n\nHistory of deep vein thrombosis in 1999.\n\n**Treatment Overview:**\n\nDiagnosed with multiple myeloma type kappa in 2015 with initially normal\nrenal function.\n\nDiagnosed with prostate carcinoma in January 2018 due to spontaneous rib\nfractures, Gleason score 8.\n\nTreatment decisions in 2018 included radiation for vertebral lesions and\nhormone therapy for prostate cancer using a GnRH analogue.\n\nSystemic therapy with Velcade and Dexamethasone initiated due to\nprogressive myeloma.\n\nRadiation therapy in August 2018 for vertebral and rib lesions.\n\n**Summary:**\n\nMr. Williams had a radio-oncological follow-up on September 29, 2018.\nHis general health has improved. He remains on thrice-weekly dialysis.\nRecent CT scans show extensive osteolysis of the spine with several\nvertebral collapses. Currently, we see no urgent fracture risk or need\nfor additional radiation therapy. We have planned regular clinical\ncheck-ups with Mr. Williams. His next follow-up is scheduled in three\nmonths.\n\n**Oncologic treatment: **\n\nDaratumumab/lenalidomide/dexamethasone regimen:\n\nDaratumumab 16mg/kg: Days 1, 8, 15, 22 for cycles 1 & 2 (every 28 days\nfor 8 weeks).\n\nDays 1, 15 for cycles 3-6 (every 28 days for 16 weeks).\n\nDay 1 for subsequent cycles (every 28 days).\n\nDexamethasone 20mg on Daratumumab days, with an additional 20mg the day\nafter (totaling 40mg/week).\n\nLenalidomide 5mg from day 1-21 (every 28 days).\n\nBondronate every 4 weeks (last administered on 12/13/2016).\n\nRe-evaluation of hemodialysis and autologous peripheral blood stem cell\ntransplant (PBSCT) after 2 cycles of daratumumab.\n\n**CT Spine scan (09/30/2018): **\n\n**Technique**: Contrast-enhanced computed tomography (Omnipaque 240) of\nthe thoracic and lumbar spine was performed with axial slices, and\nmultiplanar reconstructions in sagittal and coronal orientations.\n\n**Findings**:\n\n**Thoracic Spine**:\n\nExtensive osteolytic lesions are identified in multiple thoracic\nvertebrae. Specifically, vertebral collapses are noted at T4, T7, T9,\nT11. No significant bony destruction of pedicles, lamina and spinous\nprocesses. No evidence of paravertebral or epidural soft tissue masses.\n\n**Lumbar Spine**:\n\nProminent osteolytic changes are seen in L1 (with fracture) and L4\nvertebral bodies. However, there is no significant vertebral collapse.\nPreserved pedicles, lamina, and spinous Processes without significant\nosteolysis. No evidence of abnormal masses or lymphadenopathy.\n\nNo significant central canal stenosis or neural foraminal narrowing. The\nintervertebral discs are preserved without significant discopathies.\n\n**Impression**:\n\nExtensive osteolysis in multiple vertebral bodies, specifically in the\nthoracic and lumbar spine, with vertebral collapses at levels T4, T7,\nT9, and T11 as well as L1. Also, osteolytic changes in L4 of the lumbar\nspine.\n\nCurrently, based on imaging, there does not appear to be an urgent\nfracture risk, and no radiologic signs suggesting a need for imminent\nradiation therapy. No soft tissue abnormalities identified in the\nexamined regions.\n\n**Medication: **\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ----------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg In the morning (day after Daratumumab)\n Pantoprazole (Protonix) 40 mg Daily in the morning\n Cotrimoxazole (Bactrim) 480 mg Thrice weekly (Mon, Wed, Fri)\n Valacyclovir (Valtrex) 500 mg Daily in the morning\n Acetaminophen (Tylenol) 500 mg Orally, three times daily\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly (4-week depot) subcutaneously\n Pregabalin (Lyrica) 25 mg Twice a day\n Amlodipine (Norvasc) 5 mg Daily in the morning\n Bisoprolol (Zebeta) 5 mg Daily in the morning\n Lenalidomide (Revlimid) 5 mg Nightly\n Ondansetron (Zofran) 8 mg As needed, up to twice daily\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are updating you on Mr. John Williams\\' outpatient visit on December\n13, 2018.\n\n**Diagnosis:**\n\nFebrile respiratory infection.\n\n**Underlying Conditions:**\n\nMultiple myeloma, kappa light chain, stage IIIB as classified by Salmon\nand Durie.\n\nChronic kidney disease requiring hemodialysis.\n\nProstate cancer.\n\n**Summary:**\n\nMr. Williams came to the emergency room with fever and dry cough during\nhis multiple myeloma treatment with Darzalex, Revlimid, and\nDexamethasone. His vital signs were recorded, and laboratory tests\nshowed signs of infection and confirmed chronic kidney disease. Chest\nX-ray indicated possible inflammation. Given these findings, Mr.\nWilliams was admitted for antibiotic therapy. Further observations and\ntreatments were documented.\n\n\n\n### text_6\n**Dear colleague, **\n\nThis letter pertains to Mr. John Williams, who was hospitalized from\nDecember 14 to 21st, 2018.\n\n**Oncological Diagnosis:**\n\nMultiple myeloma, kappa light chain, initially diagnosed in June 2018 as\nstage IIIB per Durie and Salmon criteria.\n\n**Treatment Details:**\n\nHe underwent various treatment regimens for multiple myeloma over the\ncourse of the year. His current condition indicates an\ninfluenza-positive pneumonia, likely with a bacterial superinfection. He\ncontinues hemodialysis thrice a week.\n\n**Secondary Diagnoses:**\n\nSeveral renal complications were documented in June 2018.\n\n**Plan of Care:**\n\nMr. Williams\\' therapy plan was discussed in a tumor board meeting. He\nremains on a regimen of Darzalex, Revlimid, and Dexamethasone.\n\n**Summary:**\n\nMr. Williams came to the emergency room on December 13, 2018, with cough\nand fever. Further details about his history can be found in previous\ncommunications. On admission, he showed signs of a respiratory\ninfection, confirmed by a chest X-ray. He was treated with antibiotics,\nwhich were later escalated. He also tested positive for influenza A and\nwas given Tamiflu. After a short in-patient stay, he has shown\nimprovement. He is scheduled to continue his therapy in our clinic on\nDecember 22, 2018. In case of any complications, he has been advised to\nreturn to our emergency room immediately.\n\nFor future consultations, please provide a referral slip for each new\nquarter.\n\nWarm regards\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to inform you about Mr. John Williams, who was an\ninpatient in our clinic from March 1, 2019, to March 3, 2019.\n\nOncological diagnosis:\n\nMr. Williams was diagnosed with Multiple Myeloma light chain kappa. He\nreceived his follow-up diagnosis in June 2018, which was at stage IIIB\nper the Durie and Salmon staging system.\n\nTreatment:\n\nIn June 2018, he was given VelDex due to impaired renal function.\nSubsequently, he received Carfilzomib (15mg/m2 on days 1-2, 8-9, 15-16),\nLenalidomide (5 mg, on days 1-21), and Dexamethasone (40mg, on days 1,\n8, 15-16, 22). In addition, he was treated with Pomalidomide (4mg on\ndays 1-21), Doxorubicin (9mg/m2 on days 1, 4), and Dexamethasone (40mg,\non days 1, 8, 15, 22). He underwent radiation therapy to T4 of the rib\nthorax in August. Between August to October 2018, he had three cycles of\nPomalidomide, Doxorubicin, and Dexamethasone, after which the disease\nprogressed. From November 2018 to February 2019, he had four cycles of\nDaratumumab, Lenalidomide, and Dexamethasone.\n\n**Outcome:**\n\nThe response to the treatment was very good partial remission (VGPR).\n\n**Present Treatment:**\n\nHe underwent mobilization chemotherapy with cyclophosphamide, with a\ndosage adjusted due to his requirement for dialysis (1500mg/m^2^ on day\n1 and 1000mg/m^2^ on day 2). He received dialysis on March 2 in our\nnephrology department.\n\n**Secondary diagnoses:**\n\nIn March 2018, he developed renal insufficiency requiring thrice-weekly\ndialysis. In January 2018, he was diagnosed with prostate carcinoma and\nwas treated with an androgen blockade using Enantone.\n\n**Future Therapy Plan:**\n\nThe tumor board\\'s decision from March 3, 2019 was to continue with\nDaratumumab, Revlimid, and Dexamethasone due to the good response. He\nwill undergo stem cell mobilization and high-dose therapy with\nautologous stem cell transplant. Monitoring is scheduled for March 14,\n2019, followed by dialysis at our dialysis center on Mondays,\nWednesdays, and Fridays.\n\n**Medications:**\n\nHis current medications include:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------------ ---------------------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL For dialysis\n Dexamethasone (Decadron) 8 mg On March 4 and 5\n Pantoprazole (Protonix) 40 mg \n Cotrimoxazole (Bactrim) 480 mg Thrice weekly on Mondays, Wednesdays, and Fridays\n Valacyclovir (Valtrex) 500 mg \n Ibandronate (Boniva) 2 mg Every four weeks\n Leuprorelin (Lupron Depot) 3.75 mg Every four weeks\n Pregabalin (Lyrica) 25 mg \n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg \n Filgrastim (Neupogen/Granix) 48 million IU \n\n**Summary:**\n\nMr. Williams was admitted on March 1, 2019, for mobilization\nchemotherapy with cyclophosphamide. Please refer to our previous letters\nfor a detailed history. His last treatment was with daratumumab,\nRevlimid, and dexamethasone. Fortunately, this treatment showed a very\ngood response. He is dialyzed three times a week at our clinic due to\nchronic renal insufficiency. He was discharged on March 3, 2019, and we\nrequest the administration of filgrastim as per the medication plan\nstarting March 6, 2019. CD34+ monitoring is scheduled for March 14,\n2019. Depending on the CD34+ count, stem cell collection may need to be\nscheduled on a dialysis-free day. We have coordinated with our\ncolleagues at the dialysis center for the collection via the atrial\ncatheter. A follow-up for blood count and Ibandronate administration has\nbeen scheduled for March 10, 2017. If his condition deteriorates or if\nhe shows signs of infection, bleeding, or any other complications, he\nshould immediately be brought to our emergency department. Please\nremember to bring a referral form during your initial visit each\nquarter.\n\nTherapy recommendation based on Transthoracic echocardiography findings:\n\nMr. Williams has a normally sized left ventricle with standard global\nfunction. There\\'s no evidence of any regional wall motion\nabnormalities. The right ventricle is also of normal size with standard\nfunction. The left atrium is not dilated. There\\'s marked concentric\nleft ventricular hypertrophy. His aortic valve shows insufficiency of I°\n(PHT 520 ms), while the mitral and tricuspid valves appear normal. There\nis no significant pericardial effusion. Overall, he has a standard left\nventricular function with no significant valvular diseases or pulmonary\nhypertension.\n\n**Surgery Report:**\n\nDiagnosis: Terminal renal failure.\n\nProcedure: Creation of a right upper arm brachialis-basilica fistula\nwith the anterior movement of the right basilic vein.\n\n**Report:**\n\nMr. Williams required dialysis due to terminal renal insufficiency. For\nthis purpose, an arteriovenous (AV) fistula was created as a dialysis\naccess. Previously, dialysis was performed using a right atrial\ncatheter. After mapping, only the basilic vein on the right arm seemed\nsuitable. Hence, a brachialis-basilica fistula was created with anterior\ntransposition of the basilica vein. A partial mobilization of the\nbasilica vein was performed. Afterward, a brachialis-basilica\nanastomosis was carried out. The operation was uncomplicated.\n\nYour collaboration has been instrumental in managing this patient\neffectively. If you have any further queries or require additional\ndetails, please do not hesitate to contact our office.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------- ------------------ ------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Change every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg Morning on 03/05 & 03/06\n Pantoprazole (Protonix) 40 mg Morning\n Cotrimoxazole (Bactrim Forte) 480 mg Morning 3x weekly on Mon, Wed, Fri\n Valacyclovir (Valtrex) 500 mg Half tablet in the morning\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly subcutaneous (Morning)\n Pregabalin (Lyrica) 25 mg Morning and Evening\n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg Morning and Evening\n Filgrastim (Neupogen/Granix) 48 million IU Morning and Evening\n\nBest regards,\n\n\n\n### text_8\n**Dear colleague, **\n\nI am writing to provide you with a detailed report on Mr. John Williams,\nwho was admitted to our facility from May 8, 2020, to May 28, 2020.\n\n**Diagnoses:**\n\nHistory of acute mitral valve endocarditis in March 2020.\n\nSubsequent re-operation entailing mitral valve replacement using a\nBioprosthesis (29 mm) coupled with the resection of all infected tissue\nfrom the mitral valve\\'s supporting apparatus on March 24, 2020.\n\nThe origin remains uncertain, but potential associations include Demers\ncatheter infection and port catheter infection (confirmed presence of\nStaphylococcus epidermidis).\n\nSurgical removal was conducted on March 21, 2020, with no findings at\nthe catheter tips.\n\n14. Antibiotic regimen included:\n\n Meropenem from April 2, 2020, to April 23, 2020.\n\n Linezolid 600 mg from April 3, 2020, to April 19, 2020.\n\n Daptomycin from April 3, 2020, to May 27, 2020.\n\n Fosfomycin from April 19, 2020, to May 28, 2020.\n\nHistory of mitral valve reconstruction via minithoracotomy in 2015.\n\nRight-side vision loss due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia in the caput nuclei caudati/lenticular nuclei\non April 5, 2020, possibly embolic in origin from mitral valve\nendocarditis.\n\nHistory of brainstem transient ischemic attack (TIA) on March 11, 2020,\npotentially embolic in relation to mitral valve endocarditis.\n\nJugular vein thrombosis.\n\n20. Hematological/oncological diagnoses comprise:\n\n Multiple myeloma with lambda light chains, stage IIIB according to\n the Salmon and Durie criteria, first diagnosed in 2015. This was\n accompanied by multiple osteolysis occurrences, history of radiation\n to Th4 and rib thorax, and treatment with Daratumumab. Current\n treatment has been paused due to remission.\n\n A prostate carcinoma diagnosis in January 2018\n\n**Other medical conditions include:**\n\n-Chronic kidney failure necessitating dialysis since 2018, history of a\nDemer catheter with explantation on March 2020, and angioplasty on the\nright V. basilica and V. brachialis due to stenosis-related shunt\ndysfunction.\n\n-History of brainstem TIA in April 2019.\n\n-Sensations of tingling paresthesias in both lower legs.\n\n-History of bilateral deep vein thrombosis.\n\n-Frequent calf muscle cramps.\n\n**Medical History Overview:**\n\nMr. Williams\\'s latest admission on May 8, 2020, was to assess remission\nstatus and determine if continuation of treatment for his known multiple\nmyeloma was necessary. Previously, until March 2020 he was under a\nDaratumumab monotherapy (as he could not tolerate Revlimid), which\nshowed stable disease progression. Prior to this, he was treated at our\nlocal hospital for mitral valve endocarditis which had a complex\ntrajectory. At the time of admission, Mr. Williams felt generally weak\nbut was otherwise in stable condition. Upon discontinuation of the\nfentanyl patch, his back pain increased. He exhibited no fevers and had\nno known allergies. His appetite was low, and he reported no nausea.\nSince his heart surgery, he has experienced numbness in his left heel\nand toes. His residual urine output was about 190 mL per day, and he was\nundergoing regular dialysis.\n\n**Physical Examination:**\n\nThe patient was alert, responsive, and fully oriented. The examination\nof the head, neck, and lungs was unremarkable. Cardiac auscultation\nrevealed clear and rhythmic heart sounds without any abnormal findings.\nThere was a non-irritated sternotomy scar. Examination of his back\nrevealed decubitus ulcers. Abdominal examination showed a soft,\nnon-tender abdomen with normal bowel sounds. Extremity examination\nrevealed minor edema.\n\n**Diagnostic Imaging and Tests:**\n\nA series of diagnostic tests, including sonography, whole body CT scan,\nophthalmological exams, and histology were conducted. The results are\ndetailed within this report. In summary, the findings indicate:\n\n-Limited abnormalities in the heart\\'s echocardiography, with potential\nmitral valve issues to monitor.\n\n-Bone scans revealed extensive osteopenia and other abnormalities\nrelated to his known multiple myeloma, but no evidence of new\nosteolysis.\n\n-Eye examinations confirmed the previously noted vision issues,\npotentially stemming from the mitral valve endocarditis, but provided no\nclear solutions.\n\n-Histological evaluation of bone marrow samples indicates largely\nregular hematopoiesis but confirms infiltration from the known multiple\nmyeloma.\n\n**Summary and Recommendations:**\n\nMr. John Williams is a 63-year-old male with a complex medical history\ninvolving multiple organ systems. His most recent admission was in\nrelation to his multiple myeloma, for which he has been in remission and\nwill be monitored closely. His mitral valve endocarditis from earlier\nthis year has been resolved and treated appropriately. Due to the\nmultiple comorbidities, it is crucial for any treating facility or\nphysician to be fully aware of his history to provide optimal care.\nContinual monitoring of his cardiovascular and renal systems is\nessential. The importance of maintaining strict adherence to his\ndialysis regimen and potential antibiotic prophylaxis is emphasized.\nGiven his weakened general condition and chronic pain, palliative care\nmight also be a suitable approach to consider, focusing on enhancing his\nquality of life and addressing his pain management needs.\n\nPlease refer to the attached files for further details and a complete\nbreakdown of tests and findings. I trust this report will help guide the\nappropriate medical care for Mr. John Williams.\n\nSincerely,\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- -------------------- -----------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Morning\n Enoxaparin (Lovenox) 0.2 mL s.c. Evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Morning and Evening\n Leuprorelin (Lupron Depot) Monthly depot Every 4 weeks via subcutaneous injection\n Fentanyl Transdermal System 12 μg/hour Changed every 3 days\n Pantoprazole (Protonix) 40 mg Morning\n Sevelamer (Renagel) 800 mg Morning\n Multivitamin One tablet Morning\n Torsemide (Torem) 200 mg Morning\n Vitamin D3 20,000 IU Once weekly\n Sodium bicarbonate (Bicanorm) One tablet Morning\n Calcitriol (Rocaltrol) 0.25 μg Morning\n Valacyclovir (Valtrex) 500 mg half-tablet Morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Morning on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Morning on day 1 and day 2 following daratumumab administration\n\n\n\n### text_9\n**Dear colleague, **\n\nI am writing to provide an update on the medical condition and treatment\nof Mr. John Williams, who has been undergoing inpatient treatment in our\nfacility since September 30, 2021.\n\n**Diagnoses**:\n\n**Present**: Acute impairment of the visual field.\n\n**Oncological Diagnosis**:\n\n1. Diagnosis of Multiple Myeloma with kappa light chains, staged at\n IIIB as per the Salmon and Durie criteria\n\n Observable multiple osteolyses.\n\n History of radiation to the T4 and thoracic rib.\n\n Starting from 2018, he required dialysis due to renal insufficiency,\n scheduled on Mondays, Wednesdays, and Fridays in our local clinic.\n\n 2018: Treatment involved Bortezomib and Dexamethasone, but he was\n refractory to this combination. The regimen of Carfilzomib,\n Lenalidomide, and Dexamethasone was also found to be ineffective.\n\n Radiation was administered to the T4 (totaling 30 Gy) and the\n thoracic rib (totaling 20 Gy) in August 2018.\n\n Between August and October 2018: Mr. Williams underwent three cycles\n of Pomalidomide, Doxorubicin, and Dexamethasone, but the disease\n showed progression.\n\n November 2018 to February 2019: He received four treatments of\n Daratumumab, Lenalidomide, and Dexamethasone, which led to a very\n good partial response (VGPR).\n\n In March 2019, he underwent stem cell mobilization due to RSV\n pneumonia complications and then started on Daratumumab monotherapy\n (VGPR was last noted in May 2018).\n\n He continued with Daratumumab treatment until November 2019, after\n which there was a pause until March 2020 due to remission (VGPR) and\n a diagnosis of endocarditis.\n\n A whole body CT scan conducted in March 2020 did not show any new\n osteolyses.\n\n By May 2020, there was an increase in LK values, prompting the\n resumption of Daratumumab, which led to a decrease in free light\n chains.\n\n As of June 2020, there was a noted increase in light chain kappa\n values to 102 mg/L.\n\n In July 2020, therapy was escalated to include Daratumumab, Revlimid\n (5 mg), and Dexamethasone.\n\n By September 2020, a further increase in light chains was observed,\n prompting a planned switch to Elotuzumab, Pomalidomide, and\n Dexamethasone.\n\n**For his heart condition:**\n\nAcute mitral valve endocarditis was diagnosed in March 2020. He\nunderwent a re-operation for mitral valve replacement with a\nbioprosthesis (29 mm). This procedure, performed in March, 2020,\ninvolved the resection of all infected tissue from the mitral valve\\'s\nholding apparatus. The cause is presumed to be associated with a Demers\ncatheter infection or possibly related to a port catheter infection\n(Staphylococcus epidermidis was found). The catheter was surgically\nremoved in March 2020. He was on a series of antibiotics, including\nMeropenem, Linezolid, Daptomycin, and Fosfomycin.\n\n**Other pertinent medical events include:**\n\nA history of radiation treatment using a minithoracotomy technique for\nmitral valve reconstruction in 2015.\n\nRight eye amaurosis due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia diagnosed in April 2020, possibly due to\nemboli from the mitral valve endocarditis.\n\nA transient ischemic attack (TIA) in the brainstem observed on in March\n2020, which could be related to emboli from the mitral valve\nendocarditis.\n\nJugular vein thrombosis.\n\nProstate cancer diagnosed in 2018.\n\nChronic renal failure necessitating dialysis since 2018.\n\nPrevious procedures include Demers catheter placement (removed on March\n2020) and angioplasty on the right basilic vein and brachial vein due to\nstenosis causing shunt dysfunction.\n\nHistory of transient ischemic attacks.\n\nBilateral tingling paresthesias in the lower legs, history of deep vein\nthrombosis, recurrent calf cramps, and hypothyroidism.\n\nPlease let me know if you require any further information on Mr.\nWilliams. I am confident that this detailed account will assist you in\nunderstanding his medical history and ensuring optimal care.\n\n**Therapy: **\n\nTherapy schedule: Daratumumab s.c. 1800mg abs. weekly in week 1-8,\n2-weekly in week 9-24, every 4 weeks from week 25. Continuation of\nBondronat. Regular monitoring and optimal adjustment of cardiovascular\nrisk factors.\n\nMedication:\n\nPlavix (Clopidogrel) 75 mg; once daily in the morning\n\nLovenox (Enoxaparin) 0.2 ml subcutaneously; once daily in the evening on\nnon-dialysis days\n\nMarinol (Dronabinol) drops; four drops in the morning and four drops in\nthe evening\n\nDuragesic (Fentanyl transdermal patch) 12 μg/hour; change every 3 days\n\nProtonix (Pantoprazole) 40 mg; dosing: Once daily in the morning and\nonce daily in the evening for 2 weeks, then once daily in the morning\n\nRenvela 800 mg; dosing: Once daily in the morning\n\nTorem 200 mg; once daily in the morning\n\nVitamin D3 20,000 IU; once weekly\n\nCalcijex (Calcitriol) 0.25 mcg; once daily in the morning\n\nValtrex (Valacyclovir) 500 mg; dosing: Half a tablet (250 mg) once daily\nin the morning\n\nBactrim (Cotrimoxazole or trimethoprim/sulfamethoxazole) 480 mg, once\ndaily\n\nWarm regards,\n\n**Clinical Update, 11/12/2022**\n\nMr. John Williams, a 66-year-old male with a known history of multiple\nmyeloma and associated complications, presented again to our facility\nwith worsening symptoms over the past three weeks.\n\n**Symptoms**:\n\nPersistent fatigue\n\nShortness of breath on minimal exertion\n\nBilateral pitting edema in the lower extremities up to the mid-calf\n\n**Preliminary Findings**:\n\n**Physical Examination**:\n\n1. Jugular venous distention\n\n Decreased breath sounds bilaterally with mild basilar crackles\n\n S3 gallop on cardiac auscultation\n\n**Chest X-ray**:\n\n4. Cardiomegaly with an enlarged cardiac silhouette. Mild pulmonary\n edema evident.\n\n**Echocardiogram**:\n\n5. Reduced left ventricular ejection fraction (LVEF) of 35% (normal \\>\n 55%)\n\n Mild mitral regurgitation\n\n**Lab Results**:\n\n7. B-type natriuretic peptide (BNP): 890 pg/mL (Normal: \\<100 pg/mL)\n\n Serum Sodium: 130 mEq/L (Normal: 135-145 mEq/L)\n\n Serum Potassium: 5.8 mEq/L (Normal: 3.5-5.1 mEq/L)\n\n Blood Urea Nitrogen (BUN): 38 mg/dL (Normal: 7-20 mg/dL)\n\n Creatinine: 2.1 mg/dL (Normal: 0.8-1.3 mg/dL)\n\n GFR: 35 mL/min (Reduced)\n\n**Diagnosis**:\n\nCongestive Heart Failure (CHF) with reduced ejection fraction\n\nRenal insufficiency\n\nMultiple Myeloma (primary diagnosis 2015)\n\nProstate cancer\n\n**Treatment Administered**:\n\nIntravenous furosemide was administered to relieve fluid overload,\nresulting in a significant reduction in edema and improvement in\nbreathlessness over the subsequent 48 hours. Lisinopril was initiated\ncautiously to manage CHF and to potentially provide renal protection.\nMetoprolol was started at a low dose, with close monitoring of blood\npressure and heart rate. Potassium levels were closely monitored given\ninitial hyperkalemia; diet and medications were adjusted accordingly.\nDietary consult emphasized a low-sodium, moderate protein, and\npotassium-restricted diet. Close monitoring of fluid balance\n(input-output) was maintained throughout the stay.\n\n**Progress**:\n\nMr. Williams showed consistent improvement over his two-week admission.\nSerial echocardiograms indicated a slight improvement in LVEF to 39%.\nThe edema receded notably, and his shortness of breath on exertion\nreduced significantly. Labs before discharge showed:\n\nSerum Sodium: 134 mEq/L\n\nSerum Potassium: 4.9 mEq/L\n\nBUN: 32 mg/dL\n\nCreatinine: 1.9 mg/dL\n\nBNP: 550 pg/mL\n\n**Discharge Recommendations**:\n\nOutpatient cardiology follow-up in two weeks and then monthly to monitor\nLVEF and adjust medications. Nephrology consultation to keep an eye on\nrenal function, given his increased susceptibility to kidney damage.\nContinue with dietary restrictions and modifications as advised.\nCommence an outpatient cardiac rehabilitation program for supervised\nexercise and lifestyle modifications. Weekly blood tests for the first\nmonth to monitor electrolytes and kidney function.\n\nMr. Williams remains at risk due to multiple comorbidities. It is\nessential to address each condition holistically while ensuring no\nsingle treatment exacerbates another condition. A collaborative and\nvigilant approach is imperative for his ongoing health management.\n\nWarm regards,\n\n --------------------------- ---------------- ---------------------\n **Parameter** **Value** **Reference Range**\n **Blood Count** \n White Blood Cells (WBC) 5.8 x 10^9^/L 4-11 x 10^9^/L\n Red Blood Cells (RBC) 3.9 x 10^12^/L 4.5-5.5 x 10^12^/L\n Hemoglobin (Hb) 9.8 g/dL 13-18 g/dL for men\n Platelets (Plt) 150 x 10^9^/L 150-450 x 10^9^/L\n \n **Biochemistry** \n Creatinine 2.8 mg/dL 0.6-1.3 mg/dL\n Blood Urea Nitrogen (BUN) 40 mg/dL 7-20 mg/dL\n Glucose 98 mg/dL 70-100 mg/dL\n \n **Electrolytes** \n Sodium (Na) 137 mEq/L 135-145 mEq/L\n Potassium (K) 5.1 mEq/L 3.5-5.0 mEq/L\n Calcium 8.6 mg/dL 8.5-10.5 mg/dL\n Phosphate 4.5 mg/dL 2.5-4.5 mg/dL\n \n **Oncologic Markers** \n Free light chain kappa 692 mg/L 3.3-19.4 mg/L\n Free light chain lambda 12 mg/L 5.7-26.3 mg/L\n \n **Other Values** \n LDL cholesterol 80 mg/dL \\<100 mg/dL\n HbA1c 6.2% \\<5.7%\n --------------------------- ---------------- ---------------------\n\n\n\n\nHere is the query:\nBased on the clinical history of Mr. John Williams, which of the following statements is accurate?\n\nChoose the correct answer from the following options:\nA. Mr. Williams underwent a mitral valve replacement in March 2019 due to Acute mitral valve endocarditis, with all infected tissue resected from the mitral valve's holding apparatus. The cause of the infection was associated with a Demers catheter infection.\nB. In March 2019, Mr. Williams underwent stem cell mobilization due to complications from RSV pneumonia, and VGPR was last noted in May 2019. He continued with Daratumumab treatment until March 2020, after which there was a pause due to a diagnosis of endocarditis.\nC. Mr. Williams presented with symptoms of fatigue, shortness of breath, and bilateral pitting edema in the lower extremities in November 2022. Preliminary findings included a reduced LVEF of 35%, elevated BNP levels, and an echocardiogram showing mild mitral regurgitation.\nD. Mr. Williams had an increase in LK values by May 2020, which led to the resumption of Daratumumab, causing a decrease in free light chains, with a subsequent noted increase in light chain kappa values to 150 mg/l by June 2020.\nE. Mr. John Williams was diagnosed with Multiple Myeloma in 2020 and received radiation to the Th4 and thoracic rib totaling 20 Gy each.\n\n\nYour response:\n", "role": "user" }, { "content": "Mr. Williams presented with symptoms of fatigue, shortness of breath, and bilateral pitting edema in the lower extremities in November 2022. Preliminary findings included a reduced LVEF of 35%, elevated BNP levels, and an echocardiogram showing mild mitral regurgitation.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nHerewith we report on Mr. John Williams, born 08/08/1956, inpatient from\n10/03/2015 to 10/06/2015.\n\n**Diagnosis:**\n\nMultiple Myeloma IgG kappa.\n\n**Staging and Initial Diagnosis:**\n\nDate: 03/2015\n\nStage: IIA based on the Salmon and Durie scale, ISS II.\n\n- CT whole body 03/11/2015: Osteolysis detected in the seventh\n thoracic vertebra (T7); pathologic fracture observed in the first\n lumbar vertebra (L1).\n\n- Bone marrow infiltration: Initial histological evaluation showed\n 22%; cytomorphological assessment revealed 28%.\n\n**Histological Findings:**\n\nDate: 03/2015\n\n**FISH (Fluorescence In Situ Hybridization) Results:** Detected an\nadditional signal for both CCND1 and CCND3. Presence of one trisomy or\ntetrasomy 9. Additional signals observed for 5p15- and 5q31- as well as\n19p13- and 19q13-. 46, XY with a detected ASxL1 mutation.\n\n**Treatment Timeline:**\n\n**01-02/15:** Administered 2 cycles of\nCyclophosphamide-Bortezomib-Dexamethasone (CyBorD). Resulted in stable\ndisease but caused prolonged pancytopenia.\n\n**03/15 - 06/15:** Administered 3 cycles of a combination treatment\nincluding Carfilzomib, Lenalidomide, and Dexamethasone.\n\n**07/15:** Underwent stem cell mobilization using cyclophosphamide.\n\n**07-08/15:** Experienced extended pancytopenia and regeneration. Bone\nmarrow puncture showed progressive disease with a significant increase\nin plasma cell infiltration, reaching 92%.\n\n**09/02/15:** Received the first dosage of daratumumab at 16mg/kg.\nSubsequently developed thrombocytopenia. Treatment did not include\nRevlimid.\n\n**Histopathological report: **\n\nMultiple myeloma, IgG kappa. The evaluation is for myelodysplastic\nsyndrome in the presence of tricytopenia and an ASXL1 mutation.\n\n**Methods:** Hematoxylin and eosin (HE), periodic acid-Schiff (PAS),\niron, Giemsa, Gomori, chloroacetate esterase, step sections,\ndecalcification, and 1 block.\n\n**Microscopic Examination:**\n\nThe sample is a 2 cm long bone marrow biopsy core that contains more\nthan ten medullary canals. The cellularity is around 20-30%, which is\nconsidered normocellular for the patient\\'s age. There is evidence of\nbone marrow edema and heightened hemosiderosis. Recent stromal\nhemorrhages are also observed. There is a relative increase in\nerythropoiesis with a ratio of erythropoiesis to granulopoiesis being\napproximately 2:1. Erythropoiesis is present in well-defined zones with\nregular maturation. Only minimal nuclear rounding is observed.\nGranulopoiesis matures into segmented granulocytes. PAS staining reveals\nsome morphologically normal megakaryocytes. Occasionally there are bare\nnuclei and possible microforms. Scattered mature plasma cells are\nobserved with no signs of atypical proliferation. The argyrophilic\nfibrous network is fine, and no fibrosis is detected.\n\n**Preliminary Findings:**\n\nThe bone marrow biopsy is normocellular for the age with a relative\nincrease in erythropoiesis that shows only minimal cytological atypia.\nGranulopoiesis is slightly reduced, while megakaryopoiesis is\nnormocellular with a few cells that are hypolobulated.There is bone\nmarrow edema and enhanced hemosiderosis. Scattered mature plasma cells\nare also noted.\n\nBased solely on histomorphologic observations, it is not enough to\nconfirm a diagnosis of myelodysplastic syndrome (MDS), which is the\nsuspected clinical diagnosis. For a more thorough evaluation of\npotential atypicalities in the megakaryopoiesis (like\nmicromegakaryocytes), further immunohistochemical examination is\nrecommended. Assessing the blast content is also advised. There is no\nevidence currently of manifest infiltrates from the previously diagnosed\nmultiple myeloma.\n\n**Immunohistochemical Additional Findings (Dated 10/04/2015):**\n\n**Immunohistochemistry Stains Used:** CD3, CD79a, CD34, CD117, MUM-1,\nKappa, lambda, CyclinD1, CD61.\n\nBlast cells positive for CD34 and CD117 are below 5% of the total. CD3\nstains scattered T lymphocytes, and CD79a identifies sporadic B\nlymphocytes and some plasma cells. Plasma cells are also positive for\nMUM-1 and exhibit polytypic expression of kappa and lambda light chains.\nThere is no co-expression with CyclinD1. CD61 highlights the previously\ndescribed megakaryocytes, and no micromegakaryocytes are observed.\n\n**Final Report:**\n\nThe bone marrow biopsy is representative and normocellular for the\npatient\\'s age. There is a relative increase in erythropoiesis that\nshows only minor cytological atypia. Granulopoiesis appears slightly\nreduced, while megakaryopoiesis presents with a few hypolobulated cell\nforms. Evidence of bone marrow edema and increased hemosiderosis is\nnoted, along with scattered mature plasma cells.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe hereby report on Mr. Williams, John, born 08/08/1956, inpatient from\n11/30/2015 to 12/28/2015.\n\n**Oncological Diagnosis**:\n\nMultiple myeloma IgG kappa.\n\nInitial diagnosis 03/15: Stage IIA (Salmon and Durie), ISS II.\n\n**Sites**:\n\nOsteolysis in T7 vertebra, fracture in T1 vertebra.\n\nBone marrow: 22% histological, 28% cytomorphologic infiltration.\n\n**Histology**:\n\nBone marrow biopsy 11/16: FISH: Additional signals for CCND1, CCND3;\nTrisomy 3, 9; Additional signals on chromosomes 5 and 19. Chromosomal\nanalysis: 46, XY with ASxL1 mutation.\n\n**Treatment**:\n\n01-02/15: 2 cycles Cyclophosphamide-Bortezomib-Dexamethasone -\\>\nStable disease, prolonged low blood counts.\n\n03/15 - 06/15: 3 cycles Carfilzomib/Lenolidomide/Dexamethasone.\n\n07/15: Stem cell mobilization with Cyclophosphamide.\n\n07-08/15: Extended low blood count. Bone marrow biopsy: 92% plasma cell\ninfiltration.\n\n09/02/15: Darzalex 16mg/kg initial dose, with platelet count drop. No\nLenalidomide.\n\n09/04/15: 10 cycles of Darzalex, 1 cycle with Lenalidomide due to\nrenewed low platelet and white blood cell counts.\n\n11-12/15: Conditioning chemo with Fludarabine/Treosulfan, then\nallogeneic stem cell transplant from HLA-matched unrelated donor.\nImmunosuppression with ATG, cyclosporine, Mycophenolate Mofetil.\n\n**Complications**:\n\nMucositis, central line infection, gastrointestinal symptoms, urinary\ninfections with E. faecium and E.coli, JC virus bladder infection.\n\n**Secondary Diagnoses**:\n\nDry eye syndrome, Type 2 diabetes managed with oral meds, Hypertension.\n\n**Treatment Plan**:\n\nGradual reduction of immunosuppression based on graft vs. host disease\nsigns.\n\n**Radiology**:\n\nCT Whole Body: 12/01/15: Various areas of bone osteolysis. Degeneration\nof spine.\n\nCT Chest 12/02/15 and 12/03/15: Changes in lungs and some fluid\naccumulation.\n\n**Medication**:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------- ---------------\n Mycophenolic Acid (Myfortic) 360 mg Twice Daily\n Cyclosporine (Sandimmune) 200 mg Daily\n Artificial Tears As directed 3x Daily\n Candesartan (Atacand) 8 mg Daily\n Tamsulosin (Flomax) 0.4 mg Daily\n Pantoprazole (Protonix) 40 mg Daily\n Amlodipine (Norvasc) 5 mg Twice Daily\n Cotrimoxazole (Bactrim) 960 mg Mon/Wed/Fri\n Valacyclovir (Valtrex) 500 mg Twice Daily\n\n**Summary**:\n\nMr. Williams was admitted on 11/30/2015 for treatment related to his\nMultiple Myeloma. He underwent conditioning chemotherapy,\nimmunosuppressive therapy, and stem cell transplantation. He experienced\ncomplications, including infections and symptoms affecting multiple\nsystems. Close monitoring of blood pressure and glucose is recommended.\nHe was discharged on 12/28/2015 in good condition and will be followed\nup in the outpatient clinic. If there are worsening symptoms, he should\nvisit the emergency department immediately.\n\n**Dear Mr. Williams,**\n\nWe report on your outpatient treatment on 02/15/2016.\n\n**Diagnoses:**\n\n1. **Multiple Myeloma** IgG kappa, diagnosed 03/2015.\n\n Stage IIA as per Salmon and Durie, stage II as per ISS.\n\n Osteolysis at T7 vertebra, fracture at T1 vertebra.\n\n Bone marrow infiltration: 22% histologically, 28% cytologically.\n\n FISH: Indications of additional CCND1 and CCND3 signals; Trisomy 3,\n additional signals at various chromosomes.\n\n Chromosome analysis: 46, XY \\[20\\].\n\n**Secondary diagnoses:**\n\nType 2 diabetes mellitus\n\nHypertension\n\nCataract (surgery 06/2018)\n\nNodular goiter\n\nRSV pneumonia (03/2018)\n\n**Summary:**\n\nMr. Williams presents in good general health to our bone marrow\ntransplant (BMT) outpatient clinic. There are no signs of infection or\nchronic graft rejection. He has shown significant improvement in\nresilience and does not have any complaints. Vital signs are stable.\nBlood tests showed ongoing regeneration with normal light chains and\npersistent positive immunofixation. There is no need for\nmyeloma-specific therapy at present, but close monitoring of the\nparaprotein is required.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------- ---------------------- -------------------------------------------------------\n Tamsulosin (Flomax) 0.4 mg Daily in the morning\n Candesartan (Atacand) 8 mg Twice Daily\n Metformin (Glucophage) 1000 mg 0.5 tablet in the morning, 1.5 tablets in the evening\n Pantoprazole (Protonix) 20 mg Daily in the morning\n Vitamin D3 (various brands) 20,000 IU Once a week\n Allopurinol (Zyloprim) 100 mg Daily in the morning\n Insulin (various types) As per sliding scale As per sliding scale\n\nWith kind regards\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are providing an update on our shared patient, Mr. John Williams, who\nconsulted with us on June 15, 2018.\n\n**Consultation Summary:**\n\n8. **Multiple Myeloma**\n\n **Kidney biopsy scheduled for tomorrow.**\n\n **Prostate cancer**\n\n**Current Status:**\n\nAcute renal failure accompanied by proteinuria due to the recent\ndiagnosis of multiple myeloma.\n\nMultiple osteolytic lesions, including at the T4, T7, L1 vertebra and\nthe ribs.\n\n**Diagnosis:**\n\nMultiple myeloma.\n\nProstate cancer\n\n**Clinical Presentation:**\n\nOsteolytic lesion presenting as thoracic pain.\n\n**Imaging Findings:**\n\nOsteolytic lesion at T4 vertebra with involvement of the posterior edge.\n\n**Planned Procedures:**\n\nRestricted bed rest.\n\nWhole spine MRI with STIR sequences, to be presented in the upcoming\ntumor board meeting for deciding further course of action.\n\n**Previous Diagnoses:**\n\nMay, 2018, Nephrology: Enlarged kidneys noted bilaterally.\n\nJanuary, 2018, Urology: Prostate cancer\n\nDecember, 2015, Internal Medicine: Multiple myeloma without evidence of\ncomplete remission.\n\n**Previous Procedures:**\n\nTransrectal biopsy of the prostate.\n\n**Histology Report, Date: June 13, 2018:**\n\nSuspected plasmacytoma with paraproteinemia.\n\nWBC 6.47; Hb 10.8; Platelets 251,000.\n\nBone marrow biopsy: Cellularity approximated at 48%, indicating slightly\nincreased cellularity. Amidst reduced hematopoiesis, there is\nproliferation of plasmacytoid cells with certain features.\n\n**Preliminary Report:**\n\nThe bone marrow sample indicates possible infiltration due to plasma\ncell myeloma. Additional tests will be conducted to confirm and further\nelucidate this finding.\n\n**Supplementary Findings:**\n\nImmunohistochemical staining: CD138, Kappa, Lambda, CD20.\n\nMicroscopic findings confirm the presence of nodular infiltrates with\ncertain features.\n\n**Final Report:**\n\nBone marrow sample indicates infiltration by a plasma cell myeloma with\nkappa light chain restriction. Additionally, regular trilinear\nhematopoiesis is significantly reduced.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nI wish to provide an update on our mutual patient, Mr. John Williams,\nborn 08/08/1956, who presented at our clinic at 08/20/2018.\n\n**Diagnosis:**\n\nPresent condition: Multiple Myeloma IgG type, coded under ICD-10.\n\nStage: II B based on Durie and Salmon criteria; determined from Hb 9.1,\nCreatinine 4.5 mg/dL.\n\n**Histology:**\n\nBone marrow biopsy presents a strong indication of interstitial and\nfocal nodular invasion of the marrow space by plasma cell myeloma,\npredominantly of high to intermediate maturity.\n\n**Immunohistochemistry:**\n\nThe nodular infiltrates were found positive for CD138 with a kappa-light\nchain restriction (infiltration rate at 62%).\n\nCytological findings align with high-grade bone marrow infiltration by\nmultiple myeloma.\n\n**Tumor Localization:**\n\nMRI of the entire spine conducted on 06/20/2018 reveals disseminated\nbone lesions throughout the spine without any soft tissue involvement.\nThere is noted anterior vertebral body involvement at T4.\n\n**Secondary Diagnoses:**\n\nCysts in the right kidney.\n\nAs of 01/2018, a diagnosis of Prostate cancer with a Gleason score of 8\nand a PSA reading of 10.02.\n\nPrevious rib fracture, which may be associated with the multiple\nmyeloma.\n\nChronic renal failure, with ongoing dialysis treatment.\n\nDocumented mitral valve surgery in 2015.\n\nHistory of Deep Vein Thrombosis in 1999.\n\n**Prior Treatments:**\n\nInitial diagnosis of multiple myeloma IgG kappa in 2015.\n\nProstate cancer was diagnosed in 01/2018 following spontaneous rib\nfractures, Gleason score of 8.\n\nA PSMA-PET-CT scan in 05/18 showed multiple bone lesions, notably\npronounced at Th4.\n\nTumor board review in 06/2018 concluded treatment strategies for\nurological tumors, encompassing radiation therapy targeting Th4 and\nantiandrogen therapy for the identified prostate cancer, using a GnRH\nanalog.\n\nThe progression of multiple myeloma required the commencement of\nsystemic treatment with Velcade and Dexamethasone.\n\n**Study**: PSMA-PET-CT Scan\n\n**Date of Study**: 05/2018\n\n**Clinical Information**: Prostate cancer diagnosed in 01/2018 following\nspontaneous rib fractures. Gleason score of 8.\n\n**Technique**:\n\nWhole body positron emission tomography/computed tomography (PET/CT) was\nperformed following the intravenous administration of PSMA-radiotracer.\nCoronal, sagittal, and axial images were acquired and reviewed.\n\n**Findings**:\n\nBone: Notably increased PSMA uptake is seen at the level of T4 vertebral\nbody consistent with metastatic involvement. The lesion has caused\ncortical erosion and expansion with potential involvement of the\nanterior spinal canal. Multiple rib lesions are identified,\ncorresponding with the clinical history of spontaneous rib fractures.\nThese lesions exhibit no increased PSMA uptake. No other foci of\nincreased PSMA uptake throughout the axial and appendicular skeleton.\n\n**Prostate**:\n\n12. The prostate gland demonstrates diffusely increased uptake, which is\n consistent with primary prostate malignancy, especially given the\n known clinical history.\n\n**Thorax/Abdomen: **\n\n13. No abnormal PSMA avid soft tissue masses or lymphadenopathies were\n noted in the visualized fields. No pulmonary nodules or masses\n suggestive of metastatic disease were identified. Liver, spleen,\n kidneys, and adrenal glands appear unremarkable with no evidence of\n metastatic lesions.\n\n**Impression**:\n\nOsseous metastasis from prostate cancer with involvement of the T4\nvertebral body. No evidence of soft tissue, lymph node, or pulmonary\nmetastases in the visualized fields. Prostate gland showing evidence\nconsistent with primary malignancy.\n\n**Current Radiation Therapy:**\n\n**Indication:** Radiotherapy became a consideration due to a sizable\nosteolytic lesion at T4, both for pain alleviation and stabilization.\nConcurrent treatment of the aching ribs on the right side (7th-9th) was\nalso performed.\n\n**Technique:** 6 MeV photons from a linear accelerator, administering a\ncumulative dose of 30 Gy to thoracic vertebra 4 and 20 Gy to the ribs\nwith respective daily doses.\n\n1. **Treatment Duration:**\n\n Th4: 08/21/2018 to 08/27/2018\n\n Rib area: 08/21/2018 to 08/27/2018\n\n**Clinical Update:**\n\nThroughout the therapy period, Mr. Williams remained admitted to our\nOncology ward for ongoing reduced dosage chemotherapy using Velcade. He\nhas reported a decline in pain sensations during this timeframe. The\noverall health status appeared satisfactory, with no skin irritation\nobserved at the irradiated sites.\n\n**Subsequent Actions:**\n\nGuidance on skincare and potential adverse effects have been provided to\nMr. Williams. The intensity of the chemotherapy will soon be escalated.\nA radio-oncological assessment has been scheduled in our outpatient\nfacility for 09/05/2018 at 12:00 PM. I kindly request the most recent\ntest results by this date.\n\n**Note:** In compliance with the Radiation Protection Act, we shall\nundertake regular evaluations and request updates on the patient\\'s\ncondition. Mr. Williams has been apprised of the necessity for\nconsistent oncological check-ups.\n\nWarm regards,\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe wish to update you on our mutual patient, Mr. John Williams.\n\n**Diagnosis:**\n\nCurrent multiple myeloma IgG type\n\n**Tumor Localization:**\n\nBased on a whole spine MRI dated June 20, 2018:\n\nMultiple intraosseous lesions throughout the spine without soft tissue\ninvolvement.\n\nKnown intrusion of the T4 cover plate.\n\n**Secondary Diagnoses:**\n\nRight kidney cysts\n\nDiagnosed prostate carcinoma in January 2018, Gleason score 8, initial\nPSA at 10.02.\n\nHistory of a spontaneous rib fracture related to the multiple myeloma.\n\nChronic renal insufficiency; he remains on dialysis.\n\nHistory of mitral valve reconstruction in 2015.\n\nHistory of deep vein thrombosis in 1999.\n\n**Treatment Overview:**\n\nDiagnosed with multiple myeloma type kappa in 2015 with initially normal\nrenal function.\n\nDiagnosed with prostate carcinoma in January 2018 due to spontaneous rib\nfractures, Gleason score 8.\n\nTreatment decisions in 2018 included radiation for vertebral lesions and\nhormone therapy for prostate cancer using a GnRH analogue.\n\nSystemic therapy with Velcade and Dexamethasone initiated due to\nprogressive myeloma.\n\nRadiation therapy in August 2018 for vertebral and rib lesions.\n\n**Summary:**\n\nMr. Williams had a radio-oncological follow-up on September 29, 2018.\nHis general health has improved. He remains on thrice-weekly dialysis.\nRecent CT scans show extensive osteolysis of the spine with several\nvertebral collapses. Currently, we see no urgent fracture risk or need\nfor additional radiation therapy. We have planned regular clinical\ncheck-ups with Mr. Williams. His next follow-up is scheduled in three\nmonths.\n\n**Oncologic treatment: **\n\nDaratumumab/lenalidomide/dexamethasone regimen:\n\nDaratumumab 16mg/kg: Days 1, 8, 15, 22 for cycles 1 & 2 (every 28 days\nfor 8 weeks).\n\nDays 1, 15 for cycles 3-6 (every 28 days for 16 weeks).\n\nDay 1 for subsequent cycles (every 28 days).\n\nDexamethasone 20mg on Daratumumab days, with an additional 20mg the day\nafter (totaling 40mg/week).\n\nLenalidomide 5mg from day 1-21 (every 28 days).\n\nBondronate every 4 weeks (last administered on 12/13/2016).\n\nRe-evaluation of hemodialysis and autologous peripheral blood stem cell\ntransplant (PBSCT) after 2 cycles of daratumumab.\n\n**CT Spine scan (09/30/2018): **\n\n**Technique**: Contrast-enhanced computed tomography (Omnipaque 240) of\nthe thoracic and lumbar spine was performed with axial slices, and\nmultiplanar reconstructions in sagittal and coronal orientations.\n\n**Findings**:\n\n**Thoracic Spine**:\n\nExtensive osteolytic lesions are identified in multiple thoracic\nvertebrae. Specifically, vertebral collapses are noted at T4, T7, T9,\nT11. No significant bony destruction of pedicles, lamina and spinous\nprocesses. No evidence of paravertebral or epidural soft tissue masses.\n\n**Lumbar Spine**:\n\nProminent osteolytic changes are seen in L1 (with fracture) and L4\nvertebral bodies. However, there is no significant vertebral collapse.\nPreserved pedicles, lamina, and spinous Processes without significant\nosteolysis. No evidence of abnormal masses or lymphadenopathy.\n\nNo significant central canal stenosis or neural foraminal narrowing. The\nintervertebral discs are preserved without significant discopathies.\n\n**Impression**:\n\nExtensive osteolysis in multiple vertebral bodies, specifically in the\nthoracic and lumbar spine, with vertebral collapses at levels T4, T7,\nT9, and T11 as well as L1. Also, osteolytic changes in L4 of the lumbar\nspine.\n\nCurrently, based on imaging, there does not appear to be an urgent\nfracture risk, and no radiologic signs suggesting a need for imminent\nradiation therapy. No soft tissue abnormalities identified in the\nexamined regions.\n\n**Medication: **\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ----------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg In the morning (day after Daratumumab)\n Pantoprazole (Protonix) 40 mg Daily in the morning\n Cotrimoxazole (Bactrim) 480 mg Thrice weekly (Mon, Wed, Fri)\n Valacyclovir (Valtrex) 500 mg Daily in the morning\n Acetaminophen (Tylenol) 500 mg Orally, three times daily\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly (4-week depot) subcutaneously\n Pregabalin (Lyrica) 25 mg Twice a day\n Amlodipine (Norvasc) 5 mg Daily in the morning\n Bisoprolol (Zebeta) 5 mg Daily in the morning\n Lenalidomide (Revlimid) 5 mg Nightly\n Ondansetron (Zofran) 8 mg As needed, up to twice daily\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are updating you on Mr. John Williams\\' outpatient visit on December\n13, 2018.\n\n**Diagnosis:**\n\nFebrile respiratory infection.\n\n**Underlying Conditions:**\n\nMultiple myeloma, kappa light chain, stage IIIB as classified by Salmon\nand Durie.\n\nChronic kidney disease requiring hemodialysis.\n\nProstate cancer.\n\n**Summary:**\n\nMr. Williams came to the emergency room with fever and dry cough during\nhis multiple myeloma treatment with Darzalex, Revlimid, and\nDexamethasone. His vital signs were recorded, and laboratory tests\nshowed signs of infection and confirmed chronic kidney disease. Chest\nX-ray indicated possible inflammation. Given these findings, Mr.\nWilliams was admitted for antibiotic therapy. Further observations and\ntreatments were documented.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nThis letter pertains to Mr. John Williams, who was hospitalized from\nDecember 14 to 21st, 2018.\n\n**Oncological Diagnosis:**\n\nMultiple myeloma, kappa light chain, initially diagnosed in June 2018 as\nstage IIIB per Durie and Salmon criteria.\n\n**Treatment Details:**\n\nHe underwent various treatment regimens for multiple myeloma over the\ncourse of the year. His current condition indicates an\ninfluenza-positive pneumonia, likely with a bacterial superinfection. He\ncontinues hemodialysis thrice a week.\n\n**Secondary Diagnoses:**\n\nSeveral renal complications were documented in June 2018.\n\n**Plan of Care:**\n\nMr. Williams\\' therapy plan was discussed in a tumor board meeting. He\nremains on a regimen of Darzalex, Revlimid, and Dexamethasone.\n\n**Summary:**\n\nMr. Williams came to the emergency room on December 13, 2018, with cough\nand fever. Further details about his history can be found in previous\ncommunications. On admission, he showed signs of a respiratory\ninfection, confirmed by a chest X-ray. He was treated with antibiotics,\nwhich were later escalated. He also tested positive for influenza A and\nwas given Tamiflu. After a short in-patient stay, he has shown\nimprovement. He is scheduled to continue his therapy in our clinic on\nDecember 22, 2018. In case of any complications, he has been advised to\nreturn to our emergency room immediately.\n\nFor future consultations, please provide a referral slip for each new\nquarter.\n\nWarm regards\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about Mr. John Williams, who was an\ninpatient in our clinic from March 1, 2019, to March 3, 2019.\n\nOncological diagnosis:\n\nMr. Williams was diagnosed with Multiple Myeloma light chain kappa. He\nreceived his follow-up diagnosis in June 2018, which was at stage IIIB\nper the Durie and Salmon staging system.\n\nTreatment:\n\nIn June 2018, he was given VelDex due to impaired renal function.\nSubsequently, he received Carfilzomib (15mg/m2 on days 1-2, 8-9, 15-16),\nLenalidomide (5 mg, on days 1-21), and Dexamethasone (40mg, on days 1,\n8, 15-16, 22). In addition, he was treated with Pomalidomide (4mg on\ndays 1-21), Doxorubicin (9mg/m2 on days 1, 4), and Dexamethasone (40mg,\non days 1, 8, 15, 22). He underwent radiation therapy to T4 of the rib\nthorax in August. Between August to October 2018, he had three cycles of\nPomalidomide, Doxorubicin, and Dexamethasone, after which the disease\nprogressed. From November 2018 to February 2019, he had four cycles of\nDaratumumab, Lenalidomide, and Dexamethasone.\n\n**Outcome:**\n\nThe response to the treatment was very good partial remission (VGPR).\n\n**Present Treatment:**\n\nHe underwent mobilization chemotherapy with cyclophosphamide, with a\ndosage adjusted due to his requirement for dialysis (1500mg/m^2^ on day\n1 and 1000mg/m^2^ on day 2). He received dialysis on March 2 in our\nnephrology department.\n\n**Secondary diagnoses:**\n\nIn March 2018, he developed renal insufficiency requiring thrice-weekly\ndialysis. In January 2018, he was diagnosed with prostate carcinoma and\nwas treated with an androgen blockade using Enantone.\n\n**Future Therapy Plan:**\n\nThe tumor board\\'s decision from March 3, 2019 was to continue with\nDaratumumab, Revlimid, and Dexamethasone due to the good response. He\nwill undergo stem cell mobilization and high-dose therapy with\nautologous stem cell transplant. Monitoring is scheduled for March 14,\n2019, followed by dialysis at our dialysis center on Mondays,\nWednesdays, and Fridays.\n\n**Medications:**\n\nHis current medications include:\n\n **Medication** **Dosage** **Frequency**\n ------------------------------ ------------------ ---------------------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Changed every 72 hours\n Enoxaparin (Lovenox) 0.2 mL For dialysis\n Dexamethasone (Decadron) 8 mg On March 4 and 5\n Pantoprazole (Protonix) 40 mg \n Cotrimoxazole (Bactrim) 480 mg Thrice weekly on Mondays, Wednesdays, and Fridays\n Valacyclovir (Valtrex) 500 mg \n Ibandronate (Boniva) 2 mg Every four weeks\n Leuprorelin (Lupron Depot) 3.75 mg Every four weeks\n Pregabalin (Lyrica) 25 mg \n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg \n Filgrastim (Neupogen/Granix) 48 million IU \n\n**Summary:**\n\nMr. Williams was admitted on March 1, 2019, for mobilization\nchemotherapy with cyclophosphamide. Please refer to our previous letters\nfor a detailed history. His last treatment was with daratumumab,\nRevlimid, and dexamethasone. Fortunately, this treatment showed a very\ngood response. He is dialyzed three times a week at our clinic due to\nchronic renal insufficiency. He was discharged on March 3, 2019, and we\nrequest the administration of filgrastim as per the medication plan\nstarting March 6, 2019. CD34+ monitoring is scheduled for March 14,\n2019. Depending on the CD34+ count, stem cell collection may need to be\nscheduled on a dialysis-free day. We have coordinated with our\ncolleagues at the dialysis center for the collection via the atrial\ncatheter. A follow-up for blood count and Ibandronate administration has\nbeen scheduled for March 10, 2017. If his condition deteriorates or if\nhe shows signs of infection, bleeding, or any other complications, he\nshould immediately be brought to our emergency department. Please\nremember to bring a referral form during your initial visit each\nquarter.\n\nTherapy recommendation based on Transthoracic echocardiography findings:\n\nMr. Williams has a normally sized left ventricle with standard global\nfunction. There\\'s no evidence of any regional wall motion\nabnormalities. The right ventricle is also of normal size with standard\nfunction. The left atrium is not dilated. There\\'s marked concentric\nleft ventricular hypertrophy. His aortic valve shows insufficiency of I°\n(PHT 520 ms), while the mitral and tricuspid valves appear normal. There\nis no significant pericardial effusion. Overall, he has a standard left\nventricular function with no significant valvular diseases or pulmonary\nhypertension.\n\n**Surgery Report:**\n\nDiagnosis: Terminal renal failure.\n\nProcedure: Creation of a right upper arm brachialis-basilica fistula\nwith the anterior movement of the right basilic vein.\n\n**Report:**\n\nMr. Williams required dialysis due to terminal renal insufficiency. For\nthis purpose, an arteriovenous (AV) fistula was created as a dialysis\naccess. Previously, dialysis was performed using a right atrial\ncatheter. After mapping, only the basilic vein on the right arm seemed\nsuitable. Hence, a brachialis-basilica fistula was created with anterior\ntransposition of the basilica vein. A partial mobilization of the\nbasilica vein was performed. Afterward, a brachialis-basilica\nanastomosis was carried out. The operation was uncomplicated.\n\nYour collaboration has been instrumental in managing this patient\neffectively. If you have any further queries or require additional\ndetails, please do not hesitate to contact our office.\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------- ------------------ ------------------------------------\n Fentanyl Patch (Duragesic) 25 μg Change every 72 hours\n Enoxaparin (Lovenox) 0.2 mL Nightly (dialysis dose)\n Dexamethasone (Decadron) 8 mg Morning on 03/05 & 03/06\n Pantoprazole (Protonix) 40 mg Morning\n Cotrimoxazole (Bactrim Forte) 480 mg Morning 3x weekly on Mon, Wed, Fri\n Valacyclovir (Valtrex) 500 mg Half tablet in the morning\n Ibandronate (Boniva) 2 mg Every 4 weeks\n Leuprorelin (Lupron Depot) 3.75 mg Monthly subcutaneous (Morning)\n Pregabalin (Lyrica) 25 mg Morning and Evening\n Amlodipine (Norvasc) Currently paused Currently paused\n Bisoprolol (Zebeta) 2.5 mg Morning and Evening\n Filgrastim (Neupogen/Granix) 48 million IU Morning and Evening\n\nBest regards,\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nI am writing to provide you with a detailed report on Mr. John Williams,\nwho was admitted to our facility from May 8, 2020, to May 28, 2020.\n\n**Diagnoses:**\n\nHistory of acute mitral valve endocarditis in March 2020.\n\nSubsequent re-operation entailing mitral valve replacement using a\nBioprosthesis (29 mm) coupled with the resection of all infected tissue\nfrom the mitral valve\\'s supporting apparatus on March 24, 2020.\n\nThe origin remains uncertain, but potential associations include Demers\ncatheter infection and port catheter infection (confirmed presence of\nStaphylococcus epidermidis).\n\nSurgical removal was conducted on March 21, 2020, with no findings at\nthe catheter tips.\n\n14. Antibiotic regimen included:\n\n Meropenem from April 2, 2020, to April 23, 2020.\n\n Linezolid 600 mg from April 3, 2020, to April 19, 2020.\n\n Daptomycin from April 3, 2020, to May 27, 2020.\n\n Fosfomycin from April 19, 2020, to May 28, 2020.\n\nHistory of mitral valve reconstruction via minithoracotomy in 2015.\n\nRight-side vision loss due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia in the caput nuclei caudati/lenticular nuclei\non April 5, 2020, possibly embolic in origin from mitral valve\nendocarditis.\n\nHistory of brainstem transient ischemic attack (TIA) on March 11, 2020,\npotentially embolic in relation to mitral valve endocarditis.\n\nJugular vein thrombosis.\n\n20. Hematological/oncological diagnoses comprise:\n\n Multiple myeloma with lambda light chains, stage IIIB according to\n the Salmon and Durie criteria, first diagnosed in 2015. This was\n accompanied by multiple osteolysis occurrences, history of radiation\n to Th4 and rib thorax, and treatment with Daratumumab. Current\n treatment has been paused due to remission.\n\n A prostate carcinoma diagnosis in January 2018\n\n**Other medical conditions include:**\n\n-Chronic kidney failure necessitating dialysis since 2018, history of a\nDemer catheter with explantation on March 2020, and angioplasty on the\nright V. basilica and V. brachialis due to stenosis-related shunt\ndysfunction.\n\n-History of brainstem TIA in April 2019.\n\n-Sensations of tingling paresthesias in both lower legs.\n\n-History of bilateral deep vein thrombosis.\n\n-Frequent calf muscle cramps.\n\n**Medical History Overview:**\n\nMr. Williams\\'s latest admission on May 8, 2020, was to assess remission\nstatus and determine if continuation of treatment for his known multiple\nmyeloma was necessary. Previously, until March 2020 he was under a\nDaratumumab monotherapy (as he could not tolerate Revlimid), which\nshowed stable disease progression. Prior to this, he was treated at our\nlocal hospital for mitral valve endocarditis which had a complex\ntrajectory. At the time of admission, Mr. Williams felt generally weak\nbut was otherwise in stable condition. Upon discontinuation of the\nfentanyl patch, his back pain increased. He exhibited no fevers and had\nno known allergies. His appetite was low, and he reported no nausea.\nSince his heart surgery, he has experienced numbness in his left heel\nand toes. His residual urine output was about 190 mL per day, and he was\nundergoing regular dialysis.\n\n**Physical Examination:**\n\nThe patient was alert, responsive, and fully oriented. The examination\nof the head, neck, and lungs was unremarkable. Cardiac auscultation\nrevealed clear and rhythmic heart sounds without any abnormal findings.\nThere was a non-irritated sternotomy scar. Examination of his back\nrevealed decubitus ulcers. Abdominal examination showed a soft,\nnon-tender abdomen with normal bowel sounds. Extremity examination\nrevealed minor edema.\n\n**Diagnostic Imaging and Tests:**\n\nA series of diagnostic tests, including sonography, whole body CT scan,\nophthalmological exams, and histology were conducted. The results are\ndetailed within this report. In summary, the findings indicate:\n\n-Limited abnormalities in the heart\\'s echocardiography, with potential\nmitral valve issues to monitor.\n\n-Bone scans revealed extensive osteopenia and other abnormalities\nrelated to his known multiple myeloma, but no evidence of new\nosteolysis.\n\n-Eye examinations confirmed the previously noted vision issues,\npotentially stemming from the mitral valve endocarditis, but provided no\nclear solutions.\n\n-Histological evaluation of bone marrow samples indicates largely\nregular hematopoiesis but confirms infiltration from the known multiple\nmyeloma.\n\n**Summary and Recommendations:**\n\nMr. John Williams is a 63-year-old male with a complex medical history\ninvolving multiple organ systems. His most recent admission was in\nrelation to his multiple myeloma, for which he has been in remission and\nwill be monitored closely. His mitral valve endocarditis from earlier\nthis year has been resolved and treated appropriately. Due to the\nmultiple comorbidities, it is crucial for any treating facility or\nphysician to be fully aware of his history to provide optimal care.\nContinual monitoring of his cardiovascular and renal systems is\nessential. The importance of maintaining strict adherence to his\ndialysis regimen and potential antibiotic prophylaxis is emphasized.\nGiven his weakened general condition and chronic pain, palliative care\nmight also be a suitable approach to consider, focusing on enhancing his\nquality of life and addressing his pain management needs.\n\nPlease refer to the attached files for further details and a complete\nbreakdown of tests and findings. I trust this report will help guide the\nappropriate medical care for Mr. John Williams.\n\nSincerely,\n\n**Medication:**\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- -------------------- -----------------------------------------------------------------\n Clopidogrel (Plavix) 75 mg Morning\n Enoxaparin (Lovenox) 0.2 mL s.c. Evening, only on days when not receiving dialysis\n Dronabinol (Marinol) Drops 3 drops Morning and Evening\n Leuprorelin (Lupron Depot) Monthly depot Every 4 weeks via subcutaneous injection\n Fentanyl Transdermal System 12 μg/hour Changed every 3 days\n Pantoprazole (Protonix) 40 mg Morning\n Sevelamer (Renagel) 800 mg Morning\n Multivitamin One tablet Morning\n Torsemide (Torem) 200 mg Morning\n Vitamin D3 20,000 IU Once weekly\n Sodium bicarbonate (Bicanorm) One tablet Morning\n Calcitriol (Rocaltrol) 0.25 μg Morning\n Valacyclovir (Valtrex) 500 mg half-tablet Morning\n Trimethoprim/Sulfamethoxazole (Bactrim) 480 mg Morning on Mondays, Wednesdays, and Fridays\n Dexamethasone (Decadron) 4 mg Morning on day 1 and day 2 following daratumumab administration\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nI am writing to provide an update on the medical condition and treatment\nof Mr. John Williams, who has been undergoing inpatient treatment in our\nfacility since September 30, 2021.\n\n**Diagnoses**:\n\n**Present**: Acute impairment of the visual field.\n\n**Oncological Diagnosis**:\n\n1. Diagnosis of Multiple Myeloma with kappa light chains, staged at\n IIIB as per the Salmon and Durie criteria\n\n Observable multiple osteolyses.\n\n History of radiation to the T4 and thoracic rib.\n\n Starting from 2018, he required dialysis due to renal insufficiency,\n scheduled on Mondays, Wednesdays, and Fridays in our local clinic.\n\n 2018: Treatment involved Bortezomib and Dexamethasone, but he was\n refractory to this combination. The regimen of Carfilzomib,\n Lenalidomide, and Dexamethasone was also found to be ineffective.\n\n Radiation was administered to the T4 (totaling 30 Gy) and the\n thoracic rib (totaling 20 Gy) in August 2018.\n\n Between August and October 2018: Mr. Williams underwent three cycles\n of Pomalidomide, Doxorubicin, and Dexamethasone, but the disease\n showed progression.\n\n November 2018 to February 2019: He received four treatments of\n Daratumumab, Lenalidomide, and Dexamethasone, which led to a very\n good partial response (VGPR).\n\n In March 2019, he underwent stem cell mobilization due to RSV\n pneumonia complications and then started on Daratumumab monotherapy\n (VGPR was last noted in May 2018).\n\n He continued with Daratumumab treatment until November 2019, after\n which there was a pause until March 2020 due to remission (VGPR) and\n a diagnosis of endocarditis.\n\n A whole body CT scan conducted in March 2020 did not show any new\n osteolyses.\n\n By May 2020, there was an increase in LK values, prompting the\n resumption of Daratumumab, which led to a decrease in free light\n chains.\n\n As of June 2020, there was a noted increase in light chain kappa\n values to 102 mg/L.\n\n In July 2020, therapy was escalated to include Daratumumab, Revlimid\n (5 mg), and Dexamethasone.\n\n By September 2020, a further increase in light chains was observed,\n prompting a planned switch to Elotuzumab, Pomalidomide, and\n Dexamethasone.\n\n**For his heart condition:**\n\nAcute mitral valve endocarditis was diagnosed in March 2020. He\nunderwent a re-operation for mitral valve replacement with a\nbioprosthesis (29 mm). This procedure, performed in March, 2020,\ninvolved the resection of all infected tissue from the mitral valve\\'s\nholding apparatus. The cause is presumed to be associated with a Demers\ncatheter infection or possibly related to a port catheter infection\n(Staphylococcus epidermidis was found). The catheter was surgically\nremoved in March 2020. He was on a series of antibiotics, including\nMeropenem, Linezolid, Daptomycin, and Fosfomycin.\n\n**Other pertinent medical events include:**\n\nA history of radiation treatment using a minithoracotomy technique for\nmitral valve reconstruction in 2015.\n\nRight eye amaurosis due to septic-embolic central retinal artery\nocclusion.\n\nLeft hemispheric ischemia diagnosed in April 2020, possibly due to\nemboli from the mitral valve endocarditis.\n\nA transient ischemic attack (TIA) in the brainstem observed on in March\n2020, which could be related to emboli from the mitral valve\nendocarditis.\n\nJugular vein thrombosis.\n\nProstate cancer diagnosed in 2018.\n\nChronic renal failure necessitating dialysis since 2018.\n\nPrevious procedures include Demers catheter placement (removed on March\n2020) and angioplasty on the right basilic vein and brachial vein due to\nstenosis causing shunt dysfunction.\n\nHistory of transient ischemic attacks.\n\nBilateral tingling paresthesias in the lower legs, history of deep vein\nthrombosis, recurrent calf cramps, and hypothyroidism.\n\nPlease let me know if you require any further information on Mr.\nWilliams. I am confident that this detailed account will assist you in\nunderstanding his medical history and ensuring optimal care.\n\n**Therapy: **\n\nTherapy schedule: Daratumumab s.c. 1800mg abs. weekly in week 1-8,\n2-weekly in week 9-24, every 4 weeks from week 25. Continuation of\nBondronat. Regular monitoring and optimal adjustment of cardiovascular\nrisk factors.\n\nMedication:\n\nPlavix (Clopidogrel) 75 mg; once daily in the morning\n\nLovenox (Enoxaparin) 0.2 ml subcutaneously; once daily in the evening on\nnon-dialysis days\n\nMarinol (Dronabinol) drops; four drops in the morning and four drops in\nthe evening\n\nDuragesic (Fentanyl transdermal patch) 12 μg/hour; change every 3 days\n\nProtonix (Pantoprazole) 40 mg; dosing: Once daily in the morning and\nonce daily in the evening for 2 weeks, then once daily in the morning\n\nRenvela 800 mg; dosing: Once daily in the morning\n\nTorem 200 mg; once daily in the morning\n\nVitamin D3 20,000 IU; once weekly\n\nCalcijex (Calcitriol) 0.25 mcg; once daily in the morning\n\nValtrex (Valacyclovir) 500 mg; dosing: Half a tablet (250 mg) once daily\nin the morning\n\nBactrim (Cotrimoxazole or trimethoprim/sulfamethoxazole) 480 mg, once\ndaily\n\nWarm regards,\n\n**Clinical Update, 11/12/2022**\n\nMr. John Williams, a 66-year-old male with a known history of multiple\nmyeloma and associated complications, presented again to our facility\nwith worsening symptoms over the past three weeks.\n\n**Symptoms**:\n\nPersistent fatigue\n\nShortness of breath on minimal exertion\n\nBilateral pitting edema in the lower extremities up to the mid-calf\n\n**Preliminary Findings**:\n\n**Physical Examination**:\n\n1. Jugular venous distention\n\n Decreased breath sounds bilaterally with mild basilar crackles\n\n S3 gallop on cardiac auscultation\n\n**Chest X-ray**:\n\n4. Cardiomegaly with an enlarged cardiac silhouette. Mild pulmonary\n edema evident.\n\n**Echocardiogram**:\n\n5. Reduced left ventricular ejection fraction (LVEF) of 35% (normal \\>\n 55%)\n\n Mild mitral regurgitation\n\n**Lab Results**:\n\n7. B-type natriuretic peptide (BNP): 890 pg/mL (Normal: \\<100 pg/mL)\n\n Serum Sodium: 130 mEq/L (Normal: 135-145 mEq/L)\n\n Serum Potassium: 5.8 mEq/L (Normal: 3.5-5.1 mEq/L)\n\n Blood Urea Nitrogen (BUN): 38 mg/dL (Normal: 7-20 mg/dL)\n\n Creatinine: 2.1 mg/dL (Normal: 0.8-1.3 mg/dL)\n\n GFR: 35 mL/min (Reduced)\n\n**Diagnosis**:\n\nCongestive Heart Failure (CHF) with reduced ejection fraction\n\nRenal insufficiency\n\nMultiple Myeloma (primary diagnosis 2015)\n\nProstate cancer\n\n**Treatment Administered**:\n\nIntravenous furosemide was administered to relieve fluid overload,\nresulting in a significant reduction in edema and improvement in\nbreathlessness over the subsequent 48 hours. Lisinopril was initiated\ncautiously to manage CHF and to potentially provide renal protection.\nMetoprolol was started at a low dose, with close monitoring of blood\npressure and heart rate. Potassium levels were closely monitored given\ninitial hyperkalemia; diet and medications were adjusted accordingly.\nDietary consult emphasized a low-sodium, moderate protein, and\npotassium-restricted diet. Close monitoring of fluid balance\n(input-output) was maintained throughout the stay.\n\n**Progress**:\n\nMr. Williams showed consistent improvement over his two-week admission.\nSerial echocardiograms indicated a slight improvement in LVEF to 39%.\nThe edema receded notably, and his shortness of breath on exertion\nreduced significantly. Labs before discharge showed:\n\nSerum Sodium: 134 mEq/L\n\nSerum Potassium: 4.9 mEq/L\n\nBUN: 32 mg/dL\n\nCreatinine: 1.9 mg/dL\n\nBNP: 550 pg/mL\n\n**Discharge Recommendations**:\n\nOutpatient cardiology follow-up in two weeks and then monthly to monitor\nLVEF and adjust medications. Nephrology consultation to keep an eye on\nrenal function, given his increased susceptibility to kidney damage.\nContinue with dietary restrictions and modifications as advised.\nCommence an outpatient cardiac rehabilitation program for supervised\nexercise and lifestyle modifications. Weekly blood tests for the first\nmonth to monitor electrolytes and kidney function.\n\nMr. Williams remains at risk due to multiple comorbidities. It is\nessential to address each condition holistically while ensuring no\nsingle treatment exacerbates another condition. A collaborative and\nvigilant approach is imperative for his ongoing health management.\n\nWarm regards,\n\n --------------------------- ---------------- ---------------------\n **Parameter** **Value** **Reference Range**\n **Blood Count** \n White Blood Cells (WBC) 5.8 x 10^9^/L 4-11 x 10^9^/L\n Red Blood Cells (RBC) 3.9 x 10^12^/L 4.5-5.5 x 10^12^/L\n Hemoglobin (Hb) 9.8 g/dL 13-18 g/dL for men\n Platelets (Plt) 150 x 10^9^/L 150-450 x 10^9^/L\n \n **Biochemistry** \n Creatinine 2.8 mg/dL 0.6-1.3 mg/dL\n Blood Urea Nitrogen (BUN) 40 mg/dL 7-20 mg/dL\n Glucose 98 mg/dL 70-100 mg/dL\n \n **Electrolytes** \n Sodium (Na) 137 mEq/L 135-145 mEq/L\n Potassium (K) 5.1 mEq/L 3.5-5.0 mEq/L\n Calcium 8.6 mg/dL 8.5-10.5 mg/dL\n Phosphate 4.5 mg/dL 2.5-4.5 mg/dL\n \n **Oncologic Markers** \n Free light chain kappa 692 mg/L 3.3-19.4 mg/L\n Free light chain lambda 12 mg/L 5.7-26.3 mg/L\n \n **Other Values** \n LDL cholesterol 80 mg/dL \\<100 mg/dL\n HbA1c 6.2% \\<5.7%\n --------------------------- ---------------- ---------------------\n", "title": "text_9" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953. He was under our inpatient care from 04/19/2009 to\n04/28/2009.\n\n**Diagnoses:**\n\n- Progressive deterioration of renal transplant function (creeping\n creatinine) without evidence of biopsy-proven rejection\n\n- Isovolumetric tubular epithelial vacuolization\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Mr. Fisher was admitted for a renal transplant\nbiopsy due to progressive deterioration of transplant function (creeping\ncreatinine). His recent creatinine values had increased to around 1.4 --\n1.6 mg/dL, while they had previously been around 1.1 mg/dL.\n\n**Therapy and Progression:** Following appropriate preparation and\ninformed consent, a complication-free transplant puncture was performed.\nThe biopsy showed isometric tubular epithelial vacuolization without\nsignificant findings. This was followed by adjustment of Cyclosporin-A\nlevels and the addition of a lymphocyte proliferation inhibitor to the\nexisting immunosuppressive dual therapy. There was a significant\nincrease in Cyclosporin-A levels at one point due to accidental double\ndosing by the patient, but levels returned to the target range. This\nmight explain the current rise in creatinine. Another explanation could\nbe recurrent hypotensive blood pressure dysregulations, leading to the\ndiscontinuation of Minoxidile medication. For chronic atrial\nfibrillation, anticoagulation therapy with Marcumar was restarted during\nhospitalization and should be continued as an outpatient according to\nthe target INR. Low molecular weight heparin administration could be\ndiscontinued.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No dyspnea. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable.\n\nLungs: Normal chest shape, moderately mobile, resonant percussion sound,\nvesicular breath sounds bilaterally, no wheezing or crackles heard.\n\nHeart: Irregular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, markedly obese, no tenderness, no palpable\nmasses, liver and spleen not palpable due to limited access, non-tender\nkidneys. Large reducible incisional hernia on the right side following\nnephrectomy.\n\nExtremities: Occluded fistula on the right forearm. Normal peripheral\npulses; joints freely movable. Strength, motor function, and sensation\nare unremarkable.\n\n**Kidney Biopsy on 04/19/2009:** Complication-free biopsy of the\ntransplant kidney.\n\nFindings: Erythematous macules.\n\nRecommendation: Follow-up in 3 months.\n\n**Ultrasound of Transplant Kidney on 04/20/2009:** Transplant kidney\nwell visualized, located in the left iliac fossa, measurable,\noval-shaped. Parenchymal echogenicity normal, normal corticomedullary\ndifferentiation. No evidence of arteriovenous fistula or hematoma after\nkidney biopsy.\n\n**Pathological-anatomical assessment on 04/19/2009:**\n\n**Macroscopic Findings:** Singular Nodule Identified: Dimensions\nmeasuring 8 mm.\n\n**Microscopic Examination:**\n\nSampled Tissue: Renal cortex\n\nIdentified Components:\n\n- Glomeruli: Nine observed\n\n- Interlobular Artery: One segment present\n\n- Absence of medullary tissue\n\n**Diagnostic Observations:** There were no signs of inflammation or\nscarring in the renal cortex. The glomeruli appeared normocellular, and\nno signs of inflammation or pathological changes were observed in them.\nThe peritubular capillaries were free of inflammation, and the specific\ntest for C4d staining yielded negative results. The arterioles within\nthe tissue had thin walls, and there was no evidence of inflammation in\nthis vascular component.\n\nThe interlobular artery was also thin-walled and showed no evidence of\ninflammation.\n\nA notable finding was extensive damage to the tubular epithelium. The\ndamage was characterized by isometric microvesicular cytoplasmic\ntransformation, which exceeded 80%. Importantly, there was no evidence\nof cell necrosis and only minimal flattening of cells was observed. In\naddition, no pathological imprints, microcalcifications, or nuclear\ninclusion bodies were observed in the tubular epithelium.\n\n**Summary:** The predominant pathological finding in this case is\nsubstantial tubular damage. Consequently, it is highly advisable to\nclosely monitor immunosuppression levels in the patient\\'s management.\nFurther comprehensive evaluation is strongly recommended to determine\nthe underlying cause of the observed tubular damage and to address the\nclinical question concerning the presence of Chronic Allograft\nNephropathy or the potential involvement of an infection in the clinical\npresentation.\n\n**Chest X-ray (2 views) on 04/22/2009:**\n\n[Findings]{.underline}: No pneumothorax, no effusion. No evidence of\npneumonia. No focal findings. Left-biased heart without decompensation.\nMediastinum centrally positioned, not widened. Unremarkable depiction of\ncentral hilar structures. Thoracic hyperkyphosis.\n\n**Current Recommenations:** We request regular outpatient monitoring of\nretention parameters (initially every 2-3 weeks) and are available for\nfurther questions at the provided telephone number.\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 144 mEq/L 134-145 mEq/L\n Potassium 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium 9.48 mg/dL 8.6-10.6 mg/dL\n Chloride 106 mEq/L 95-112 mEq/L\n Phosphorus 2.88 mg/dL 2.5-4.5 mg/dL\n Transferrin Saturation 20 % 16-45 %\n Magnesium 1.9 mg/dL 1.8-2.6 mg/dL\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n Glomerular Filtration Rate 36 mL/min \\>90 mL/min\n BUN (Blood Urea Nitrogen) 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n C-Reactive Protein 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 ng/mL 30-300 ng/mL\n ALT (Alanine Aminotransferase) 17 U/L \\<45 U/L\n AST (Aspartate Aminotransferase) 20 U/L \\<50 U/L\n Alkaline Phosphatase 119 U/L 40-129 U/L\n GGT (Gamma-Glutamyltransferase) 94 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n TSH (Thyroid-Stimulating Hormone) 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43% 40-52%\n Red Blood Cells 4.60 M/uL 4.6-6.2 M/uL\n White Blood Cells 8.78 K/uL 4.5-11.0 K/uL\n Platelets 205 K/uL 150-400 K/uL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/uL 1.8-7.7 K/uL\n Lymphocytes 2.37 K/uL 1.4-3.7 K/uL\n Monocytes 0.93 K/uL 0.2-1.0 K/uL\n Eosinophils 1.67 K/uL \\<0.7 K/uL\n Basophils 0.09 K/uL 0.01-0.10 K/uL\n Nucleated Red Blood Cells Negative \\<0.01 K/uL\n APTT (Activated Partial Thromboplastin Time) 45.1 sec 26-40 sec\n Antithrombin Activity 85 % 80-120 %\n\n**Medication upon discharge**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Cyclosporine (Neoral) 1 mg 1-0-1\n Mycophenolic Acid (Myfortic) 180 mg 1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0\n Aspirin 81 mg 1-0-0\n Candesartan (Atacand) 16 mg 0-0-1\n Metoprolol (Lopressor) 50 mg 1-1-1-1\n Isosorbide Dinitrate (Isordil) 60 mg 1-0-0\n Torsemide (Demadex) 10 mg As directed\n Ranitidine (Zantac) 300 mg 0-0-1\n Fluvastatin (Lescol) 20 mg 0-0-1\n Allopurinol (Zyloprim) 100 mg 0-1-0\n Tamsulosin (Flomax) 0.4 mg 1-0-0\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide an update on our patient, Mr. Alan Fisher,\nborn on 12/09/1953.\n\nHe was under our inpatient care from 10/02/2018 to 10/03/2018.\n\n**Diagnoses:**\n\n- Urosepsis\n\n- Acute postrenal kidney failure\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Previous Surgeries:** Previous prostate vesiculectomy with regional\nlymphadenectomy\n\n**Planned procedure:** Urethro-cystoscopy with catheter placement for\nurethral stricture\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by the outpatient urologist due to suspicion of\na urethral stricture. Mr. Fisher reports a worsening urinary retention\nfor approximately 6 months. Despite multiple unsuccessful attempts at\ncatheter placement, ureterocystoscopy with catheter insertion was\nperformed. Intraoperatively, purulent cystitis and a bladder outlet\nobstruction were observed.\n\nMr. Fisher regularly attends follow-up examinations for his history of\nkidney transplantation in 1995 and previous prostate vesiculectomy with\nregional lymphadenectomy in 01/2018.\n\n**Physical Examination:** Neurology: RASS 0, alert, CAM-ICU negative, no\nnew focal neurology\n\nLungs: Bilateral air entry, no rales or wheezing, sufficient gas\nexchange on 2L/O2 Cardiovascular: Normal sinus rhythm, normotensive on\n0.01 µg/kg/min NA\n\nAbdomen: Soft, no guarding, sparse peristalsis, advanced oral diet,\nregular bowel movements\n\nDiuresis: Normal urine output, retention values within normal range,\ngoal: balanced fluid status\n\nSkin/Wounds: Non-irritated, no peripheral edema\n\n**Therapy and Progression**: We received Mr. Fisher, who was awake and\nspontaneously breathing under a 2L O2 mask via nasal cannula, to our\nintensive care unit due to urosepsis. To maintain an adequate\ncirculation, low-dose catecholamine therapy was required but could be\ndiscontinued on the first postoperative day. Pulmonary function remained\nstable with intensive non-invasive ventilation and breathing training.\n\nGiven his immunosuppression, we escalated the intraoperatively initiated\nanti-infective therapy from Ceftriaxone to Piperacillin/Tazobactam.\nPneumococcal and Legionella rapid tests were negative. Following\nappropriate volume resuscitation and diuretic therapy with Furosemide,\ndiuresis became sufficient. Oral diet progression occurred without\ncomplications. Anticoagulation was initially in prophylactic dosing with\nHeparin and later switched to therapeutic dosing with Enoxaparin.\n\n**Current Recommendations:**\n\n- Switch unfractionated Heparin to Fragmin\n\n- baseline Crea 2mg/dL, target CyA level: 50-60ng/mL, Myfortic\n continued.\n\n- Urological care of the stricture in progress, leave catheter until\n then.\n\n- Mobilization\n\n**Medication upon Discharge:**\n\n **Medication (Brand)** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Torsemide (Demadex) 10 mg 1-1-0-0\n Prednisone (Deltasone) 5 mg 1-1-0-0\n Pantoprazole (Protonix) 20 mg 1-1-0-0\n Mycophenolate Mofetil (CellCept) 360 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 100 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Candesartan (Atacand) 16 mg 0-0.5-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Allopurinol (Zyloprim) 100 mg 1-0-0-0\n Aspirin 81 mg 1-0-0-0\n Paracetamol (Tylenol) 500 mg As needed\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. Alan Fisher, born on\n12/09/1953.\n\nHe was under our inpatient care from 11/04/2018 to 11/12/2018.\n\n**Current Symptoms:** Decreased diuresis, rising creatinine, frustrating\ncatheterization.\n\n**Diagnoses:**\n\n- Acute on chronic graft failure\n\n<!-- -->\n\n- Creatinine increased from 1.56 mg/dL to a maximum of 2.35 mg/dL.\n\n- Likely postrenal origin due to urethral stricture; sonographically,\n Grade II urinary stasis with urinary retention and residual urine\n formation.\n\n- Frustrating catheterization due to urethral stricture\n\n- Urethro-cystoscopy with bougie and catheter placement\n\n- Parainfectious component in purulent cystitis with urosepsis\n\n- Discharged with indwelling catheter\n\n- Inpatient readmission to the colleagues in Urology for internal\n urethrotomy\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by an outpatient urologist due to suspected\nurethral stricture. Mr. Fisher reports increasing difficulty urinating\nfor approximately 6 months. He has to \\\"squeeze out\\\" his bladder\ncompletely. Frustrating catheterization was performed due to urinary\nretention. Intraoperatively, purulent cystitis and bladder outlet\nstenosis were observed. Mr. Fisher regularly undergoes follow-up\nexaminations for a history of kidney transplantation in 1995 and a\nprostate vesiculectomy with regional lymphadenectomy in 01/2018.\n\n**Vegetative Findings:** The patient had a bowel movement 4 days ago,\nindwelling catheter irritation (3L of diuresis the previous day), no\nnausea/vomiting, no fever or night sweats, weight loss of 30kg from\nFebruary to April 2020.\n\n**Physical Capacity:** Limited, can still climb 2 stairs but needs to\ntake a break due to shortness of breath.\n\n**Physical Examination:** Temperature 37.4°C, Blood pressure 128/72\nmmHg; Pulse 72/min; Respiratory rate 15/min, O2 saturation under 2L O2:\n96%\n\nAwake, alert, cooperative, oriented to time, place, person, and\nsituation.\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; Clear paranasal\nsinuses; moist and pink mucous membranes; unremarkable dentition; moist\nand glossy tongue; non-palpable thyroid enlargement.\n\n[Chest]{.underline}: Normal configuration; Non-tender spine; free renal\nbeds bilaterally.\n\n[Heart]{.underline}: Rhythmic, clear heart sounds, normal rate, no\nsplitting; non-distended jugular veins. [Lungs]{.underline}: Vesicular\nbreath sounds; Resonant percussion note; no adventitious sounds; no\nstridor; normal chest expansion.\n\n[Abdomen]{.underline}: Protuberant, known incisional hernia, normal\nperistalsis in all quadrants; soft; no pathological resistance; no\ntenderness; liver palpable below the costal margin; spleen not palpable.\n\n[Lymph nodes:]{.underline} No pathologically enlarged cervical nodes\npalpable; axillary and inguinal nodes not palpable.\n\nSkin: No pathological skin findings.\n\n[Extremities:]{.underline} Warm; mild bilateral ankle edema.\n\n[Pulse status (right/left):]{.underline} A. carotis +/+, A. radialis\n+/+, A. femoralis +/+, A. tibialis post. +/+, A. dorsalis ped. +/+\n\n[Neurological]{.underline}: Oriented and unremarkable.\n\n**Therapy and Progression:** The patient was admitted through our\nemergency department upon referral by an outpatient urologist due to\nsuspected urethral stricture, which had been causing increasingly\ndifficult urination for approximately 6 months. Sonography showed Grade\nII urinary stasis with urinary retention and residual urine. Frustrating\ncatheterization was performed, followed by ureterocystoscopy with bougie\nand catheter placement. Intraoperatively, purulent cystitis and bladder\noutlet stenosis were observed. Laboratory tests revealed acute kidney\ntransplant failure, with creatinine increasing from 1.56 mg/dL to 2.35\nmg/dL, along with significantly elevated infection parameters: CRP up to\n186 mg/dL, PCT 12.82 µg/L, and leukocytosis of 21.6/nL. After obtaining\nblood cultures, empirical antibiotic therapy with Ceftriaxone was\ninitiated. Upon detecting Pseudomonas aeruginosa, therapy was switched\nto Piperacillin/Tazobactam on 12/06/20 and continued until 12/13/20.\nUnder this treatment, infection parameters significantly improved, and\nMr. Fisher remained afebrile. Kidney retention parameters also decreased\nto a discharge creatinine of 2.05 mg/dL. Regarding the urethral\nstricture, he was initially discharged with an indwelling catheter. A\nfollow-up appointment for internal urethrotomy and potentially Allium\nstent placement was scheduled for 4 weeks later. During the hospital\nstay, ciclosporin levels remained within the target range. Following\nprostate vesiculectomy earlier in the year, anticoagulation was switched\nfrom Enoxaparin to Apixaban 2.5 mg twice daily, and Aspirin therapy was\ndiscontinued.\n\n**Recommendations**: We recommend regular monitoring of kidney retention\nparameters and infection parameters. Regarding the urethral stricture,\nthe patient will be discharged with an indwelling catheter. We scheduled\na follow-up with colleagues in Urology for internal urethrotomy and\npotentially Allium stent placement. Pause oral anticoagulation with\nApixaban one day before inpatient admission.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Candesartan (Atacand) 8 mg 0-1-0-0\n Torsemide (Demadex) 10 mg 1-1-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU Pause\n Magnesium Oxide 400 mg 1-0-0-0\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under outpatient care on 07/01/2019.\n\n**Current Symptoms:** Pain on the left side at rib level**,** Dyspnea\n\n**Diagnoses:**\n\n- Infection of unclear origin\n\n - CT Thorax and Abdomen showed no focus\n\n - Urine dipstick and cultures were bland\n\n - Antibiotics: Meropenem from 06/11/2019 to 06/19/2019\n\n- Acute Transplant Dysfunction\n\n - Serum Creatinine: 2.4 -\\> 4.5 -\\> 2.6 mg/dl\n\n - Renal ultrasound: 123 x 54 x 24 mm, not dilated, some areas of\n increased echogenicity, no twinkling, no acoustic shadowing, no\n signs of urolithiasis.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Initial presentation was at the local emergency\ndepartment on referral from the primary care physician for suspected\nacute coronary syndrome. Mr. Fisher described left-sided rib pain, which\nwas related to breathing and pressure, as well as dyspnea for a few\ndays. Laboratory tests showed acute-on-chronic kidney failure and\nelevated infection parameters. A urine dipstick test was negative for\nnitrites and leukocytes. Chest CT ruled out pulmonary pathology, and\nacute coronary syndrome was also excluded. Mr. Fisher reported a urinary\ntract infection about 4 weeks ago, which was treated with antibiotics as\nan outpatient.\n\n**Physical Examination:** Alert, oriented, cooperative, and responsive\nto time, place, person, and situation\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; clear nasal\nsinuses; moist pink mucous membranes; unremarkable dental status; moist\ntongue\n\n[Chest]{.underline}: Normal configuration; no tenderness in the spine;\nboth renal beds free\n\n[Heart]{.underline}: Arrhythmic heart sounds, pure, tachycardic, not\nsplit\n\n[Lungs]{.underline}: Vesicular breath sounds; somewhat decreased breath\nsounds bilaterally; no adventitious sounds; no stridor\n\n[Abdomen]{.underline}: Regular peristalsis in all quadrants; soft; right\nlower abdomen notably distended with increased vascular markings, liver\nand spleen not palpable, transplant kidney non-tender\n\n[Lymph Nodes:]{.underline} No pathologically enlarged cervical lymph\nnodes palpable\n\n[Skin]{.underline}: No pathological skin findings\n\n[Extremities:]{.underline} Warm; no edema; cyanosis of toes bilaterally\nafter prolonged leg dependency\n\n- Pulse status (right/left): Carotid artery +/+, Radial artery +/+,\n Posterior tibial artery +/+\n\n- Neurology: Normal cranial nerves; round, moderately dilated pupils;\n prompt bilateral pupillary light reflex; no sensory or motor\n deficits; ubiquitous muscle strength 5/5\n\n**Therapy and Progression:** We admitted the patient for further\ndiagnosis and treatment. Initially suspected acute coronary syndrome was\nruled out. Laboratory results showed elevated retention and infection\nparameters. With volume substitution, we achieved baseline creatinine\nlevels again. The transplant kidney appeared non-dilated and\nwell-perfused. For the infection, the patient received the mentioned\nimaging studies, which did not reveal any definitive findings. Our urine\nanalyses and cultures also showed bland results. It should be noted that\nprior outpatient treatment for suspected urinary tract infection was\nlikely with cotrimoxazole. Ultimately, considering the recent\nantibiograms, we decided on a calculated antibiotic therapy with\nMeropenem. This led to a significant improvement in infection\nparameters. The last measured Ciclosporin level was slightly\nsubtherapeutic, so we adjusted the dosage accordingly. We recommend\nfollow-up with the primary care physician.\n\n**Chest CT on 06/10/2019:**\n\n[Clinical Information, Question, Justification]{.underline}: Patient\nwith a history of kidney transplantation. Bursting pain on both sides at\nthe ribcage. Cough. Elevated inflammatory markers. Question about\ninfiltrates, pleural effusion, congestion.\n\n[Technique]{.underline}: Digital overview radiographs. Plain 80-line CT\nof the chest. MPR (Multiplanar reconstruction). DLP (Dose-Length\nProduct) 120.6 mGy\\*cm.\n\n[Findings]{.underline}: No previous images available for comparison.\nSymmetric thyroid. Minimal pericardial effusion, accentuated at the\nbase, measuring up to 8 mm in width (Series 5, Image 293). Coronary\natherosclerosis. No pathologically enlarged lymph nodes in the\nmediastinum, axilla, or hilum on plain images. Multisegmental calcified\n(micro)nodules. No suspicious pulmonary nodules indicative of\nmalignancy. No pneumonic infiltrates. No pleural effusions. No\npneumothorax. No pulmonary venous congestion. Delicate scar tissue at\nthe bases bilaterally. Small axial hiatal hernia. Rounded soft tissue\nstructure in the right adrenal space (Series 5, measuring 411 x 10 mm).\nIncidentally captured at the image margins is a shrunken left kidney.\nSpondylosis deformans of the thoracic spine. Interpretation: No\npneumonic infiltrates. No pleural effusions. No pulmonary venous\ncongestion. Minimal pericardial effusion. Multisegmental calcified\n(micro)nodules, likely post-inflammatory.\n\n**Abdomen/Pelvis CT on 06/14/2019:**\n\n[Clinical Information, Question, Justification:]{.underline} Acute\nkidney failure. Question regarding kidney or ureteral stones.\n\n[Technique]{.underline}: Plain 80-line CT of the abdomen. MPR. DLP 947\nmGy\\*cm. Findings and [Interpretation:]{.underline}\n\nThe left transplant kidney shows pelvic dilation with an expanded renal\npelvis and ureter (hydronephrosis grade II) but no evidence of stones.\nStatus post-right nephrectomy. Shrunken left kidney. Known large,\nbroad-based right-sided abdominal wall weakness with prolapsed\nintestinal loops and mesenteric fat tissue without evidence of\nincarceration. No ileus. Diverticulosis of the sigmoid colon. Small\naxial hiatal hernia. No free or encapsulated fluid or free air in the\nabdomen with the right diaphragmatic dome not fully visualized.\n\nCholecystolithiasis. No cholestasis. Vascular sclerosis. No\nlymphadenopathy. Bilaterally aerated lung bases captured without change.\nUnchanged irregularly thickened and coarsely structured right iliac\nbone, consistent with Paget\\'s disease.\n\n**Recommendations:**\n\nCiclosporin level monitoring\n\n**Medication upon discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Candesartan Cilexetil (Atacand) 8 mg 0-1-0-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU 1 x/week\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 70-0-70-0\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under our inpatient care from 02/19/2020 to\n03/01/2020.\n\n**Current Symptoms:** Decreased general condition, weakness,\ndecompensation\n\n**Diagnosis**: Acute episode of recurrent urinary tract infection with\ndetection of E. faecalis, E. faecium, and Enterobacter cloacae in urine\n(blood cultures sterile).\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our internal\nmedicine emergency department. He presented with worsening general\ncondition and increasing weakness, following the recommendation of our\nlocal nephrological telemedicine. He particularly noticed the increasing\nweakness when getting up, describing his legs as feeling like rubber. He\nalso experienced shortness of breath. His walking distance was greater\nthan 100 meters. There was no fever, chills, nausea, vomiting, dysuria,\nor changes in bowel movements. Before the outpatient visit, the patient\nhad collected urine for 24 hours, totaling 1700 ml, with a fluid intake\nof approximately 2 liters. His blood pressure at home was approximately\n120/60 mmHg. In the emergency department, he had negative urinary\ndipstick results and a non-specific chest X-ray. Blood and urine\ncultures were obtained, and he was subsequently transferred to our\ngeneral ward. No angina pectoris symptoms. The patient had normal bowel\nmovements, specifically no melena, and no blood-tinged stools. Urine was\ndescribed as clear and light.\n\n**Physical Examination:** Alert, oriented, cooperative, oriented to\ntime, place, person, and situation. Height 179 cm; Weight 114 kg\n\n[Head/neck:]{.underline} No tender nerve exit points; Clear nasal\nsinuses; No tenderness over the skull; Mucous membranes pink and moist;\nDental status is rehabilitated; Tongue moist and glossy\n[Thorax]{.underline}: Normally shaped; Spine without tenderness; Renal\nregions free of tenderness\n\n[Heart]{.underline}: Heart sounds are faint, arrhythmic, clear, regular\nrate, no splitting of heart sounds; Jugular veins are not distended\n\n[Lungs]{.underline}: Faint vesicular breath sounds; Resonant percussion\nnote; Dullness on the left, no added sounds; No stridor; Normal breath\nexcursion\n\n[Abdomen]{.underline}: Large right abdominal wall hernia, normal\nperistalsis in all quadrants; Soft; No pathological resistances; No\ntenderness (especially not over the left lower abdomen)\n\n[Skin status:]{.underline} No pathological skin findings\n\nExtremities: Warm; Mild edema.\n\n[Neurology:]{.underline} Alert. No focal deficits\n\n**Treatment and Progression:** The patient was admitted through our\nemergency department due to a decrease in general condition and\nweakness, accompanied by significantly elevated laboratory infection\nparameters and slightly worsened retention parameters (Creatinine max\n3.4 mg/dL compared to the current baseline of 3 mg/dL). Upon admission,\napart from a known and persistent leukocyturia since 2020, there were no\nindications of any other infectious focus. We were able to detect\nEnterobacter cloacae and Enterococcus faecalis in the urine, and we\ninitially treated the patient with intravenous Tazobactam. Blood\ncultures remained sterile. The patient\\'s general condition improved\nwithin a few days, along with a regression of infection parameters.\n\nFor further investigation of recurrent urinary tract infections (UTIs)\nand in the context of a history of urethral stricture treatment in\nFebruary 2021 with bougienage of the urethra one year ago, a urological\nconsultation was arranged. During this consultation, there was suspicion\nof a recurrence of the urethral stricture due to a significant residual\nurine volume of 175 ml. A scheduled readmission for repeat surgical\nmanagement was set for May 16, 2022. Due to the lack of normalization of\nelevated infection parameters and significant residual urine, a urinary\ncatheter was inserted. Subsequently, Enterococcus faecium was detected,\nand we continued treatment with oral Linezolid after the completion of\nintravenous antibiotic therapy.\n\nThe antibiotic treatment was planned to continue on an outpatient basis\nfor a total of 10 days. We kindly request an outpatient follow-up to\nmonitor infection parameters next week. The urinary catheter will be\nmaintained until the urological follow-up appointment, and the patient\nhas been provided with a prescription for medication.\n\nFurthermore, the patient exhibited atrial tachyarrhythmia. We reduced\nthe heart rate using Digoxin, as the patient was already on maximum\nbeta-blocker therapy. The atrial tachyarrhythmia significantly improved\nunder this treatment.\n\nAdditionally, there was a non-puncture-worthy pleural effusion and a\nchronic pericardial effusion, which was not hemodynamically relevant.\nThere were no clinical indications of pericarditis.\n\n**Current Recommendations:**\n\n1. Inpatient admission to Urology Department.\n\n2. Outpatient laboratory monitoring and referral issuance by the\n primary care physician.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on mutual patient, Mr. Alan Fisher, born on 12/09/1953,\nwho was under our inpatient care from 03/14/2020 to 03/15/2020.\n\n**Diagnoses**: Anastomotic stricture following history of prostatectomy\nand history of urethrotomy interna.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Procedure**:\n\n- Urethrotomy interna according to Sachse\n\n- Calculated intravenous antibiotic therapy with Meropenem starting on\n 03/14/2020\n\n- Extension of therapy to include antifungal treatment with\n Fluconazole on 03/15/2020\n\n**Medical History:** The patient presents with a recurrence of\nsymptomatic urethral stricture at the anastomosis site following\nprostatectomy. The main symptoms are frequent urination, dysuria, and\nresidual urine formation up to 175 ml. In January 2019, urethrotomy\ninterna was already performed. Since the last hospitalization due to a\nurinary tract infection, the patient has had a continuous\ncatheterization.\n\n**Physical Examination:** Patient in a reduced general condition and\nobese nutritional status. The abdomen is soft, without signs of\nresistance or pain. Kidney beds on both sides are indolent.\n\n**Urine Diagnostics**: Urine dipstick: Leukocytes 500, Nitrite negative,\nErythrocytes 50\n\n**Microbiology**: Candida in urine, collected by the general\npractitioner on 03/11/2020.\n\n**Chest X-ray in two planes on 02/19/2020:**\n\n[Clinical Information, Question, Justification for the\nExamination]{.underline}: Deterioration of general condition. History of\nrecurrent sepsis. History of lung transplantation. Infiltrates?\n\n**Findings**: The heart is shifted to the left and has a mitral\nconfiguration. No signs of acute congestion. The mediastinum shows no\nsigns of emphysema, is centrally located, and of normal width. No active\npneumonia in the ventilated lung regions. Progressive costophrenic angle\neffusion on the left. No pleural effusion on the right, as far as can be\nassessed. No pneumothorax. Degenerative changes in the spine.\nHyperkyphosis of the thoracic spine.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complication. Scar tissue at the level of the bladder sphincter\nwas incised. The postoperative course was uneventful. The transurethral\nindwelling catheter was removed on the 19th postoperative day. At the\ntime of discharge, the patient could urinate without residual urine with\na good urinary stream. We discharged the patient on 03/19/2020 for\nfurther outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------------- ------------------- ------------------\n Magnesium Oxide 400 mg 1-0-0-0\n Atorvastatin (Lipitor) 43.3 mg 0-0-1-0\n Candesartan Cilexetil (Atacand) 16 mg 1-1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol, oily) 20,000 IU 1x every 2 weeks\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 385 mg 1-0-1-0\n Pantoprazole (Protonix) 22.6 mg 1-0-0-0\n Piperacillin/Tazobactam (Zosyn) 4.17 g and 0.54 g 1-1-1-0\n Cyclosporine, microemulsified (Neoral) 10 mg 1-0-1-0\n Cyclosporine, microemulsified (Neoral) 50 mg 1-0-1-0\n Torsemide (Demadex) 10 mg 2-1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------------ ---------------------\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 3.02 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 19 mL/min/1.73m² \\-\n Total Bilirubin 0.73 mg/dL \\< 1.20 mg/dL\n Direct Bilirubin 0.41 mg/dL \\< 0.30 mg/dL\n C-reactive Protein 78.3 mg/dL \\< 5.0 mg/dL\n Alanine Aminotransferase 35 U/L \\< 41 U/L\n Aspartate Aminotransferase 33 U/L \\< 50 U/L\n Alkaline Phosphatase 273 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 184 U/L 8-61 U/L\n Lipase 102 U/L 13-60 U/L\n Hemoglobin 12.3 g/dL 12.5-17.2 g/dL\n Hematocrit 39.0% 37.0-49.0%\n Red Blood Cells 4.2 M/uL 4.0-5.6 M/uL\n White Blood Cells 10.41 K/uL 3.90-10.50 K/uL\n Platelets 488 K/uL 150-370 K/uL\n Mean Corpuscular Volume 92.4 fL 80.0-101.0 fL\n Mean Corpuscular Hemoglobin 29.1 pg 27.0-34.0 pg\n Mean Corpuscular Hemoglobin Concentration 31.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.3 fL 7.0-12.0 fL\n Red Cell Distribution Width 13.5% 11.5-15.0%\n\n\n\n\nHere is the query:\nWhat change occurred in Mr. Fisher's hemoglobin levels from April 2009 to March 2020?\n\nChoose the correct answer from the following options:\nA. Levels increased within the normal range\nB. Levels decreased but remained within the normal range\nC. Levels decreased below the normal range\nD. Levels increased above the normal range\nE. Levels remained stable within the reference range\n\n\nYour response:\n", "role": "user" }, { "content": "Levels decreased below the normal range", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953. He was under our inpatient care from 04/19/2009 to\n04/28/2009.\n\n**Diagnoses:**\n\n- Progressive deterioration of renal transplant function (creeping\n creatinine) without evidence of biopsy-proven rejection\n\n- Isovolumetric tubular epithelial vacuolization\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Mr. Fisher was admitted for a renal transplant\nbiopsy due to progressive deterioration of transplant function (creeping\ncreatinine). His recent creatinine values had increased to around 1.4 --\n1.6 mg/dL, while they had previously been around 1.1 mg/dL.\n\n**Therapy and Progression:** Following appropriate preparation and\ninformed consent, a complication-free transplant puncture was performed.\nThe biopsy showed isometric tubular epithelial vacuolization without\nsignificant findings. This was followed by adjustment of Cyclosporin-A\nlevels and the addition of a lymphocyte proliferation inhibitor to the\nexisting immunosuppressive dual therapy. There was a significant\nincrease in Cyclosporin-A levels at one point due to accidental double\ndosing by the patient, but levels returned to the target range. This\nmight explain the current rise in creatinine. Another explanation could\nbe recurrent hypotensive blood pressure dysregulations, leading to the\ndiscontinuation of Minoxidile medication. For chronic atrial\nfibrillation, anticoagulation therapy with Marcumar was restarted during\nhospitalization and should be continued as an outpatient according to\nthe target INR. Low molecular weight heparin administration could be\ndiscontinued.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No dyspnea. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable.\n\nLungs: Normal chest shape, moderately mobile, resonant percussion sound,\nvesicular breath sounds bilaterally, no wheezing or crackles heard.\n\nHeart: Irregular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, markedly obese, no tenderness, no palpable\nmasses, liver and spleen not palpable due to limited access, non-tender\nkidneys. Large reducible incisional hernia on the right side following\nnephrectomy.\n\nExtremities: Occluded fistula on the right forearm. Normal peripheral\npulses; joints freely movable. Strength, motor function, and sensation\nare unremarkable.\n\n**Kidney Biopsy on 04/19/2009:** Complication-free biopsy of the\ntransplant kidney.\n\nFindings: Erythematous macules.\n\nRecommendation: Follow-up in 3 months.\n\n**Ultrasound of Transplant Kidney on 04/20/2009:** Transplant kidney\nwell visualized, located in the left iliac fossa, measurable,\noval-shaped. Parenchymal echogenicity normal, normal corticomedullary\ndifferentiation. No evidence of arteriovenous fistula or hematoma after\nkidney biopsy.\n\n**Pathological-anatomical assessment on 04/19/2009:**\n\n**Macroscopic Findings:** Singular Nodule Identified: Dimensions\nmeasuring 8 mm.\n\n**Microscopic Examination:**\n\nSampled Tissue: Renal cortex\n\nIdentified Components:\n\n- Glomeruli: Nine observed\n\n- Interlobular Artery: One segment present\n\n- Absence of medullary tissue\n\n**Diagnostic Observations:** There were no signs of inflammation or\nscarring in the renal cortex. The glomeruli appeared normocellular, and\nno signs of inflammation or pathological changes were observed in them.\nThe peritubular capillaries were free of inflammation, and the specific\ntest for C4d staining yielded negative results. The arterioles within\nthe tissue had thin walls, and there was no evidence of inflammation in\nthis vascular component.\n\nThe interlobular artery was also thin-walled and showed no evidence of\ninflammation.\n\nA notable finding was extensive damage to the tubular epithelium. The\ndamage was characterized by isometric microvesicular cytoplasmic\ntransformation, which exceeded 80%. Importantly, there was no evidence\nof cell necrosis and only minimal flattening of cells was observed. In\naddition, no pathological imprints, microcalcifications, or nuclear\ninclusion bodies were observed in the tubular epithelium.\n\n**Summary:** The predominant pathological finding in this case is\nsubstantial tubular damage. Consequently, it is highly advisable to\nclosely monitor immunosuppression levels in the patient\\'s management.\nFurther comprehensive evaluation is strongly recommended to determine\nthe underlying cause of the observed tubular damage and to address the\nclinical question concerning the presence of Chronic Allograft\nNephropathy or the potential involvement of an infection in the clinical\npresentation.\n\n**Chest X-ray (2 views) on 04/22/2009:**\n\n[Findings]{.underline}: No pneumothorax, no effusion. No evidence of\npneumonia. No focal findings. Left-biased heart without decompensation.\nMediastinum centrally positioned, not widened. Unremarkable depiction of\ncentral hilar structures. Thoracic hyperkyphosis.\n\n**Current Recommenations:** We request regular outpatient monitoring of\nretention parameters (initially every 2-3 weeks) and are available for\nfurther questions at the provided telephone number.\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 144 mEq/L 134-145 mEq/L\n Potassium 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium 9.48 mg/dL 8.6-10.6 mg/dL\n Chloride 106 mEq/L 95-112 mEq/L\n Phosphorus 2.88 mg/dL 2.5-4.5 mg/dL\n Transferrin Saturation 20 % 16-45 %\n Magnesium 1.9 mg/dL 1.8-2.6 mg/dL\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n Glomerular Filtration Rate 36 mL/min \\>90 mL/min\n BUN (Blood Urea Nitrogen) 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n C-Reactive Protein 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 ng/mL 30-300 ng/mL\n ALT (Alanine Aminotransferase) 17 U/L \\<45 U/L\n AST (Aspartate Aminotransferase) 20 U/L \\<50 U/L\n Alkaline Phosphatase 119 U/L 40-129 U/L\n GGT (Gamma-Glutamyltransferase) 94 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n TSH (Thyroid-Stimulating Hormone) 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43% 40-52%\n Red Blood Cells 4.60 M/uL 4.6-6.2 M/uL\n White Blood Cells 8.78 K/uL 4.5-11.0 K/uL\n Platelets 205 K/uL 150-400 K/uL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/uL 1.8-7.7 K/uL\n Lymphocytes 2.37 K/uL 1.4-3.7 K/uL\n Monocytes 0.93 K/uL 0.2-1.0 K/uL\n Eosinophils 1.67 K/uL \\<0.7 K/uL\n Basophils 0.09 K/uL 0.01-0.10 K/uL\n Nucleated Red Blood Cells Negative \\<0.01 K/uL\n APTT (Activated Partial Thromboplastin Time) 45.1 sec 26-40 sec\n Antithrombin Activity 85 % 80-120 %\n\n**Medication upon discharge**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Cyclosporine (Neoral) 1 mg 1-0-1\n Mycophenolic Acid (Myfortic) 180 mg 1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0\n Aspirin 81 mg 1-0-0\n Candesartan (Atacand) 16 mg 0-0-1\n Metoprolol (Lopressor) 50 mg 1-1-1-1\n Isosorbide Dinitrate (Isordil) 60 mg 1-0-0\n Torsemide (Demadex) 10 mg As directed\n Ranitidine (Zantac) 300 mg 0-0-1\n Fluvastatin (Lescol) 20 mg 0-0-1\n Allopurinol (Zyloprim) 100 mg 0-1-0\n Tamsulosin (Flomax) 0.4 mg 1-0-0\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient, Mr. Alan Fisher,\nborn on 12/09/1953.\n\nHe was under our inpatient care from 10/02/2018 to 10/03/2018.\n\n**Diagnoses:**\n\n- Urosepsis\n\n- Acute postrenal kidney failure\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Previous Surgeries:** Previous prostate vesiculectomy with regional\nlymphadenectomy\n\n**Planned procedure:** Urethro-cystoscopy with catheter placement for\nurethral stricture\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by the outpatient urologist due to suspicion of\na urethral stricture. Mr. Fisher reports a worsening urinary retention\nfor approximately 6 months. Despite multiple unsuccessful attempts at\ncatheter placement, ureterocystoscopy with catheter insertion was\nperformed. Intraoperatively, purulent cystitis and a bladder outlet\nobstruction were observed.\n\nMr. Fisher regularly attends follow-up examinations for his history of\nkidney transplantation in 1995 and previous prostate vesiculectomy with\nregional lymphadenectomy in 01/2018.\n\n**Physical Examination:** Neurology: RASS 0, alert, CAM-ICU negative, no\nnew focal neurology\n\nLungs: Bilateral air entry, no rales or wheezing, sufficient gas\nexchange on 2L/O2 Cardiovascular: Normal sinus rhythm, normotensive on\n0.01 µg/kg/min NA\n\nAbdomen: Soft, no guarding, sparse peristalsis, advanced oral diet,\nregular bowel movements\n\nDiuresis: Normal urine output, retention values within normal range,\ngoal: balanced fluid status\n\nSkin/Wounds: Non-irritated, no peripheral edema\n\n**Therapy and Progression**: We received Mr. Fisher, who was awake and\nspontaneously breathing under a 2L O2 mask via nasal cannula, to our\nintensive care unit due to urosepsis. To maintain an adequate\ncirculation, low-dose catecholamine therapy was required but could be\ndiscontinued on the first postoperative day. Pulmonary function remained\nstable with intensive non-invasive ventilation and breathing training.\n\nGiven his immunosuppression, we escalated the intraoperatively initiated\nanti-infective therapy from Ceftriaxone to Piperacillin/Tazobactam.\nPneumococcal and Legionella rapid tests were negative. Following\nappropriate volume resuscitation and diuretic therapy with Furosemide,\ndiuresis became sufficient. Oral diet progression occurred without\ncomplications. Anticoagulation was initially in prophylactic dosing with\nHeparin and later switched to therapeutic dosing with Enoxaparin.\n\n**Current Recommendations:**\n\n- Switch unfractionated Heparin to Fragmin\n\n- baseline Crea 2mg/dL, target CyA level: 50-60ng/mL, Myfortic\n continued.\n\n- Urological care of the stricture in progress, leave catheter until\n then.\n\n- Mobilization\n\n**Medication upon Discharge:**\n\n **Medication (Brand)** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Torsemide (Demadex) 10 mg 1-1-0-0\n Prednisone (Deltasone) 5 mg 1-1-0-0\n Pantoprazole (Protonix) 20 mg 1-1-0-0\n Mycophenolate Mofetil (CellCept) 360 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 100 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Candesartan (Atacand) 16 mg 0-0.5-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Allopurinol (Zyloprim) 100 mg 1-0-0-0\n Aspirin 81 mg 1-0-0-0\n Paracetamol (Tylenol) 500 mg As needed\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. Alan Fisher, born on\n12/09/1953.\n\nHe was under our inpatient care from 11/04/2018 to 11/12/2018.\n\n**Current Symptoms:** Decreased diuresis, rising creatinine, frustrating\ncatheterization.\n\n**Diagnoses:**\n\n- Acute on chronic graft failure\n\n<!-- -->\n\n- Creatinine increased from 1.56 mg/dL to a maximum of 2.35 mg/dL.\n\n- Likely postrenal origin due to urethral stricture; sonographically,\n Grade II urinary stasis with urinary retention and residual urine\n formation.\n\n- Frustrating catheterization due to urethral stricture\n\n- Urethro-cystoscopy with bougie and catheter placement\n\n- Parainfectious component in purulent cystitis with urosepsis\n\n- Discharged with indwelling catheter\n\n- Inpatient readmission to the colleagues in Urology for internal\n urethrotomy\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our emergency\ndepartment upon referral by an outpatient urologist due to suspected\nurethral stricture. Mr. Fisher reports increasing difficulty urinating\nfor approximately 6 months. He has to \\\"squeeze out\\\" his bladder\ncompletely. Frustrating catheterization was performed due to urinary\nretention. Intraoperatively, purulent cystitis and bladder outlet\nstenosis were observed. Mr. Fisher regularly undergoes follow-up\nexaminations for a history of kidney transplantation in 1995 and a\nprostate vesiculectomy with regional lymphadenectomy in 01/2018.\n\n**Vegetative Findings:** The patient had a bowel movement 4 days ago,\nindwelling catheter irritation (3L of diuresis the previous day), no\nnausea/vomiting, no fever or night sweats, weight loss of 30kg from\nFebruary to April 2020.\n\n**Physical Capacity:** Limited, can still climb 2 stairs but needs to\ntake a break due to shortness of breath.\n\n**Physical Examination:** Temperature 37.4°C, Blood pressure 128/72\nmmHg; Pulse 72/min; Respiratory rate 15/min, O2 saturation under 2L O2:\n96%\n\nAwake, alert, cooperative, oriented to time, place, person, and\nsituation.\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; Clear paranasal\nsinuses; moist and pink mucous membranes; unremarkable dentition; moist\nand glossy tongue; non-palpable thyroid enlargement.\n\n[Chest]{.underline}: Normal configuration; Non-tender spine; free renal\nbeds bilaterally.\n\n[Heart]{.underline}: Rhythmic, clear heart sounds, normal rate, no\nsplitting; non-distended jugular veins. [Lungs]{.underline}: Vesicular\nbreath sounds; Resonant percussion note; no adventitious sounds; no\nstridor; normal chest expansion.\n\n[Abdomen]{.underline}: Protuberant, known incisional hernia, normal\nperistalsis in all quadrants; soft; no pathological resistance; no\ntenderness; liver palpable below the costal margin; spleen not palpable.\n\n[Lymph nodes:]{.underline} No pathologically enlarged cervical nodes\npalpable; axillary and inguinal nodes not palpable.\n\nSkin: No pathological skin findings.\n\n[Extremities:]{.underline} Warm; mild bilateral ankle edema.\n\n[Pulse status (right/left):]{.underline} A. carotis +/+, A. radialis\n+/+, A. femoralis +/+, A. tibialis post. +/+, A. dorsalis ped. +/+\n\n[Neurological]{.underline}: Oriented and unremarkable.\n\n**Therapy and Progression:** The patient was admitted through our\nemergency department upon referral by an outpatient urologist due to\nsuspected urethral stricture, which had been causing increasingly\ndifficult urination for approximately 6 months. Sonography showed Grade\nII urinary stasis with urinary retention and residual urine. Frustrating\ncatheterization was performed, followed by ureterocystoscopy with bougie\nand catheter placement. Intraoperatively, purulent cystitis and bladder\noutlet stenosis were observed. Laboratory tests revealed acute kidney\ntransplant failure, with creatinine increasing from 1.56 mg/dL to 2.35\nmg/dL, along with significantly elevated infection parameters: CRP up to\n186 mg/dL, PCT 12.82 µg/L, and leukocytosis of 21.6/nL. After obtaining\nblood cultures, empirical antibiotic therapy with Ceftriaxone was\ninitiated. Upon detecting Pseudomonas aeruginosa, therapy was switched\nto Piperacillin/Tazobactam on 12/06/20 and continued until 12/13/20.\nUnder this treatment, infection parameters significantly improved, and\nMr. Fisher remained afebrile. Kidney retention parameters also decreased\nto a discharge creatinine of 2.05 mg/dL. Regarding the urethral\nstricture, he was initially discharged with an indwelling catheter. A\nfollow-up appointment for internal urethrotomy and potentially Allium\nstent placement was scheduled for 4 weeks later. During the hospital\nstay, ciclosporin levels remained within the target range. Following\nprostate vesiculectomy earlier in the year, anticoagulation was switched\nfrom Enoxaparin to Apixaban 2.5 mg twice daily, and Aspirin therapy was\ndiscontinued.\n\n**Recommendations**: We recommend regular monitoring of kidney retention\nparameters and infection parameters. Regarding the urethral stricture,\nthe patient will be discharged with an indwelling catheter. We scheduled\na follow-up with colleagues in Urology for internal urethrotomy and\npotentially Allium stent placement. Pause oral anticoagulation with\nApixaban one day before inpatient admission.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Ciclosporin (Neoral) 100 mg 60-0-70-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Candesartan (Atacand) 8 mg 0-1-0-0\n Torsemide (Demadex) 10 mg 1-1-0-0\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU Pause\n Magnesium Oxide 400 mg 1-0-0-0\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting to you regarding our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under outpatient care on 07/01/2019.\n\n**Current Symptoms:** Pain on the left side at rib level**,** Dyspnea\n\n**Diagnoses:**\n\n- Infection of unclear origin\n\n - CT Thorax and Abdomen showed no focus\n\n - Urine dipstick and cultures were bland\n\n - Antibiotics: Meropenem from 06/11/2019 to 06/19/2019\n\n- Acute Transplant Dysfunction\n\n - Serum Creatinine: 2.4 -\\> 4.5 -\\> 2.6 mg/dl\n\n - Renal ultrasound: 123 x 54 x 24 mm, not dilated, some areas of\n increased echogenicity, no twinkling, no acoustic shadowing, no\n signs of urolithiasis.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** Initial presentation was at the local emergency\ndepartment on referral from the primary care physician for suspected\nacute coronary syndrome. Mr. Fisher described left-sided rib pain, which\nwas related to breathing and pressure, as well as dyspnea for a few\ndays. Laboratory tests showed acute-on-chronic kidney failure and\nelevated infection parameters. A urine dipstick test was negative for\nnitrites and leukocytes. Chest CT ruled out pulmonary pathology, and\nacute coronary syndrome was also excluded. Mr. Fisher reported a urinary\ntract infection about 4 weeks ago, which was treated with antibiotics as\nan outpatient.\n\n**Physical Examination:** Alert, oriented, cooperative, and responsive\nto time, place, person, and situation\n\n[Head/Neck:]{.underline} Non-tender nerve exit points; clear nasal\nsinuses; moist pink mucous membranes; unremarkable dental status; moist\ntongue\n\n[Chest]{.underline}: Normal configuration; no tenderness in the spine;\nboth renal beds free\n\n[Heart]{.underline}: Arrhythmic heart sounds, pure, tachycardic, not\nsplit\n\n[Lungs]{.underline}: Vesicular breath sounds; somewhat decreased breath\nsounds bilaterally; no adventitious sounds; no stridor\n\n[Abdomen]{.underline}: Regular peristalsis in all quadrants; soft; right\nlower abdomen notably distended with increased vascular markings, liver\nand spleen not palpable, transplant kidney non-tender\n\n[Lymph Nodes:]{.underline} No pathologically enlarged cervical lymph\nnodes palpable\n\n[Skin]{.underline}: No pathological skin findings\n\n[Extremities:]{.underline} Warm; no edema; cyanosis of toes bilaterally\nafter prolonged leg dependency\n\n- Pulse status (right/left): Carotid artery +/+, Radial artery +/+,\n Posterior tibial artery +/+\n\n- Neurology: Normal cranial nerves; round, moderately dilated pupils;\n prompt bilateral pupillary light reflex; no sensory or motor\n deficits; ubiquitous muscle strength 5/5\n\n**Therapy and Progression:** We admitted the patient for further\ndiagnosis and treatment. Initially suspected acute coronary syndrome was\nruled out. Laboratory results showed elevated retention and infection\nparameters. With volume substitution, we achieved baseline creatinine\nlevels again. The transplant kidney appeared non-dilated and\nwell-perfused. For the infection, the patient received the mentioned\nimaging studies, which did not reveal any definitive findings. Our urine\nanalyses and cultures also showed bland results. It should be noted that\nprior outpatient treatment for suspected urinary tract infection was\nlikely with cotrimoxazole. Ultimately, considering the recent\nantibiograms, we decided on a calculated antibiotic therapy with\nMeropenem. This led to a significant improvement in infection\nparameters. The last measured Ciclosporin level was slightly\nsubtherapeutic, so we adjusted the dosage accordingly. We recommend\nfollow-up with the primary care physician.\n\n**Chest CT on 06/10/2019:**\n\n[Clinical Information, Question, Justification]{.underline}: Patient\nwith a history of kidney transplantation. Bursting pain on both sides at\nthe ribcage. Cough. Elevated inflammatory markers. Question about\ninfiltrates, pleural effusion, congestion.\n\n[Technique]{.underline}: Digital overview radiographs. Plain 80-line CT\nof the chest. MPR (Multiplanar reconstruction). DLP (Dose-Length\nProduct) 120.6 mGy\\*cm.\n\n[Findings]{.underline}: No previous images available for comparison.\nSymmetric thyroid. Minimal pericardial effusion, accentuated at the\nbase, measuring up to 8 mm in width (Series 5, Image 293). Coronary\natherosclerosis. No pathologically enlarged lymph nodes in the\nmediastinum, axilla, or hilum on plain images. Multisegmental calcified\n(micro)nodules. No suspicious pulmonary nodules indicative of\nmalignancy. No pneumonic infiltrates. No pleural effusions. No\npneumothorax. No pulmonary venous congestion. Delicate scar tissue at\nthe bases bilaterally. Small axial hiatal hernia. Rounded soft tissue\nstructure in the right adrenal space (Series 5, measuring 411 x 10 mm).\nIncidentally captured at the image margins is a shrunken left kidney.\nSpondylosis deformans of the thoracic spine. Interpretation: No\npneumonic infiltrates. No pleural effusions. No pulmonary venous\ncongestion. Minimal pericardial effusion. Multisegmental calcified\n(micro)nodules, likely post-inflammatory.\n\n**Abdomen/Pelvis CT on 06/14/2019:**\n\n[Clinical Information, Question, Justification:]{.underline} Acute\nkidney failure. Question regarding kidney or ureteral stones.\n\n[Technique]{.underline}: Plain 80-line CT of the abdomen. MPR. DLP 947\nmGy\\*cm. Findings and [Interpretation:]{.underline}\n\nThe left transplant kidney shows pelvic dilation with an expanded renal\npelvis and ureter (hydronephrosis grade II) but no evidence of stones.\nStatus post-right nephrectomy. Shrunken left kidney. Known large,\nbroad-based right-sided abdominal wall weakness with prolapsed\nintestinal loops and mesenteric fat tissue without evidence of\nincarceration. No ileus. Diverticulosis of the sigmoid colon. Small\naxial hiatal hernia. No free or encapsulated fluid or free air in the\nabdomen with the right diaphragmatic dome not fully visualized.\n\nCholecystolithiasis. No cholestasis. Vascular sclerosis. No\nlymphadenopathy. Bilaterally aerated lung bases captured without change.\nUnchanged irregularly thickened and coarsely structured right iliac\nbone, consistent with Paget\\'s disease.\n\n**Recommendations:**\n\nCiclosporin level monitoring\n\n**Medication upon discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ---------------\n Atorvastatin (Lipitor) 40 mg 0-0-0-1\n Candesartan Cilexetil (Atacand) 8 mg 0-1-0-0\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol) 20,000 IU 1 x/week\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Magnesium Oxide 400 mg 1-0-0-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 360 mg 1-0-1-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n Ciclosporin (Neoral) 100 mg 70-0-70-0\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Alan Fisher, born on\n12/09/1953, who was under our inpatient care from 02/19/2020 to\n03/01/2020.\n\n**Current Symptoms:** Decreased general condition, weakness,\ndecompensation\n\n**Diagnosis**: Acute episode of recurrent urinary tract infection with\ndetection of E. faecalis, E. faecium, and Enterobacter cloacae in urine\n(blood cultures sterile).\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Medical History:** The patient was admitted through our internal\nmedicine emergency department. He presented with worsening general\ncondition and increasing weakness, following the recommendation of our\nlocal nephrological telemedicine. He particularly noticed the increasing\nweakness when getting up, describing his legs as feeling like rubber. He\nalso experienced shortness of breath. His walking distance was greater\nthan 100 meters. There was no fever, chills, nausea, vomiting, dysuria,\nor changes in bowel movements. Before the outpatient visit, the patient\nhad collected urine for 24 hours, totaling 1700 ml, with a fluid intake\nof approximately 2 liters. His blood pressure at home was approximately\n120/60 mmHg. In the emergency department, he had negative urinary\ndipstick results and a non-specific chest X-ray. Blood and urine\ncultures were obtained, and he was subsequently transferred to our\ngeneral ward. No angina pectoris symptoms. The patient had normal bowel\nmovements, specifically no melena, and no blood-tinged stools. Urine was\ndescribed as clear and light.\n\n**Physical Examination:** Alert, oriented, cooperative, oriented to\ntime, place, person, and situation. Height 179 cm; Weight 114 kg\n\n[Head/neck:]{.underline} No tender nerve exit points; Clear nasal\nsinuses; No tenderness over the skull; Mucous membranes pink and moist;\nDental status is rehabilitated; Tongue moist and glossy\n[Thorax]{.underline}: Normally shaped; Spine without tenderness; Renal\nregions free of tenderness\n\n[Heart]{.underline}: Heart sounds are faint, arrhythmic, clear, regular\nrate, no splitting of heart sounds; Jugular veins are not distended\n\n[Lungs]{.underline}: Faint vesicular breath sounds; Resonant percussion\nnote; Dullness on the left, no added sounds; No stridor; Normal breath\nexcursion\n\n[Abdomen]{.underline}: Large right abdominal wall hernia, normal\nperistalsis in all quadrants; Soft; No pathological resistances; No\ntenderness (especially not over the left lower abdomen)\n\n[Skin status:]{.underline} No pathological skin findings\n\nExtremities: Warm; Mild edema.\n\n[Neurology:]{.underline} Alert. No focal deficits\n\n**Treatment and Progression:** The patient was admitted through our\nemergency department due to a decrease in general condition and\nweakness, accompanied by significantly elevated laboratory infection\nparameters and slightly worsened retention parameters (Creatinine max\n3.4 mg/dL compared to the current baseline of 3 mg/dL). Upon admission,\napart from a known and persistent leukocyturia since 2020, there were no\nindications of any other infectious focus. We were able to detect\nEnterobacter cloacae and Enterococcus faecalis in the urine, and we\ninitially treated the patient with intravenous Tazobactam. Blood\ncultures remained sterile. The patient\\'s general condition improved\nwithin a few days, along with a regression of infection parameters.\n\nFor further investigation of recurrent urinary tract infections (UTIs)\nand in the context of a history of urethral stricture treatment in\nFebruary 2021 with bougienage of the urethra one year ago, a urological\nconsultation was arranged. During this consultation, there was suspicion\nof a recurrence of the urethral stricture due to a significant residual\nurine volume of 175 ml. A scheduled readmission for repeat surgical\nmanagement was set for May 16, 2022. Due to the lack of normalization of\nelevated infection parameters and significant residual urine, a urinary\ncatheter was inserted. Subsequently, Enterococcus faecium was detected,\nand we continued treatment with oral Linezolid after the completion of\nintravenous antibiotic therapy.\n\nThe antibiotic treatment was planned to continue on an outpatient basis\nfor a total of 10 days. We kindly request an outpatient follow-up to\nmonitor infection parameters next week. The urinary catheter will be\nmaintained until the urological follow-up appointment, and the patient\nhas been provided with a prescription for medication.\n\nFurthermore, the patient exhibited atrial tachyarrhythmia. We reduced\nthe heart rate using Digoxin, as the patient was already on maximum\nbeta-blocker therapy. The atrial tachyarrhythmia significantly improved\nunder this treatment.\n\nAdditionally, there was a non-puncture-worthy pleural effusion and a\nchronic pericardial effusion, which was not hemodynamically relevant.\nThere were no clinical indications of pericarditis.\n\n**Current Recommendations:**\n\n1. Inpatient admission to Urology Department.\n\n2. Outpatient laboratory monitoring and referral issuance by the\n primary care physician.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on mutual patient, Mr. Alan Fisher, born on 12/09/1953,\nwho was under our inpatient care from 03/14/2020 to 03/15/2020.\n\n**Diagnoses**: Anastomotic stricture following history of prostatectomy\nand history of urethrotomy interna.\n\n**Other Diagnoses:**\n\n- History of renal transplantation on 10/25/1995\n\n- Dual immunosuppression with Cyclosporin A/Steroid since 10/1995\n\n- Terminal renal insufficiency due to chronic pyelonephritis and\n nephrolithiasis\n\n- Chronic hemodialysis from 09-10/1995\n\n- Right laparoscopic nephrectomy on 03/2007 due to suspected renal\n cell carcinoma, histologically not confirmed\n\n- Incisional hernia after nephrectomy, diagnosed on 07/2007\n\n- Secondary hyperparathyroidism\n\n- Coronary artery disease, CAD-3:\n\n - Previous anterior wall infarction in 1989, treated with\n thrombolysis and PTCA\n\n - PTCA + stent in the right coronary artery (RIVA) in 05/1995\n\n - PTCA + drug-eluting stent (DES) in RIVA on 05/15/2005\n\n - PTCA + Genous (anti CD34+ Antibody-coated) in RIVA on 08/14/2006\n\n - Remaining: 75% stenosis in D1 and occlusion of the small RCA\n (last cardiac catheterization on 03/24/2008)\n\n - Stress echocardiography planned for 01/09 if ischemia is\n detected, followed by bypass surgery if necessary\n\n- Right superficial femoral artery profundaplasty on 03/11/2007\n\n- Permanent atrial fibrillation, diagnosed in 03/07, unsuccessful\n cardioversion on 03/2008, anticoagulated with Marcumar\n\n- Arterial hypertension\n\n- Hyperlipoproteinemia, possible dose-dependent Fluvastatin\n intolerance\n\n- COPD GOLD Stage II\n\n- Mild sleep apnea syndrome in 01/2005\n\n- Massive diverticulosis (last colonoscopy on 07/2008)\n\n- History of Hepatitis B infection\n\n- Cholecystolithiasis\n\n**Procedure**:\n\n- Urethrotomy interna according to Sachse\n\n- Calculated intravenous antibiotic therapy with Meropenem starting on\n 03/14/2020\n\n- Extension of therapy to include antifungal treatment with\n Fluconazole on 03/15/2020\n\n**Medical History:** The patient presents with a recurrence of\nsymptomatic urethral stricture at the anastomosis site following\nprostatectomy. The main symptoms are frequent urination, dysuria, and\nresidual urine formation up to 175 ml. In January 2019, urethrotomy\ninterna was already performed. Since the last hospitalization due to a\nurinary tract infection, the patient has had a continuous\ncatheterization.\n\n**Physical Examination:** Patient in a reduced general condition and\nobese nutritional status. The abdomen is soft, without signs of\nresistance or pain. Kidney beds on both sides are indolent.\n\n**Urine Diagnostics**: Urine dipstick: Leukocytes 500, Nitrite negative,\nErythrocytes 50\n\n**Microbiology**: Candida in urine, collected by the general\npractitioner on 03/11/2020.\n\n**Chest X-ray in two planes on 02/19/2020:**\n\n[Clinical Information, Question, Justification for the\nExamination]{.underline}: Deterioration of general condition. History of\nrecurrent sepsis. History of lung transplantation. Infiltrates?\n\n**Findings**: The heart is shifted to the left and has a mitral\nconfiguration. No signs of acute congestion. The mediastinum shows no\nsigns of emphysema, is centrally located, and of normal width. No active\npneumonia in the ventilated lung regions. Progressive costophrenic angle\neffusion on the left. No pleural effusion on the right, as far as can be\nassessed. No pneumothorax. Degenerative changes in the spine.\nHyperkyphosis of the thoracic spine.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complication. Scar tissue at the level of the bladder sphincter\nwas incised. The postoperative course was uneventful. The transurethral\nindwelling catheter was removed on the 19th postoperative day. At the\ntime of discharge, the patient could urinate without residual urine with\na good urinary stream. We discharged the patient on 03/19/2020 for\nfurther outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------------- ------------------- ------------------\n Magnesium Oxide 400 mg 1-0-0-0\n Atorvastatin (Lipitor) 43.3 mg 0-0-1-0\n Candesartan Cilexetil (Atacand) 16 mg 1-1-0-1\n Prednisone (Deltasone) 5 mg 1-0-0-0\n Vitamin D3 (Cholecalciferol, oily) 20,000 IU 1x every 2 weeks\n Apixaban (Eliquis) 2.5 mg 1-0-1-0\n Metoprolol Succinate (Toprol-XL) 95 mg 1-0-1-0\n Mycophenolic Acid (Myfortic) 385 mg 1-0-1-0\n Pantoprazole (Protonix) 22.6 mg 1-0-0-0\n Piperacillin/Tazobactam (Zosyn) 4.17 g and 0.54 g 1-1-1-0\n Cyclosporine, microemulsified (Neoral) 10 mg 1-0-1-0\n Cyclosporine, microemulsified (Neoral) 50 mg 1-0-1-0\n Torsemide (Demadex) 10 mg 2-1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------------ ---------------------\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 3.02 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 19 mL/min/1.73m² \\-\n Total Bilirubin 0.73 mg/dL \\< 1.20 mg/dL\n Direct Bilirubin 0.41 mg/dL \\< 0.30 mg/dL\n C-reactive Protein 78.3 mg/dL \\< 5.0 mg/dL\n Alanine Aminotransferase 35 U/L \\< 41 U/L\n Aspartate Aminotransferase 33 U/L \\< 50 U/L\n Alkaline Phosphatase 273 U/L 40-130 U/L\n Gamma-Glutamyl Transferase 184 U/L 8-61 U/L\n Lipase 102 U/L 13-60 U/L\n Hemoglobin 12.3 g/dL 12.5-17.2 g/dL\n Hematocrit 39.0% 37.0-49.0%\n Red Blood Cells 4.2 M/uL 4.0-5.6 M/uL\n White Blood Cells 10.41 K/uL 3.90-10.50 K/uL\n Platelets 488 K/uL 150-370 K/uL\n Mean Corpuscular Volume 92.4 fL 80.0-101.0 fL\n Mean Corpuscular Hemoglobin 29.1 pg 27.0-34.0 pg\n Mean Corpuscular Hemoglobin Concentration 31.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.3 fL 7.0-12.0 fL\n Red Cell Distribution Width 13.5% 11.5-15.0%\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n\n\n\n\nHere is the query:\nHow did the dosage of Captopril change from Mr. Nilsson's admission on 01/20/05 to his discharge on 02/02/05?\n\nChoose the correct answer from the following options:\nA. Increased from 2 mg to 3 mg\nB. Decreased from 3 mg to 2 mg\nC. Remained the same at 2 mg\nD. Was discontinued\nE. Changed from twice daily to three times daily\n\n\nYour response:\n", "role": "user" }, { "content": "Remained the same at 2 mg", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004, who was under our inpatient care from 01/26/05 to\n02/02/05.\n\n**Diagnoses:**\n\n- Upper respiratory tract infection\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Medical History:** Emil has a Hypoplastic Left Heart Syndrome. The\ncorrective procedure, including the Damus-Kaye-Stansel and\nBlalock-Taussig Anastomosis, took place three months ago. Under the\ncurrent medication, the cardiac situation has been stable. He has shown\nsatisfactory weight gain. Emil is the first child of parents with\nhealthy hearts. An external nursing service provides home care every two\ndays. The parents feel confident in the daily care of the child,\nincluding the placement of gastric tubes.\n\n**Current Presentation:** Since the evening before admission, Emil had\nelevated temperatures up to 40°C with a slight runny nose. No coughing,\nno diarrhea, no vomiting. After an outpatient visit to the treating\npediatrician, Emil was referred to our hospital due to the complex\ncardiac history. Admission for the Glenn procedure is scheduled for\n01/20/05.\n\n**Physical Examination:** Stable appearance and condition. Pinkish skin\ncolor, good skin turgor.\n\n- Cardiovascular: Rhythmic, 3/6 systolic murmur auscultated on the\n left parasternal side, radiating to the back.\n\n- Respiratory: Bilateral vesicular breath sounds, no rales.\n\n- Abdomen: Soft and unremarkable, no hepatosplenomegaly, no\n pathological resistances.\n\n- ENT exam, except for runny nose, unremarkable.\n\n- Good spontaneous motor skills with cautious head control.\n\n- Current Weight: 4830 g; Current Length: 634cm. Transcutaneous Oxygen\n Saturation: 78%.\n\n- Blood Pressure Measurement (mmHg): Left Upper Arm 89/56 (66), Right\n Upper Arm 90/45\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n**ECG on 01/27/2006:** Sinus rhythm, heart rate 83/min, sagittal type.\nP: 60 ms, PQ: 100 ms, QRS: 80 ms, QT: 260 ms. T-wave negative in V1 and\nV2, biphasic in V3, positive from V4 onward, no arrhythmias. Signs of\nright ventricular hypertrophy.\n\n**Echocardiography on 01/27/2006:** Satisfactory function of the\nmorphological right ventricle, small hypoplastic left ventricle with\nminimal contractility. Hypoplastic mitral and original aortic valve\nbarely opening. Regular flow profile in the neoaorta. Aortic arch and\nBlalock-Taussig shunt not optimally visible due to restlessness. Trivial\ntricuspid valve insufficiency.\n\n**Chest X-ray on 01/28/2006:** Widened heart shadow, cardiothoracic\nratio 0.5. Slight diffuse increase in markings on the right lung, no\nsigns of pulmonary congestion. Hilum delicate. Recesses visible, no\neffusion. No localized infiltrations. No pneumothorax.\n\n**Therapy and Progression:** Based on the clinical and paraclinical\npicture of a pulmonary infection, we treated Emil with intravenous\nCefuroxime for five days, along with daily physical therapy. Under this\ntreatment, Emil's condition improved rapidly, with no auscultatory lung\nabnormalities. CRP and leukocyte count reduced. No fever. In the course\nof treatment, Emil had temporary diarrhea, which was well managed with\nadequate fluid substitution.\n\nWe were able to discharge Emil in a significantly improved and stable\ngeneral condition on the fifth day of treatment, with a weight of 5060\ng. Transcutaneous oxygen saturations were consistently between 70%\n(during infection) and 85%.\n\nThree days later, the mother presented the child again at the emergency\ndepartment due to vomiting after each meal and diarrhea. After changing\nthe gastric tube and readmission here, there was no more vomiting, and\nfeeding was feasible. Three to four stools of adequate consistency\noccurred daily. Cardiac medication remained unchanged.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D (Drisdol) 500 IU Once daily\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the inpatient stay of your patient Emil Nilsson,\nborn on 12/04/2004, who received inpatient care from 01/20/2005 to\n01/27/2005.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Bidirectional Glenn Anastomosis, enlargement\nof the pulmonary trunk, and closure of BT shunt\n\n**Medical History:** We kindly assume that you are familiar with the\ndetailed medical history.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Furosemide (Lasix) 4 mg 1-1-1-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Hydrochlorothiazide (Microzide) 2 mg 1-0-1\n Aspirin 10 mg 1-0-0\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n\n**Physical Examination:** Stable general condition, no fever. Gastric\ntube.\n\nUnremarkable sternotomy scar, dry. Drains in situ, unremarkable.\n\n[Heart]{.underline}: Rhythmic heart action, 2/6 systolic murmur audible\nleft parasternal.\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no additional\nsounds.\n\n[Abdomen]{.underline}: Soft liver 1.5 cm below the costal margin. No\npathological resistances.\n\nPulses palpable on all sides.\n\n[Current weight:]{.underline} 4765 g; current length: 62 cm; head\ncircumference: 37 cm.\n\nTranscutaneous oxygen saturation: 85%.\n\n[Blood pressure (mmHg):]{.underline} Left arm 91/65 (72), right arm\n72/55 (63).\n\n**Echocardiography on 01/21/2005 and 01/27/2005:**\n\nGlobal mildly impaired function of the morphologically right systemic\nventricle with satisfactory contractility. Minimal tricuspid\ninsufficiency with two small jets (central and septal), Inflow merged\nVmax 0.9 m/s. DKS anastomosis well visible, aortic VTI 14-15 cm. Free\nflow in Glenn with breath-variable flow pattern, Vmax 0.5 m/s. No\npleural effusions, good diaphragmatic mobility bilaterally, no\npericardial effusion. Isthmus optically free with Vmax 1.8 m/s.\n\n**Speech Therapy Consultation on 01/23/2005:**\n\nNo significant orofacial disorders. Observation of drinking behavior\nrecommended initially. Stimulation of sucking with various pacifiers.\nInstruction given to the father.\n\n**Therapy and Progression:** On 02/15/2006, the BT shunt was severed and\na bidirectional Glenn Anastomosis was created, along with an enlargement\nof the pulmonary artery. The course was uncomplicated with swift\nextubation and transfer to the intermediate care unit on the second\npostoperative day. Timely removal of drains and pacemaker wires. The\nchild remained clinically stable throughout the stay. The child\\'s own\ndrinking performance is satisfactory, with varying amounts of fluid\nintake between 60 and 100 ml per meal. The tube feeding is well\ntolerated, no vomiting, and discharged without a tube. Stool normal. IV\nantibiotics were continued until 01/22/2005. Transition from\nheparinization to daily Aspirin. Inhalation was also stopped during the\ncourse with a stable clinical condition.\n\nDue to persistently elevated mean pressures of 70 to 80 mmHg and limited\nglobal contractility of the morphologically right systemic ventricle, we\nincreased both Carvedilol and Captopril medication. Blood pressures have\nchanged only slightly. Therefore, we request an outpatient long-term\nblood pressure measurement and, if necessary, further medication\noptimization. Echocardiographically, we observed impaired but\nsatisfactory contractility of the right systemic ventricle with only\nminimal tricuspid valve insufficiency, as well as a well-functioning\nGlenn Anastomosis. No insufficiency of the neoaortic valve with a VTI of\n15 cm. No pericardial effusion or pleural effusions upon discharge.\n\nA copy of the summary has been sent to the involved external home care\nservice for further outpatient care.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-0-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Spironolactone (Aldactone) 10 mg 1-0-0-0\n Iron Supplement 4 drops 1-0-1\n Omeprazole (Prilosec) 2.5 mg 1-0-1\n Vitamin D 500 IU Once daily\n Aspirin 10 mg 1-0-0\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004. He was admitted to our ward from 03/01/2008\nto 03/10/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Inpatient admission for dental rehabilitation\nunder intubation anesthesia\n\n**Medical History:** We may kindly assume that you are familiar with the\nmedical history. Prior to the planned Fontan completion, dental\nrehabilitation under intubation anesthesia was required due to the\npatient\\'s carious dental status, which led to the scheduled inpatient\nadmission.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds.\n\n- Initial neurological examination unremarkable.\n\n- Current weight: 12.4 kg; current body length: 93 cm.\n\n- Percutaneous oxygen saturation: 76%.\n\n- Blood pressure (mmHg): Right upper arm 117/50, left upper arm\n 110/57, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ -----------------------------------------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 10 mg 1-0-0 (discontinued 10 days before admission)\n\n**ECG at Admission:** Sinus rhythm, heart rate 84/min, sagittal type. P\nwave 50 ms, PQ interval 120 ms, QRS duration 80 ms, QT interval 360 ms,\nQTc interval 440 ms, R/S transition in V4, T wave positive in V3 to V6.\nPersistent S wave in V4 to V6 -1.1 mV, no extrasystoles in the rhythm\nstrip.\n\n**Consultation with Maxillofacial Surgery on 02/03/2008:**\n\nTimely wound conditions, clot at positions 55, 65, 84 in situ, Aspirin\nmay be resumed today, further treatment by the Southern Dental Clinic.\n\n**Treatment and Progression:** Upon admission, the necessary\npre-interventional diagnostics were performed. Dental rehabilitation\n(extraction and fillings) was performed without complications under\nintubation anesthesia on 03/02/2008. After anesthesia, the child\nexperienced pronounced restlessness, requiring a single sedation with\nintravenous Midazolam. The child\\'s behavior improved over time, and the\nwound conditions were unremarkable. Discharge on 03/03/2008 after\nconsultation with our maxillofacial surgeon into outpatient follow-up\ncare. We request pediatric cardiology and dental follow-up checks.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------------------------------- --------------- ---------------------\n Calcium 2.33 mEq/L 2.10-2.55 mEq/L\n Phosphorus 1.12 mEq/L 0.84-1.45 mEq/L\n Osmolality 286 mOsm/kg 280-300 mOsm/kg\n Iron 20.4 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.3% 16.0-45.0%\n Magnesium 1.84 mg/dL 1.5-2.3 mg/dL\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Blood Urea Nitrogen (BUN) 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 ng/mL 14.0-152.0 ng/mL\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 138 U/L 55-149 U/L\n Butyrylcholinesterase (Pseudo-Cholinesterase) 5.62 kU/L 5.32-12.92 kU/L\n GLDH 3.1 U/L \\<6.4 U/L\n Gamma-GT 96 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 20.0-50.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/mL 0.50-4.30 mIU/mL\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting about the inpatient stay of our patient, Emil Nilsson,\nborn on 12/04/2004. He was admitted to our ward from 07/02/2008 to\n07/23/2008.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n**Current Presentation:** Planned admission for Fontan Procedure\n\n**Medical History:** We may assume that you are familiar with the\ndetailed medical history.\n\n**Physical Examination:** Friendly toddler in stable general condition,\npale skin color, central cyanosis, no edema.\n\n- ENT unremarkable, large tonsils, no cervical lymphadenopathy.\n\n- Heart: Heart sounds clear, rhythmic, 1/6 systolic murmur with a\n point of maximal intensity over the 3rd intercostal space on the\n left.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds. Initial\n neurological examination unremarkable.\n\n- Percutaneous oxygen saturation: 77%.\n\n- Blood pressure (mmHg): Right upper arm 124/60, left upper arm\n 112/59, right lower leg 134/55, left lower leg 146/71.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ---------------------- ------------ ---------------\n Captopril (Capoten®) 2 mg 1-1-1\n Carvedilol (Coreg®) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Surgical Report:**\n\nMedian Sternotomy, dissection of adhesions to access the anterior aspect\nof the heart, cannulation for extracorporeal circulation with bicaval\ncannulation. Further preparation of the heart, followed by clamping of\nthe inferior vena cava towards the heart. Cutting the vessel, suturing\nthe cardiac end, and then anastomosis of the inferior vena cava with an\n18mm Gore-Tex prosthesis, which is subsequently tapered and sutured to\nthe central pulmonary artery in an open anastomosis technique.\nResumption of ventilation, smooth termination of extracorporeal\ncirculation. Placement of 2 drains. Layered wound closure.\nTransesophageal Echocardiogram shows good biventricular function. The\npatient is transferred back to the ward with ongoing catecholamine\nsupport.\n\n**ECG on 07/02/2008:** Sinus rhythm, heart rate 76/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**Therapy and Progression:**\n\nThe patient was admitted for a planned Fontan procedure on 07/02/2008.\nThe procedure was performed without complications. An extracardiac\nconduit without overflow was created. Postoperatively, there was a rapid\nrecovery. Extubation took place 2 hours after the procedure. Peri- and\npostoperative antibiotic treatment with Cefuroxim was administered.\nBilateral pleural effusions were drained using thoracic drains, which\nwere subsequently changed to pigtail drains after transfer to the\ngeneral ward. Daily aspiration of the pleural effusions was performed.\nThese effusions decreased over time, and the drains were removed on\n07/14/2008. No further pleural effusions occurred. A minimal pericardial\neffusion and ascites were still present. Diuretic therapy was initially\ncontinued but could be significantly reduced by the time of discharge.\nEchocardiography showed a favorable postoperative result. Monitoring of\nvital signs and consciousness did not reveal any abnormalities. However,\nthe ECG showed occasional idioventricular rhythms during bradycardia.\nOxygen saturation ranged between 95% and 100%. Scarring revealed a\ndehiscence in the middle third and apical region. Regular dressing\nchanges and disinfection of the affected wound area were performed.\nAfter consulting with our pediatric surgical colleagues, glucose was\nlocally applied. There was no fever. Antibiotic treatment was\ndiscontinued after the removal of the pigtail drain, and the\npostoperatively increased inflammatory parameters had already returned\nto normal. The patient received physiotherapy, and their general\ncondition improved daily. We were thus able to discharge Emil on\n07/23/2008.\n\n**Current Recommendations:**\n\n- We recommend regular wound care with Octinisept.\n\n- Follow-up in the pediatric cardiology outpatient clinic.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.54 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.42 mEq/L 0.84-1.45 mEq/L\n Osmolality 298 mOsm/kg 280-300 mOsm/kg\n Iron 20.6 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 34 % 16.0-45.0 %\n Magnesium 0.61 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.84 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 132 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea 29 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.34 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.42 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.94 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.65 g/L 0.50-1.90 g/L\n Cystatin C 0.93 mg/L 0.50-1.00 mg/L\n Transferrin 2.89 g/L \n Ferritin 54.2 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Apolipoprotein A1 0.91 g/L 1.04-2.02 g/L\n ALT 37 U/L \\<41 U/L\n AST 33 U/L \\<50 U/L\n Alkaline Phosphatase 139 U/L 55-149 U/L\n GLDH 3.5 U/L \\<6.4 U/L\n Gamma-GT 24 U/L 8-61 U/L\n LDH 145 U/L 135-250 U/L\n Parathyroid Hormone 57.2 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 34.2 nmol/L 50.0-150.0 nmol/L\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about the inpatient stay of our patient, Emil\nNilsson, born on 12/04/2004, who was admitted to our clinic from\n10/20/2021 to 10/22/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Diagnostic cardiac catheterization in analgosedation on\n10/20/2021.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current admission is based on a referral from the outpatient\npediatric cardiologist for a diagnostic cardiac catheterization to\nevaluate Fontan hemodynamics in the context of desaturation during a\nstress test. Emil reports feeling subjectively well, but during school\nsports, he can only run briefly before experiencing palpitations and\ndyspnea. Emil attends a special needs school. He is currently free from\ninfection and fever.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------- --------------- ---------------------\n Calcium 2.38 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.19 mEq/L 0.84-1.45 mEq/L\n Osmolality 282 mOsm/Kg 280-300 mOsm/Kg\n Iron 20.0 µg/dL 4.8-24.7 µg/dL\n Transferrin Saturation 28.1 % 16.0-45.0 %\n Magnesium 0.79 mEq/L 0.62-0.91 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 131 mL/min \n Estimated GFR (eGFR Cystatin) \\>90.0 mL/min \n Urea (BUN) 27 mg/dL 18-45 mg/dL\n Total Bilirubin 0.92 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.38 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.47 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.99 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.61 g/L 0.50-1.90 g/L\n Cystatin C 0.95 mg/L 0.50-1.00 mg/L\n Transferrin 2.83 g/L \n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 62 mg/dL \n Apolipoprotein A1 0.94 g/L 1.04-2.02 g/L\n ALT (GPT) 35 U/L \\<41 U/L\n AST (GOT) 32 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.65 kU/L 5.32-12.92 kU/L\n GLDH 3.7 U/L \\<6.4 U/L\n Gamma-GT 89 U/L 8-61 U/L\n LDH 184 U/L 135-250 U/L\n Parathyroid Hormone 55.0 pg/mL 15.0-65.0 pg/mL\n 25-OH-Vitamin D3 10.9 ng/mL 50.0-150.0 ng/mL\n Free Thyroxine 17.90 ng/dL 9.50-16.40 ng/dL\n TSH 3.56 mIU/L 0.50-4.30 mIU/L\n\n**ECG on 10/20/21:** Sinus rhythm, heart rate 79/min, steep type, PQ\ninterval 140 ms, QRS duration 110 ms, QT interval 340 ms, QTc 385 mmHg.\nST depression, descending in V2+V3. T-wave positivity from V2. No\nextrasystoles. No pauses.\n\n**ECG on 11/20/2021:** Sinus rhythm, heart rate 70/min, left type,\ninverted RS wave in lead I, PQ 160, QRS 100 ms, QT 340 ms, QTc 390 ms.\n\nST depression, descending in V1+V2, T-wave positivity from V2,\nisoelectric in V5/V6, S-wave persistence until V6. Intraventricular\nconduction disorder. No extrasystoles. No pauses.\n\n**Holter monitor from 11/21/2021:** Normal heart rate spectrum, min 64\nbpm, median 81 bpm, max 102 bpm, no intolerable bradycardia or pauses,\nmonomorphic ventricular extrasystole in 0.5% of QRS complexes, no\ncouplets or salvos.\n\n**Echocardiography on 10/20/2021:** Poor ultrasound conditions, TI I+°,\ngood RV function, no LV cavity, aortic arch normal. No pulmonary\nembolism after catheterization.\n\n**Abdominal Ultrasound on 10/20/2021:** Borderline enlarged liver with\nextremely hypoechoic basic structure, wide hepatic veins extending into\nsecond-order branches, and a barely compressible wide inferior vena\ncava. The basic architecture is preserved, the ventral contour is\nsmooth, no nodularity. No suspicious focal lesions, no portal vein\nthrombosis, no ascites, no splenomegaly.\n\n[Measurement values as follows:]{.underline}\n\nATI damping coefficient (as always in congestion livers) very low,\nsometimes below 0.45 dB/cm/MHz, thus certainly no steatosis.\n\nElastography with good measurement quality (IQR=0.22) with 1.9 m/s or\n10.9 kPa with significantly elevated values (attributed to all\nconventional elastography, including Fibroscan, measurement error in\ncongestion livers).\n\nDispersion measurement (parametrized not for fibrosis, but for\nviscosity, here therefore the congestion component) in line with the\nimages at 18 (m/s)/kHz, significantly elevated, thus corroborating that\nthe elastography values are too high.\n\nIn the synopsis of the different parameterizations as well as the\noverall image, mild fibrosis at a low F2 level.\n\n[Other Status]{.underline}:\n\nNo enlargement of intra- and extrahepatic bile ducts. Normal-sized\ngallbladder with echo-free lumen and delicate wall. The pancreas is well\ndefined, with homogeneous parenchyma; no pancreatic duct dilation, no\nfocal lesions. The spleen is homogeneous and not enlarged. Both kidneys\nare orthotopic and normal in size. The parenchymal rim is not narrowed.\nThe non-bridging bile duct is closed, no evidence of stones. The\nmoderately filled bladder is unremarkable. No pathological findings in\nthe pelvis. No enlarged lymph nodes along the large vessels, no free\nfluid.\n\n[Result:]{.underline} Morphologically and parametrically (after\ndowngrading the significantly elevated elastography value due to\ncongestion), there is evidence of chronic congestive liver with mild\nfibrosis (low F2 level).\n\nOtherwise, an unremarkable abdominal overview.\n\n**Cardiac Angiography and Catheterization on 10/20/2021:**\n\n[X-ray data]{.underline}: 5.50 min / 298.00 cGy\\*cm²\n\n[Medication]{.underline}: 4 mg Acetaminophen (5 mg/5 mL, 5 mL/amp); 4000\nIU Heparin RATIO (25000 IU/5 ml, 5 mL/IJF); 156 mg Propofol 1% MCT (200\nmg/20 mL, 20 mL/amp); 5 mg/ml, 5 mL/vial)\n\n[Contrast agent:]{.underline} 105 ml Iomeron 350\n\n[Puncture site]{.underline}: Right femoral vein (Terumo Pediatric Sheath\n5F 7 cm).\n\nRight femoral artery (Terumo Pediatric Sheath 5F 7 cm).\n\n[Vital Parameters:]{.underline}\n\n- Height: 169.0 cm\n\n- Weight: 47.00 kg\n\n- Body surface area: 1.44 m²\n\n- \n\n[Catheter course]{.underline}**:** Puncture of the above-mentioned\nvessels under analgosedation and local anesthesia. Performance of\noximetry, pressure measurements, and angiographies. After completing the\nexamination, removal of the sheaths, Angioseal 6F AFC right, manual\ncompression until hemostasis, and application of a pressure bandage.\nTransfer of the patient in a cardiopulmonary stable condition to the\npost-interventional intensive care unit 24i for heparinization and\nmonitor monitoring.\n\n[Pressure values (mmHg):]{.underline}\n\n- VCI: 8 mmHg\n\n- VCS: 9 mmHg\n\n- RV: 103/0-8 syst/diast-edP mmHg\n\n- RPA: 8 syst/diast mmHg\n\n- LPA: 8 syst/diast mmHg\n\n- AoAsc 103/63 (82) syst/diast mmHg\n\n- AoDesc 103/61 (81) syst/diast mmHg\n\n- PCW left: 6 mmHg\n\n- PCW right: 6 mmHg\n\n[Summary]{.underline}**:** Uncomplicated arterial and venous puncture,\n5F right femoral arterial sheath, cannulation of VCI, VCS up to V.\nanonyma, LPA and RPA with 5F wedge and 5F pigtail catheters. Retrograde\naorta to atretic AoV and via Neo-AoV (PV) into RV. Low pressures, Fontan\n8 mmHg, TPG 2 mmHg with wedge 6 mmHg, max. RVedP 8 mmHg. No shunt\noximetrically, CI 2.7 l/min/m2. No gradient across Neo-AoV and arch.\nAngiographically no veno-venous collaterals, no MAPCA. Glenn wide, LPA\nand RPA stenosis-free, well-developed, rapid capillary phase and\npulmonary vein return to LA/RA. Fontan tunnel centrally constricted to\n12.5 mm, to VCI 18 mm. Satisfactory function of the hypertrophic right\nsystemic ventricle, mild TI. No Neo-AI, native AoV without flow, normal\ncoronary arteries, wide DKS, aortic arch without any stenosis.\n\n**Abdominal Ultrasound on 10/21/2022: **\n\n[Clinical Information, Question, Justification:]{.underline} Post-Fontan\nprocedure. Evaluation for chronic congestive liver.\n\n[Findings]{.underline}: Moderately enlarged liver with an extremely\nhypoechoic texture, which is typical for congestive livers. There are\ndilated liver veins extending into the second-order branches and a\nbarely compressible wide inferior vena cava. The basic architecture of\nthe liver is preserved, and the contour is smooth without nodularity. On\nthe high-frequency scan, there are subtle but significant periportal\ncuffing enhancements throughout the liver, consistent with mild\nfibrosis. No suspicious focal lesions, no portal vein thrombosis, no\nascites, and no splenomegaly are observed. Measurement values as\nfollows: ATI damping coefficient (as usual in congestive livers) is very\nlow, sometimes less than 0.45 dB/cm/MHz, indicating no steatosis. Shear\nwave elastography with good measurement quality (IQR=0.22) shows a\nvelocity of 1.9 m/s or 10.9 kPa, which are significantly higher values\n(attributable to measurement errors inherent in all conventional\nelastography techniques, including Fibroscan, in congestive livers).\nDispersion measurement (parameters not indicating fibrosis but\nviscosity, which in this case represents congestion) corresponds to the\nimages, with a significantly high 18 (m/s)/kHz, thus supporting that the\nshear wave elastography values are too high (and should be lower).\nOverall, a mild fibrosis at a low F2 level is evident based on the\nsynopsis of various parameterizations and the overall image impression.\n\n[Other findings:]{.underline} No dilation of intrahepatic and\nextrahepatic bile ducts. The gallbladder is of normal size with anechoic\nlumen and a delicate wall. The pancreas is well-defined with homogeneous\nparenchyma, no dilation of the pancreatic duct, and no focal lesions.\nThe spleen is homogeneous and not enlarged. Both kidneys are and of\nnormal size. The parenchymal rim is not narrowed. No evidence of stones\nin the renal collecting system. The moderately filled bladder is\nunremarkable. No pathological findings in the small pelvis. No enlarged\nlymph nodes along major vessels, and no free fluid. Conclusion:\nMorphologically and parametrically (after downgrading the significantly\nelevated elastography values due to congestion), the findings are\nconsistent with chronic congestive liver with mild fibrosis. Otherwise,\nthe abdominal overview is unremarkable.\n\n[Assessment]{.underline}: Very good findings after Norwood I-III, no\ncurrent need for intervention. In the long term, there may be an\nindication for BAP/stent expansion of the central conduit constriction.\nThe routine blood test for Fontan patients showed no abnormalities;\nvitamin D supplementation may be recommended in case of low levels. A\ncardiac MRI with flow measurement in the Fontan tunnel is initially\nrecommended, followed by a decision on intervention in that area.\n\nWe kindly remind you of the unchanged necessity of endocarditis\nprophylaxis in case of all bacteremias and dental restorations. An\nappropriate certificate is available for Emil, and the family is\nwell-informed about the indication and the existence of the certificate.\nA LIMAX examination can only be performed in an inpatient setting, which\nwas not possible during this stay due to organizational reasons. This\nshould be done in the next inpatient stay.\n\n**Summary**: We are discharging Emil in good general condition and slim\nbuild, with no signs of infection. Puncture site is unremarkable.\nCardiac status: Rhythmic heart action, no pathological heart sounds.\nPulse status is normal. Lungs: Clear. Abdomen: Soft.\n\nPulse oximetry oxygen saturation: 93%\n\nBlood pressure measurement (mmHg): 117/74\n\n**Current Recommendations:**\n\n- Cardiac MRI in follow-up, appointment will be communicated, possibly\n including LIMAX\n\n- Vitamin D supplementation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Captopril (Capoten) 2 mg 1-1-1\n Carvedilol (Coreg) 0.2 mg 1-0-1\n Aspirin 25 mg 1-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------ -------------- ---------------------\n Calcium 2.34 mEq/L 2.10-2.55 mEq/L\n Phosphate 1.20 mEq/L 0.84-1.45 mEq/L\n Osmolality 285 mosmo/Kg 280-300 mosmo/Kg\n Iron 20.0 µmol/L 4.8-24.7 µmol/L\n Transferrin Saturation 28.1% 16.0-45.0%\n Magnesium 0.77 mEq/L 0.62-0.91 mEq/L\n Creatinine (Jaffé) 0.85 mg/dL 0.70-1.20 mg/dL\n Urea 26 mg/dL 18-45 mg/dL\n Total Bilirubin 0.97 mg/dL \\<1.20 mg/dL\n Direct Bilirubin 0.33 mg/dL \\<0.30 mg/dL\n Immunoglobulin G 11.44 g/L 5.49-15.84 g/L\n Immunoglobulin A 1.95 g/L 0.61-3.48 g/L\n Immunoglobulin M 0.62 g/L 0.50-1.90 g/L\n Cystatin C 0.96 mg/L 0.50-1.00 mg/L\n Transferrin 2.87 g/L \\-\n Ferritin 54.5 µg/L 14.0-152.0 µg/L\n Total Cholesterol 110 mg/dL 82-192 mg/dL\n Triglycerides 64 mg/dL \\-\n Apolipoprotein A1 0.96 g/L 1.04-2.02 g/L\n GPT 36 U/L \\<41 U/L\n GOT 35 U/L \\<50 U/L\n Alkaline Phosphatase 135 U/L 55-149 U/L\n Pseudo-Cholinesterase 5.64 kU/L 5.32-12.92 kU/L\n GLDH 3.2 U/L \\<6.4 U/L\n Gamma-GT 92 U/L 8-61 U/L\n LDH 180 U/L 135-250 U/L\n Parathyroid Hormone 55.0 ng/L 15.0-65.0 ng/L\n 25-OH-Vitamin D3 10.9 nmol/L 50.0-150.0 nmol/L\n Free Thyroxine 17.90 ng/L 9.50-16.40 ng/L\n TSH 3.56 mU/L 0.50-4.30 mU/L\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting about the examination of our patient, Emil Nilsson,\nborn on 12/04/2004, who presented to our outpatient clinic on\n12/10/2021.\n\n**Diagnoses:**\n\n- Hypoplastic Left Heart Syndrome\n\n- Persistent foramen ovale\n\n- Persistent ductus arteriosus botalli (under Prostaglandin E1\n Infusion)\n\n- Dysplasia of the mitral valve\n\n- Damus-Kaye-Stansel Procedure and aortopulmonary anastomosis on the\n right (modified BT-Shunt)\n\n- Secondary thoracic closure\n\n- Tricuspid valve insufficiency\n\n- Mild aortic valve insufficiency\n\n- Status post Glenn procedure\n\n- Fontan conduit retrocardial narrowing, extended hepatic vein\n window/VCI\n\n- Chronic liver congestion with mild fibrosis (sonography)\n\n**Procedures**: Cardiac MRI.\n\n**Medical History:** We kindly assume that the detailed medical history\nis known to you and refer to previous medical reports from our clinic.\nThe current presentation is based on a referral from the outpatient\npediatric cardiologist for a Cardiac MRI. Emil reports feeling\nsubjectively well.\n\n**Physical Examination:** Emil is in good general condition and slim\nbuild, with no signs of infection.\n\n- Cardiac status: Rhythmic heart action, 2/6 systolic murmur.\n\n- Pulse status: Normal.\n\n- Lungs: Bilateral equal ventilation, vesicular breath sounds, no\n rales.\n\n- Abdomen: Soft, no hepatosplenomegaly. Unremarkable sternal scars. No\n signs of cardiopulmonary decompensation.\n\n- Current weight: 47 kg; current height: 169 cm.\n\n- Pulse oximetry oxygen saturation: 95%.\n\n- Blood pressure (mmHg): Right upper arm 132/94, left upper arm\n 121/98, right lower leg 158/94, left lower leg 156/94.\n\n**Cardiac MRI on 03/02/2022:**\n\n[Clinical Information, Question, Justification:]{.underline} Hypoplastic\nLeft Heart Syndrome, Fontan procedure, congestive liver, retrocardiac\nFontan tunnel narrowing, VCI dilation, Fontan tunnel flow pathology?\n\n[Technique]{.underline}: 1.5 Tesla MRI. Localization scan.\nTransverse/coronal T2 HASTE. Cine Fast Imaging with Steady-State\nPrecession functional assessment in short-axis view, two-chamber view,\nfour-chamber view, and three-chamber view. Flow quantifications of the\nright and left pulmonary arteries, main pulmonary artery, superior vena\ncava, and inferior vena cava using through-plane phase-contrast\ngradient-echo measurement. Contrast-enhanced MR angiography.\n\n[Findings]{.underline}: No prior images for comparison available.\nAnatomy: Hypoplastic left heart with DKS (Damus-Kaye-Stansel)\nanastomosis, dilated and hypertrophied right ventricle, broad ASD. No\nfocal wall thinning or outpouchings. No intracavitary thrombi detected.\nNo pericardial effusion. Descending aorta on the left side. Status post\ntotal cavopulmonary anastomosis with slight tapering between the LPA and\nthe anastomosis at 7 mm, LPA 11 mm, RPA 14 mm. No pleural effusions. No\nevidence of confluent pulmonary infiltrates in the imaged lung regions.\nCongestive liver. Cine MRI: The 3D volumetry shows a normal global RVEF\nin the setting of Fontan procedure. No regional wall motion\nabnormalities. Mild tricuspid valve prolapse with minor regurgitation\njet.\n\n**Volumetry: **\n\n[1) Left Ventricle:]{.underline}\n\n- Left Ventricle Absolute Normalized LV-EF: 29 %\n\n LV-EDV: 6 ml 4.2 mL/m²\n\n<!-- -->\n\n- LV-ESV: 4 ml 3 mL/m²\n\n- LV-SV: 2 ml 1 mL/m²\n\n- Cardiac Output: 0.1 L/min 0.1 L/min*m² *\n\n[2) Right Ventricle:]{.underline}\n\n- Right Ventricle maximum flow velocity: 109 cm/s\n\n- Antegrade volume 50 mL\n\n- Retrograde volume 2 mL\n\n- Regurgitation fraction 4 %\n\n[3) Right Pulmonary Artery: ]{.underline}\n\n- Right Pulmonary Artery maximum flow velocity: 27 cm/s\n\n<!-- -->\n\n- Antegrade volume: 14 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n- CAVE: Right upper pulmonary artery not captured\n\n[4) Left Pulmonary Artery:]{.underline}\n\n- Maximum flow velocity: 33 cm/s\n\n- Antegrade volume: 18 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[5) Inferior Vena Cava:]{.underline}\n\n- Maximum flow velocity: 38 cm/s\n\n- Antegrade volume: 30 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[6) Fontan Tunnel:]{.underline}\n\n- Maximum flow velocity: 53 cm/s\n\n- Antegrade volume 31: mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[7) Superior Vena Cava]{.underline}:\n\n- Maximum flow velocity: 23 cm/s\n\n- Antegrade volume: 16 mL\n\n- Retrograde volume: 0 mL\n\n- Regurgitation fraction: 0 %\n\n[Assessment:]{.underline} In the setting of status post Total\nCavopulmonary Anastomosis with DKS anastomosis for hypoplastic left\nheart, there is good right ventricular systolic function with only\nminimal ejection above the aortic valve.\n\nSlight tapering of the baffles up to 13 mm compared to VCI up to 21 mm\nwithout evidence of stenosis or major baffle leakage.\n\nMorphologically, slight tapering between the LPA and the anastomosis\nwith essentially balanced flow between the LPA and RPA.\n\nMild tricuspid valve prolapse with discrete insufficiency.\n\nHepatomegaly with signs of chronic congestion.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\n\nWe are writing to report on the outpatient treatment of Mrs. Laura\nMiller, born on 04/03/1967, on 05/22/2020.\n\n**Diagnosis**: Osteoporotic vertebral body sintering (lumbar vertebra 2\nand thoracic vertebra 8).\n\n**Medical History**: Mrs. Miller presents with pain in her back, legs\nradiating, after fall on the back 6 weeks ago. The complaints were\nprogressive with intermittent paresthesia in both legs.\n\n**Other Diagnoses** (not fully collectible):\n\n- Status post apoplexy\n\n**Current Medication (**not ascertainable):\n\n- Blood pressure medication\n\n- Osteoporosis medication\n\n- No anticoagulation.\n\n**Physical Examination: Lumbar spine:** Skin without pathological\nfindings. No redness, no evidence of infection.\n\nTapping pain over thoracic spine/lumbar spine, no compression pain, no\ntorsion pain, no pressure pain over spinous process.\n\nRadiation of pain into the right and left leg, paravertebral muscle\nhardness.\n\nNo paresthesias in the genital area, no breech anesthesia, no peripheral\nneurologic deficits, No bladder or rectal dysfunction.\n\nPeripheral Circulation/Motor function/Sensitivity intact.\n\nStrength grade on all sides: Hip Flex/Ex: 5/5, Knee Flex/Ex: 5/5,\n\nFoot extensor muscles of the lower leg/flexor muscles of the lower leg:\n3/5.\n\nBig toe extensor muscles of the lower leg/big toe flexor muscles of the\nlower leg: 2/5.\n\n**Thoracic Spine 2 levels from 05/22/2020, Lumbar spine in 2 planes from\n05/22/2020:**\n\nClinical indication: Status post fall\n\nQuestion: new fracture?\n\nPreliminary images: none comparable\n\n**Findings**\n\n1\\) [Thoracic Spine]{.underline}: Multiple thoracic vertebral bodies\nexhibit decreased height, most notably at the central region where a\nmeasurement of approximately 17 mm suggests significant height loss and\npotential acute fracture. Additionally, there are endplate impressions\nin individual vertebrae of the lower thoracic spine. Aortic sclerosis is\npresent, along with degenerative changes throughout the thoracic\nvertebrae. The osseous structure presents osteoporotic features. A\nsuspected hemangioma is identified in a vertebral body of the lower\nthoracic spine.\n\n2\\) [Lumbar Spine]{.underline}: In a presumed five-segment lumbar spine,\nthe L1 vertebra shows a subtle reduction in height with a questionable\nendplate impression. Osteoporotic features are evident in the bony\nstructure.\n\n**Assessment:** Multiple fractures are evident in both thoracic\nvertebrae and the first lumbar vertebra, some of which may be acute. MRI\nis recommended for further evaluation. Osseous structure displays\npronounced osteoporotic features.\n\nGrade III esophageal varices present without definitive high-risk\nstigmata. Varices also noted at the gastroesophageal junction,\nclassified as GOV 1 according to Sarin\\'s classification. Band ligation\nof the varices is not performed, as no unambiguous source of bleeding is\nidentifiable and a significant portion of the stomach remains outside\nthe field of view.\n\n**Recommendation**: Terlipressin, monitor surveillance, Erythromycin\n\n**Computed Tomography Thoracic spine from 05/22/2020:**\n\nFracture at the base plate of lumbar vertebra 2 with involvement of the\nposterior margin. Left lateral, no significant reduction in height of\nthe vertebral body. No tension of the spine.\n\nSuspicion of new small fracture also at the cover plate at thoracic\nvertebra 8.\n\nMultiple, older, osteoporotic compression fractures at the thoracic\nspine and\n\nupper lumbar spine.\n\n**Additional Finding:**\n\nLiver cirrhosis with multiple nodules, low ascites, and portal vein\ncongestion. Splenomegaly. If not already known, further workup of liver\nlesions is recommended. Hydrops of the gallbladder.\n\n**Current Recommendations**: There is a general indication for admission\nof the patient and further diagnostics before surgical treatment of the\nfractures. Mrs. Miller is generally opposed to surgical care. She was\nthoroughly informed about the risks (progression, cross-section, death).\n\nRe-presentation with current bone densitometry and update of\nosteoporosis medication, as well as current holospinal MRI. In the\nmeantime, analgesia as needed using Acetaminophen 500mg 1-1-1 under\ngastric protection.\n\n**Esophagogastroduodenoscopy from 05/22/2020:**\n\n[Esophagus]{.underline}: Unobstructed intubation of the esophageal\nopening was achieved under direct visualization. In the upper third of\nthe esophagus, multiple prominent varices protrude into the lumen,\nunaltered by air insufflation. In the middle third, there are areas with\nwhitish overlying material that do not resemble the typical white nipple\nsign. Despite meticulous inspection, no active bleeding sites were\nidentified. The Z-line reveals isolated minor erosions. Cardiac\nsphincter closure is complete.\n\n[Stomach]{.underline}: Full distension of the gastric lumen was\naccomplished with air insufflation. The major curvature of the stomach\ncontained food mixed with hematin. The mucosal surface was similarly\ncoated with hematin, but no active bleeding was discernible in the\nvisualized areas. Peristaltic movement was widespread. Upon\nretroflexion, pronounced varices were noted near the cardiac region on\nthe lesser curvature. The pylorus was unremarkable and easily\ntraversable.\n\n[Duodenum]{.underline}: Adequate distension of the duodenal bulb was\nachieved, providing a clear view up to the descending part of the\nduodenum. Overall, the mucosa appeared normal with minor remnants of\nhematin, and no source of bleeding was identified.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about Mrs. Laura Miller, born on 04/03/1967, who was in\nour inpatient treatment from 05/27/2020 to 06/22/2020.\n\n**Diagnoses**: Initial diagnosis of hepatocellular carcinoma.\n\n- MRI liver: disseminated HCC foci in all segments, the largest foci\n is localized in segments 5 / 7 / 8\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: sophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: Residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Physical Examination:** Patient in mildly reduced general and normal\nnutritional status (BMI 20.3).\n\n- Lungs: Vesicular breath sound, no pathological secondary sounds.\n SpO2 96%.\n\n- Heart: Pure, rhythmic. Systolic with maximum at Erb\\'s point and\n continuation into the carotids. HR: 87/min. BP: 124/54mmHg\n\n- Abdomen: Lively bowel sounds, no tenderness, no guarding, no\n resistance, no peritonism. Soft abdomen. Liver not enlarged,\n palpable. Renal bed not palpable.\n\n- Extremities: Edema of the lower extremities on both sides, foot\n pulses bilaterally well palpable.\n\n- Spine: No tap pain.\n\n- Orienting neurological examination: Right leg weakness, known\n paresis of the extensor muscles of the lower leg/flexor muscles of\n the lower leg.\n\n**Therapy and Progression:** Mrs. Miller was taken over for suspected\nupper GI bleeding. Initially, the patient had presented with increasing\nback pain since approximately 6 weeks at status post fall in the Park\nClinic on 04/26/2020. The patient was known there for her stroke in\n2016. On the day of admission to the Park Clinic, normochromic\nnormocytic anemia (Hemoglobin 3 g/dL) was noticed, which is why the\ntransfer to our clinic was made.\n\nOn inpatient admission, the patient presented in slightly reduced\ngeneral condition. She reported having black stools once. In addition,\nMs. Miller had coffee ground-like emesis once. Dyspnea, angina pectoris\ncomplaints, and B symptoms were denied. There were no problems with\nmicturition. Recently, there were no abnormalities in bowel movements.\nSo far, no colonoscopy has been performed. There were no known\nintestinal diseases in the family.\n\n[Noxae]{.underline}: Ex-nicotine use (since 1996, previously cumulative\nca. 3 PY), occasional alcohol consumption (probably abstinent for about\n5 years).\n\nLaboratory results showed that the patient had elevated infectious\nparameters. The\n\nurinalysis was unremarkable. X-ray chest showed no clear picture of\npneumonia. In a first emergency esophagogastroduodenoscopy on\n05/28/2020, esophageal varices °III were found without clear signs of\nrisk. Furthermore, varices in the area of the cardia (GOV 1 after Sarin)\nwere seen. When the source of bleeding was inconclusive, it was referred\nto a banding initially waived. In a renewed esophagogastroduodenoscopy\nin the morning of 05/30/2020, 2 ampoules of Histoacryl were applied to\nthe cardia varices. In addition, the picture of an incipient\nportal-hypertensive gastropathy. Antibiotic intravenous therapy with\nceftriaxone was initiated. At 06/13/2020, a\nre-esophagogastroduodenoscopy took place, during which a renewed twofold\nbanding of the esophageal varices was performed with injection of 0.5 ml\nHistoacryl. Abdominal ultrasound showed a picture of liver cirrhosis\nwith splenomegaly and perihepatic ascites. In addition, the liver showed\nmultiple echo-poor nodes in the right lobe and a suspicious\n2.4x3.6x4.4cm echo-poor area with a halo in SII. This was followed by an\nMRI of the liver, in which the HCC in segment II was confirmed by\nimaging.\n\nMultiple additional arterial hypervascularized areas/round foci in all\nliver lobes without definite washout. There is no evidence of suspicious\nnodular changes on CT chest/abdomen/pelvis. At an in-house liver\nconference, systemic therapy (Lenvatinib or Sorafenib in Child B7) was\nrecommended.\n\nDue to the back pain, a holospinal MRI was performed, which showed a\nsubacute cover plate compression fracture in the thoracic vertebra 8 as\nwell as multiple older compression fractures of the thoracic spine and\nupper lumbar spine. The colleagues of neurosurgery were consulted, who\ngave the indication for surgery. On 06/14/2020, the planned surgery with\nkyphoplasty thoracic vertebra 8 under C-arm fluoroscopy could be\nperformed without complications. Postoperatively, the patient remained\ncirculatory stable.\n\nDue to auscultatory suspicion of aortic valve stenosis, further\nclarification was performed by cardiac echography, showing no\nhigher-grade valvular vitiation.\n\nWe are transferring Mrs. Miller in improved general condition to the\nSenior Citizens\\' Residence Seaview. If you have any questions, please\ndo not hesitate to contact us.\n\n**Addition:**\n\n**Ultrasound of the upper abdomen on 05/27/2020:**\n\nLimited assessable due to meteorism.\n\n**Liver**: Liver dimensions are within normal limits, measuring 15.9 cm\nin the craniocaudal axis. Echotexture demonstrates inhomogeneous\ngranularity. There is hepatic margin convexity and nodular surface\nappearance. Rarification of hepatic veins. Segment III reveals two\nhypoechoic lesions measuring 3 cm and 1 cm in diameter. Portal vein\ndemonstrates orthograde flow with a maximum velocity of 17 cm/s.\n\n**Gallbladder:** Gallbladder is partially contracted; its wall appears\nunremarkable without sonographic evidence of cholecystitis. No\ntenderness elicited upon sonographic examination.\n\n**Biliary Tract**: Intrahepatic bile ducts are patent. Common hepatic\nduct measures 6 mm in diameter. Common bile duct appears transiently\ndilated up to 9 mm and is otherwise unremarkable as far as can be\nvisualized prepapillary.\n\n**Pancreas**: Limited visualization of the pancreas; however, the\nvisible parenchyma appears homogeneously echoic.\n\n**Spleen**: Spleen is enlarged, measuring 13 x 4 cm, with homogeneous\nparenchyma.\n\n**Kidneys**: Kidneys are morphologically unremarkable, without evidence\nof pelvicalyceal system dilation.\n\n**Abdominal Vessels**: Aorta is partially visualized and appears within\nnormal calibers.\n\nIntestinal/Peritoneal Cavity: No evidence of free intraperitoneal fluid.\n\nUrinary Bladder/Genitalia: Urinary bladder is adequately distended,\nappearing unremarkable upon limited assessment. Uterus is not\nvisualized.\n\n**Virology from 05/28/2020:**\n\n- SARS CoV-2 PCR PCR negative Geq/ml\n\n- Findings: No detection of SARS-CoV-2 by PCR in the submitted\n material.\n\n**Chest X-ray a.p. from 05/28/2020:**\n\nLimited assessability in supine position, malrotation. The diaphragmatic\ncrests are smooth. The marginal sinuses are free of effusions and\ncalluses. Heart and mediastinum lie cryptically. The aorta is sclerosed.\nCranialization of the vessels as well as slightly elevated vascular\nmarkings in the supine position, especially in the right upper field.\nDystelectasis on the right. Sharply defined vertical shadowing in the\nleft upper field. The upper mediastinum is narrow, the trachea is in the\nmidline and is not constricted. Degenerative changes in the cervical\nspine. Overlying foreign material.\n\n**Assessment**: Sharply defined vertical shadowing in the left upper\nfield. Dystelectasis on the right side. Conventional radiographic\nexamination No evidence of a mass. No effusion.\n\n**Esophagogastroduodenoscopy of 05/28/2020:**\n\n**Esophagus**: Successful intubation of the esophageal orifice under\ndirect visualization. Multiple intraluminal protrusions noted in the\nupper third of the esophagus. Non-collapsible variceal strands observed\nupon air insufflation, beginning from the middle third. Whitish\nproliferations seen at multiple sites, not consistent with typical white\nnipple signs. No evidence of active bleeding on close inspection. Z-line\nobserved with isolated minor erosions. Cardiac sphincter fully\ncompetent.\n\n**Stomach**: Gastric lumen fully distended under air insufflation.\nCorpus predominantly contains hematin-laden food remnants. Mucosal\nsurface also stained with hematin but without visible active bleeding.\nPeristalsis noted throughout. Distinct coronary vasculature observed on\nthe lesser curvature. Pylorus unremarkable, offering no resistance to\npassage.\n\n**Duodenum**: Bulbus duodeni well-formed. Pars descendens duodeni\nvisualized clearly. Overall mucosa appears unremarkable, with scattered\nhematin remnants observed without an identifiable bleeding source.\n\n**Assessment**: Esophageal varices graded as °III, with no definitive\nhigh-risk stigmata. Varices also noted in the cardia, classified as GOV\n1 according to Sarin\\'s classification. Ligation of varices was not\nperformed due to the absence of an identifiable bleeding source and\nincomplete visualization of the gastric lumen.\n\n**Ultrasound of the abdomen on 05/29/2020:**\n\n**Quality of Exam**: Limited due to patient non-cooperation and\nmeteorism.\n\n**Liver**: Liver size is paradoxically reported both as normal at 15.9\ncm and enlarged at 18.7 cm. Margins are rounded. Echotexture is markedly\ninhomogeneous with nodular surface. Multiple hypoechoic nodules are\npresent in the right lobe, along with a suspicious hypoechoic area\nmeasuring 2.4 x 3.6 x 4.4 cm with peripheral halo in segment II. Hepatic\nveins are rarified. Portal vein shows orthograde flow with a vmax of 28\ncm/s.\n\n**Gallbladder**: Morphologically unremarkable with no wall thickening.\nCholelithiasis noted with concretions measuring at least 2 to 1.6 cm.\n\n**Biliary Tract:** Intrahepatic bile ducts are not dilated; Common\nhepatic duct measures up to 8.5 mm and common bile duct measures 6.6 mm\nin diameter.\n\n**Pancreas**: Partially visualized; adequacy of assessment is\ncompromised.\n\n**Spleen**: Enlarged with homogeneous internal echotexture.\n\n**Kidneys**: Morphologically unremarkable; no evidence of\nhydronephrosis.\n\n**Abdominal Vessels:** Aorta is not dilated.\n\n**Gastrointestinal**: Perihepatic ascites noted. Both small and large\nintestines appear unremarkable upon limited assessment.\n\n**Urinary Bladder/Genitalia:** Bladder is moderately filled and\nunremarkable in shape and size.\n\n**Assessment**: Limited study due to patient non-cooperation and\nmeteorism. Findings are suggestive of liver cirrhosis and grade I\nascites. Additional findings include suspected hepatic space-occupying\nlesions, splenomegaly, and cholelithiasis. Mild dilation of DHC and DC\nobserved without signs of intrahepatic cholestasis.\n\n**Virology from 06/01/2020:**\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HAV IgG 0.73 negative\n Anti HAV IgM \\<0.1 negative\n\n**Interpretation:** Serologically no evidence of fresh or expired\ninfection with\n\nHepatitis A virus, no immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n HBs antigen 0.21 negative\n Anti HBs \\<0.1 negative\n Anti HBc 0.1 negative\n\n**Interpretation:** Serologically no evidence of acute, chronic or\nexpired Hepatitis B virus infection. No immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HCV 0.06 negative\n\n**Interpretation:** Serologically no evidence of hepatitis C virus\ninfection. At possible fresh infection resubmission in 2-4 weeks and HCV\nPCR recommended.\n\n**MRI total spine plain from 06/04/2020:**\n\n**Technique**: T2 Dixon Sagittal and T2 Axial MRI Sequences. Coverage\nextends from the craniocervical junction to the sacrum.\n\n**Findings:**\n\n**General Spine:** Full extent from craniocervical junction to sacrum\nvisualized. Conus medullaris appropriately located at T12-L1 level.\nMyelon demonstrates uniform width and homogeneous signal. Evaluation of\nthoracolumbar transition and lumbar spine is compromised by artifact\nsuperimposition from ascites.\n\n**Cervical Spine:** Irregular alignment of the posterior vertebral body\nmargins noted, with evidence of disc protrusions and ligamentum flavum\nhypertrophy. Focal T2 hyperintensity observed at C5 level. No evidence\nof prevertebral soft tissue proliferation.\n\n**Thoracic Spine**: Maintained alignment of the posterior vertebral body\nmargins. Multiple anterior endplate compression fractures noted at T5,\nT8, T9, T11, T12 levels. Focal T2 hyperintensity near the anterior\nendplate of T8 involving the posterior margin, indicative of a\nnon-displaced fracture without spinal canal compromise. Hypertrophic\nfacet joint arthrosis at T10-T11 levels resulting in relative spinal\nnarrowing. Bilateral pleural effusions noted, more pronounced on the\nright, with a maximum width of approximately 2 cm. No evidence of\nsignificant neuroforaminal stenosis.\n\n**Lumbar Spine:** Maintained alignment of posterior vertebral body\nmargins. Known anterior endplate compression fractures at L1 and\nbaseplate compression fracture at L2. No evidence of pathological T2\nedema within the vertebral bodies, although assessment is limited due to\nsuperimposed artifacts from ascites. Spinal canal dimensions appear\nadequate throughout. Moderate fatty degeneration of sacral bone noted.\n\n**Assessment**: Evaluation limited due to ascites-related artifacts.\nSubacute anterior endplate compression fracture at T8, along with\nseveral other likely older compression fractures in the thoracic and\nupper lumbar spine. Bilateral pleural effusions observed. Multiple\nneuroforaminal narrowings as detailed above.\n\n**MR Liver plain + contast agent from 06/06/2020**\n\n**Findings:**\n\n1) [Lesion 1]{.underline}\n\n- Size of the lesion 41 mm\n\n- Segment 2\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: yes\n\n- Pseudocapsule: yes\n\n- Behavior delayed leaching: yes\n\n- pseudocapsule macrovascular invasion: no\n\n2) [Lesion 2]{.underline}\n\n- Size of the lesion 104 mm\n\n- Segment 5 / 7 / 8\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: no\n\n- Pseudocapsule: no\n\n- Behavior delayed washing out: no\n\n- Pseudocapsule: no\n\n- Macrovascular invasion: yes\n\n**Comments:**\n\n- MRI with Gadovist intravenous.\n\n- Multiple other satellite foci in all liver segments.\n\n- Signs of liver cirrhosis with nodular liver parenchyma and\n hypertrophy of the left lobe.\n\n- Cholecystolithiasis and gallbladder hydrops. No cholestasis.\n\n- Varices of the esophagus and fundus. Splenomegaly. Ascites. Pleural\n effusions on both sides.\n\n- Lymph node (approximately 8 mm) between the small curvature of the\n Stomach and S1 of the liver.\n\n- Axial hernia.\n\n**Assessment:** Milan fulfilled**.** Dissiminated HCC foci in all\nsegments, the largest foci being in segments 5 / 7 / 8 localized. Portal\nhypertension with bypass circulation and splenomegaly. Ascites and\npleural effusions.\n\n**Microbiology from 06/09/2020:**\n\n[Material]{.underline}: Ascites in blood culture bottles\n\n[Microscopic]{.underline}: No cells, no germs\n\n- Anaerobic culture negative after 48 hours\n\n- So far, no growth in the anaerobic cultures. The cultures are\n incubated for a total of 5 days. In case of growth of anaerobes we\n will send you a follow-up report.\n\n- No growth after 48 hours\n\n**Esophagogastroduodenoscopy of 06/11/2020:**\n\n**Esophagus**: In the distal esophagus, multiple band-like ulcerations\nas well as residual varices with risk signs that may not completely pass\nair insufflation. Z-line without erosions.\n\n**Stomach**: Mosaic-like occupancy of the gastric mucosa. With inversion\nthe\n\nknown small-curved lateral cardiavarii, which is hard on palpation with\nclosed forceps after histoacryl injection. Directly next to it, another\ncardiavarice can now be seen, which has not yet been injected with\nhistoacryl and is soft on palpation.\n\n**Duodenum**: Endoscopic therapy: Injection of 0.5 mL Histoacryl (+0.5\nmL Lipoidol) in the new cardiavarice. Application of 3 rubber band\nligatures to the residual varices in the esophagus.\n\n**Assessment:** Residual varices in the esophagus, application of 3\nrubber band ligations; portal hypertensive gastropathy\n\n**Spine-whole: 2 planes from 06/13/2020**\n\nThe perpendicular of C7 protrudes about 15 mm laterally to the left of\nsacral vertebra 1 in the anterior-posterior image and about 9.3 cm in\nfront of sacral vertebra 1 in the lateral ray path. Slight left convex\nscoliosis thoracolumbally with thoracic counter-swing (Cobb angle \\< 10°\nin each case). The lungs are unremarkable as far as technically\nassessable.\n\n**Assessment**: decompensated positive sagittal spinal imbalance. There\nis no relevant lateral trunk overhang.\n\n**Critical Findings Report:**\n\nA conspicuous single cell population of cells with partial signet ring\ncell character is detected in the smears. A cell block is prepared from\nthe remaining liquid material for further typing of these cells. A\nfollow-up report will follow.\n\n**Thoracic spine in 2 planes from 06/15/2020:**\n\n**Findings**: Thoracic vertebra 8: Post-kyphoplasty status with notable\nimprovement in vertebral height, now measuring 21 mm compared to a\npreoperative height of 13 mm. Mild straightening of the vertebral column\nobserved at this level.\n\nThoracic vertebra 9: Known older anterior endplate collapse.\n\nThoracolumbar spine: Multisegmental height reduction in vertebral bodies\nconsistent with osteoporotic changes. No signs of contrast\nextravasation.\n\nAdditional Finding: Pre-existing calcified structure projecting onto the\nleft upper abdomen; likely unrelated to current surgical site.\n\n**Assessment**: Unremarkable postoperative imaging following kyphoplasty\nof T8. No evidence of postoperative sintering or newly identifiable\nfractures. Overall, the surgical intervention appears successful in\nincreasing vertebral height and stabilizing the fracture site.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 06/18/2020:**\n\n**Technique**: Multislice spiral CT of the chest, abdomen, and pelvis\nwas performed post-bolus intravenous injection of 120 ml of Imeron 400.\nImaging conducted in arterial, portal venous, and venous phases. Oral\ncontrast agent administered with Micropaque 1:7 in water and Gastrolux\n1:33 in water. Thin-slice reconstructions and secondary coronal and\nsagittal reformats were performed.\n\n**Chest**: Presence of struma nodosa. Bilateral minor pleural effusions\nwith adjacent atelectasis, more pronounced on the right and extending\ninto the interlobar region. No signs of infiltrative changes. Isolated\nsmall nodular opacities in the right lung. Few small bullae noted.\nMediastinal lymph nodes mildly enlarged up to 0.5 cm; axillary and hilar\nnodes are not enlarged. No pericardial effusion observed.\n\n**Abdomen/Pelvis**: Known esophageal and fundal varices present. Liver\ndemonstrates nodular changes in the context of known Child-Pugh B stage\ncirrhosis. A solid hepatic cellular carcinoma lesion in segment II and\ndiffuse HCC nodules in segments V/VII/VIII visualized, corroborating\nprior MRI findings. They show pronounced arterial enhancement and\ncentral washout. Splenomegaly noted. Adrenal glands unremarkable. Renal\nand urinary systems are inconspicuous. No intestinal motility\nabnormalities detected. Marked ascites present; no pathologically\nenlarged abdominal lymph nodes noted upon limited assessment.\n\n**Skeletal**: Moderate coxarthrosis bilaterally. An old, minimally\ndisplaced fracture of the right 7th rib noted. Advanced degenerative\nchanges in thoracic vertebrae 10, 12, and lumbar spine.\nPost-vertebroplasty status at thoracic vertebra 9. Hemangioma at\nthoracic vertebra 11.\n\n**Assessment**:\n\n- Marked ascites in the setting of liver cirrhosis with multifocal HCC\n lesions, as corroborated by prior MRI. No evidence of extrahepatic\n or lymphatic spread.\n\n- Bilateral minor pleural effusions with associated atelectasis.\n\n- Skeletal findings include moderate coxarthrosis and degenerative\n changes in the spine.\n\nOverall, the scan provides vital information that aligns with and\nelaborates upon existing clinical and imaging data.\n\n**Histology**:\n\n**Pathology from 06/19/2020:**\n\n[Clinical Data:]{.underline} Hepatocellular carcinoma, hydropic\ndecompensated liver cirrhosis Child B,\n\n[Extraction date:]{.underline} 06/13/2020\n\n[Material:]{.underline} 1 Liquid material 7 ml light yellow\n\n[Editing]{.underline}: Papanicolaou and MGG staining\n\n\\+ Protein precipitation\n\n\\+ Erythrocytes\n\n\\+ Lymphocytes\n\n(+) Granulocytes Eosinophils\n\n\\+ Histiocytic cell forms\n\n\\+ Mesothelium\n\n\\+ Active mesothelium\n\n**Other**: Single mononuclear cells with large, eccentric nuclei with\nnucleoli and a narrow cytoplasmic space, partly with signet ring cells.\n\n**Supplementary findings from 06/19/2020**\n\n[Processing]{.underline}: Cell block, HE\n\n**Microscopic:**\n\nAs announced, from the remaining liquid material a cell block was\nprepared. In the HE stain only isolated evidence of mononuclear Cells\nand some blood. No cell atypia.\n\n**Critical Findings Report:** After examination of the remaining liquid\nmaterial in the cell block no Extension of the initial findings in the\nabsence of further diagnostic cell material. The finding is thus based\nexclusively on the Smear material:\n\n- Detection of a single-cell population consisting of cells with\n partial signet ring cell character. Differentially it could be The\n mesothelium may be a reactive change of the approaching mesothelium.\n Cells of an epithelial neoplasia are not visible on the present\n material. to be ruled out with certainty.\n\n**Diagnostic classification:** Suspicious\n\n**Current Recommendations:**\n\n- An appointment at our outpatient clinic to start therapy was\n organized for 06/26/2020.\n\n- An appointment for a health department check-up with varicose vein\n status survey and, if necessary, repeat rubber band ligation has\n been scheduled for 07/22/2020. Please come to the endoscopy on this\n day at 08:30 am fasting with current lab results. incl. coagulation,\n signed consent form as well as SARS-CoV-2 PCR not older than 48h.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report to you on Mrs. Laura Miller, born 04/03/1967, whom we examined\non 06/08/2020 in the course of a consultation.\n\n**Consilar Request:**\n\n- Liver cirrhosis, Child-Pugh B, ethyltoxic genesis\n\n- HCC\n\n- Laboratory albumin: 2.6\n\n- Nutritional advice requested\n\n**Nutritional counseling in cirrhosis of the liver:**\n\n- Albumin at 2.6\n\n- 70kg at admission (stable weight in recent years).\n\n- Height: 1.72m\n\n- BMI falsified by ascites\n\n- Patient reports that she always a \\\"bad eater\\\"\n\n- She reports to eat less due to numerous medication intake\n\n- Patient is noticeably overwhelmed and seems very burdened by\n diagnosis\n\n**Assessment:**\n\n- Protein malnutrition with inadequate oral nutrition\n\n- Patient appears desperate and overwhelmed, questionable compliance\n\n**Recommendations: **\n\n- High-calorie food for more choices (already ordered)\n\n- High-calorie drinks (contains more protein)\n\n- Incorporate protein-rich snacks such as yogurt, sippy cups,\n crispbread\n\n- with cheese.\n\n- A high-energy, high-protein food choice was made with the patient\\'s\n discussed in detail\n\n- Contact details were handed out\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 08/21/2020 to\n08/23/2020.\n\n**Diagnoses**:\n\n- MRI of the liver: disseminated HCC foci in all segments, the largest\n foci is localized in segments 5 / 7 / 8\n\n<!-- -->\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: esophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Current Presentation:** Mrs. Miller presented electively for\ngastroscopy for variceal screening with continuation of banding therapy\ndue to esophageal variceal bleeding.\n\n**Medical History**: For a detailed medical history, we refer to\nprevious reports from our department. In summary, we present a liver\ncirrhosis due to ethyl toxicity leading to the development of multifocal\nHCC. Similar to the liver board decision of 06/13/20, a recommendation\nfor systemic therapy with Lenvatinib or Sorafenib was made in the\nsetting of partially compensated Child B7 cirrhosis with multifocal HCC\nin both lobes of the liver.\n\n**Therapy and Course:** Upon admission, the patient was in\nage-appropriate general condition and largely symptom-free. There were\nno signs of acute infection, jaundice, encephalopathic symptoms, or GI\nbleeding. No irregularities in bowel movements or urination were\nreported. The patient denied abdominal pain and dyspnea. There were no\nknown allergies.\n\nOn the day of admission, an uncomplicated gastroscopy was performed,\nincluding the application of 4 rubber band ligations for residual\nesophageal varices. Post-interventional pain was adequately controlled\nwith double-standard doses of Pantoprazole and intravenous analgesic\ntherapy. The further inpatient course was uneventful, and the patient\ntolerated the post-interventional diet without signs of GI bleeding.\n\nBased on laboratory findings and clinical evaluation, particularly with\nregressed ascites, a compensated Child A6 cirrhosis was confirmed.\nTherefore, a re-presentation at our interdisciplinary liver board was\ninitiated for discussion of potential treatment options in the context\nof compensated liver function.\n\nAs per the consensus recommendation from the liver board, a follow-up\ngastroscopy is scheduled within the next two weeks. Depending on the\nvariceal status, systemic therapy with Atezolizumab/Bevacizumab or\nLenvatinib will follow.\n\nThroughout the monitoring period, the patient remained stable in terms\nof circulation and hemoglobin levels. Therefore, on 08/23/20, we\ndischarged Mrs. Miller for outpatient follow-up care. The patient was\nthoroughly informed about reasons that necessitate immediate\nre-presentation. Please note the listed procedural appointments.\n\n**Physical Examination:** Awake, alert, oriented\n\n- Heart: Regular heart tones, no murmurs\n\n- Lungs: Clear vesicular breath sounds, no crackles or wheezes\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, palpable firm liver edge under the rib cage, no palpable\n spleen enlargement, non-painful renal angle\n\n- Extremities: Good peripheral pulses, no edema\n\n- Neurology: No focal neurological deficits.\n\n**EGD on 08/21/2020:**\n\n**Findings:**\n\n**Esophagus**: Unobstructed intubation of the esophagus under direct\nvision. Multiple variceal cords and scarring changes due to banding were\nobserved in the lower half of the esophagus. Z-line at 35 cm\ndiaphragmatic passage at 39 cm. Two variceal cords extend along the\nsmall curve into the stomach, two of the varices show alarm signs (red\nspots). 4 rubber band ligations were performed.\n\n**Stomach**: In the proximal corpus a picture of portal hypertensive\ngastropathy, otherwise unremarkable. No fundus varices.\n\n**Duodenum**: Good unfolding of the duodenal bulb, contact-sensitive\nmucosa. Good insight into the descending part of the duodenum. Overall,\nunremarkable mucosa.\n\n**Assessment:** Esophageal varices, Gastroesophageal varices Type I.\nBanding therapy.\n\n**Current Recommendations:**\n\n- Regular clinical and laboratory checks by the primary care\n physician.\n\n- In case of fever, acute deterioration of the general condition, or\n clinical signs of bleeding such as melena or hematemesis, we request\n immediate re-presentation, even at night and on weekends, through\n our interdisciplinary emergency department.\n\n- Decision of the liver board: Improvement of liver function with\n alcohol abstinence, but also progression of multifocal HCC over 2\n months without tumor-specific therapy. Consensus: Repeat EGD in 7-14\n days, depending on variceal status, Atezolizumab/Bevacizumab, or\n Lenvatinib.\n\n- Follow-up appointment on 09/11/20 in our HCC outpatient clinic for\n clinical control and explanation of the EGD.\n\n- Follow-up in our endoscopy for EGD to determine variceal status and\n possible banding -\\> Please bring a COVID PCR test (maximum 48 hours\n old) for inpatient admission.\n\nIf complaints persist or worsen, we recommend immediate re-presentation.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 09/18/2020 to\n09/20/2020.\n\n**Diagnoses:**\n\n- 4-time banding therapy with 4 rubber band ligations for residual\n esophageal varices without alarm signs\n\n- Hepatocellular Carcinoma (HCC)\n\n- MR Liver: Disseminated HCC lesions in all segments, with the largest\n lesion located in segments 5/7/8\n\n- Decompensated cirrhosis of the liver (Child B) since 05/20 due to\n ethyltoxic origin.\n\n- Transfusion-dependent anemia due to a history of variceal bleeding.\n\n- Osteoporotic thoracic vertebral fracture of vertebra BWK8 (OF3) with\n kyphoplasty.\n\n- Portal hypertension with portosystemic collaterals\n\n- Splenomegaly\n\n- Cholelithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- History of stroke (2016)\n\n- Allergies: Amalgam\n\n**Presentation:** Mrs. Miller\\'s elective presentation was for a\nfollow-up examination for known esophageal varices.\n\n**Medical History:** For a detailed medical history, please refer to\nprevious reports from our department. In summary, in June 2020, the\npatient was diagnosed with decompensated liver cirrhosis attributed to\nethyltoxicity. MR imaging showed multifocal HCC. According to the liver\nboard decision on 06/15/20, initial therapy was recommended with\nLenvatinib or Sorafenib for partially compensated Child B7 cirrhosis\nwith multifocal HCC in both liver lobes. Despite improvement in liver\nfunction with alcohol cessation, there was a short-term progression of\nmultifocal HCC without tumor-specific therapy, leading to a\nrecommendation for a repeat variceal screening on 08/28/20. Depending on\nthe findings, therapy with Atezolizumab/Bevacizumab or Lenvatinib was\nadvised. The last EGD was performed on 08/21/20, revealing esophageal\nvarices with alarm signs, and a 4-time banding was performed.\n\n**Physical Examination upon Admission:** Blood pressure: 80/150 mmHg,\nheart rate 88/min, temperature 36.4°C, SpO2 97% in room air.\n\nPatient in good general condition and normal mental status. Mrs. Miller\nis fully oriented. Pupils are equal and reactive.\n\n- Cardiovascular: Clear heart sounds, no murmurs.\n\n- Lungs: Equal breath sounds bilaterally, no crackles, resonant\n percussion.\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, liver and spleen not palpable.\n\n- Extremities: No edema, good peripheral pulses. No focal neurological\n deficits.\n\n**Course and Therapy:** On the day of admission, the EGD was performed\nwithout complications. Residual varices without warning signs were\nobserved, and a 4-time rubber band ligation was performed. Portal\nhypertensive gastropathy was also diagnosed. After the procedure, the\npatient was transferred to our gastroenterological normal ward.\n\nThe post-interventional course was uneventful. There were no clinical or\nlaboratory signs of post-interventional bleeding. The diet was\nreintroduced without any issues. Therefore, on 09/20/2020, we discharged\nMrs. Miller for outpatient care. We request a follow-up appointment at\nour in-house HCC outpatient clinic. Additionally, we request a follow-up\nEGD with variceal control.\n\n\n\n\nHere is the query:\nWhen was Laura Miller's last inpatient treatment as per the report?\n\nChoose the correct answer from the following options:\nA. 06/08/2020\nB. 06/18/2020\nC. 08/21/2020\nD. 09/18/2020\nE. 09/20/2020\n\n\nYour response:\n", "role": "user" }, { "content": "09/18/2020", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\n\nWe are writing to report on the outpatient treatment of Mrs. Laura\nMiller, born on 04/03/1967, on 05/22/2020.\n\n**Diagnosis**: Osteoporotic vertebral body sintering (lumbar vertebra 2\nand thoracic vertebra 8).\n\n**Medical History**: Mrs. Miller presents with pain in her back, legs\nradiating, after fall on the back 6 weeks ago. The complaints were\nprogressive with intermittent paresthesia in both legs.\n\n**Other Diagnoses** (not fully collectible):\n\n- Status post apoplexy\n\n**Current Medication (**not ascertainable):\n\n- Blood pressure medication\n\n- Osteoporosis medication\n\n- No anticoagulation.\n\n**Physical Examination: Lumbar spine:** Skin without pathological\nfindings. No redness, no evidence of infection.\n\nTapping pain over thoracic spine/lumbar spine, no compression pain, no\ntorsion pain, no pressure pain over spinous process.\n\nRadiation of pain into the right and left leg, paravertebral muscle\nhardness.\n\nNo paresthesias in the genital area, no breech anesthesia, no peripheral\nneurologic deficits, No bladder or rectal dysfunction.\n\nPeripheral Circulation/Motor function/Sensitivity intact.\n\nStrength grade on all sides: Hip Flex/Ex: 5/5, Knee Flex/Ex: 5/5,\n\nFoot extensor muscles of the lower leg/flexor muscles of the lower leg:\n3/5.\n\nBig toe extensor muscles of the lower leg/big toe flexor muscles of the\nlower leg: 2/5.\n\n**Thoracic Spine 2 levels from 05/22/2020, Lumbar spine in 2 planes from\n05/22/2020:**\n\nClinical indication: Status post fall\n\nQuestion: new fracture?\n\nPreliminary images: none comparable\n\n**Findings**\n\n1\\) [Thoracic Spine]{.underline}: Multiple thoracic vertebral bodies\nexhibit decreased height, most notably at the central region where a\nmeasurement of approximately 17 mm suggests significant height loss and\npotential acute fracture. Additionally, there are endplate impressions\nin individual vertebrae of the lower thoracic spine. Aortic sclerosis is\npresent, along with degenerative changes throughout the thoracic\nvertebrae. The osseous structure presents osteoporotic features. A\nsuspected hemangioma is identified in a vertebral body of the lower\nthoracic spine.\n\n2\\) [Lumbar Spine]{.underline}: In a presumed five-segment lumbar spine,\nthe L1 vertebra shows a subtle reduction in height with a questionable\nendplate impression. Osteoporotic features are evident in the bony\nstructure.\n\n**Assessment:** Multiple fractures are evident in both thoracic\nvertebrae and the first lumbar vertebra, some of which may be acute. MRI\nis recommended for further evaluation. Osseous structure displays\npronounced osteoporotic features.\n\nGrade III esophageal varices present without definitive high-risk\nstigmata. Varices also noted at the gastroesophageal junction,\nclassified as GOV 1 according to Sarin\\'s classification. Band ligation\nof the varices is not performed, as no unambiguous source of bleeding is\nidentifiable and a significant portion of the stomach remains outside\nthe field of view.\n\n**Recommendation**: Terlipressin, monitor surveillance, Erythromycin\n\n**Computed Tomography Thoracic spine from 05/22/2020:**\n\nFracture at the base plate of lumbar vertebra 2 with involvement of the\nposterior margin. Left lateral, no significant reduction in height of\nthe vertebral body. No tension of the spine.\n\nSuspicion of new small fracture also at the cover plate at thoracic\nvertebra 8.\n\nMultiple, older, osteoporotic compression fractures at the thoracic\nspine and\n\nupper lumbar spine.\n\n**Additional Finding:**\n\nLiver cirrhosis with multiple nodules, low ascites, and portal vein\ncongestion. Splenomegaly. If not already known, further workup of liver\nlesions is recommended. Hydrops of the gallbladder.\n\n**Current Recommendations**: There is a general indication for admission\nof the patient and further diagnostics before surgical treatment of the\nfractures. Mrs. Miller is generally opposed to surgical care. She was\nthoroughly informed about the risks (progression, cross-section, death).\n\nRe-presentation with current bone densitometry and update of\nosteoporosis medication, as well as current holospinal MRI. In the\nmeantime, analgesia as needed using Acetaminophen 500mg 1-1-1 under\ngastric protection.\n\n**Esophagogastroduodenoscopy from 05/22/2020:**\n\n[Esophagus]{.underline}: Unobstructed intubation of the esophageal\nopening was achieved under direct visualization. In the upper third of\nthe esophagus, multiple prominent varices protrude into the lumen,\nunaltered by air insufflation. In the middle third, there are areas with\nwhitish overlying material that do not resemble the typical white nipple\nsign. Despite meticulous inspection, no active bleeding sites were\nidentified. The Z-line reveals isolated minor erosions. Cardiac\nsphincter closure is complete.\n\n[Stomach]{.underline}: Full distension of the gastric lumen was\naccomplished with air insufflation. The major curvature of the stomach\ncontained food mixed with hematin. The mucosal surface was similarly\ncoated with hematin, but no active bleeding was discernible in the\nvisualized areas. Peristaltic movement was widespread. Upon\nretroflexion, pronounced varices were noted near the cardiac region on\nthe lesser curvature. The pylorus was unremarkable and easily\ntraversable.\n\n[Duodenum]{.underline}: Adequate distension of the duodenal bulb was\nachieved, providing a clear view up to the descending part of the\nduodenum. Overall, the mucosa appeared normal with minor remnants of\nhematin, and no source of bleeding was identified.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about Mrs. Laura Miller, born on 04/03/1967, who was in\nour inpatient treatment from 05/27/2020 to 06/22/2020.\n\n**Diagnoses**: Initial diagnosis of hepatocellular carcinoma.\n\n- MRI liver: disseminated HCC foci in all segments, the largest foci\n is localized in segments 5 / 7 / 8\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: sophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: Residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Physical Examination:** Patient in mildly reduced general and normal\nnutritional status (BMI 20.3).\n\n- Lungs: Vesicular breath sound, no pathological secondary sounds.\n SpO2 96%.\n\n- Heart: Pure, rhythmic. Systolic with maximum at Erb\\'s point and\n continuation into the carotids. HR: 87/min. BP: 124/54mmHg\n\n- Abdomen: Lively bowel sounds, no tenderness, no guarding, no\n resistance, no peritonism. Soft abdomen. Liver not enlarged,\n palpable. Renal bed not palpable.\n\n- Extremities: Edema of the lower extremities on both sides, foot\n pulses bilaterally well palpable.\n\n- Spine: No tap pain.\n\n- Orienting neurological examination: Right leg weakness, known\n paresis of the extensor muscles of the lower leg/flexor muscles of\n the lower leg.\n\n**Therapy and Progression:** Mrs. Miller was taken over for suspected\nupper GI bleeding. Initially, the patient had presented with increasing\nback pain since approximately 6 weeks at status post fall in the Park\nClinic on 04/26/2020. The patient was known there for her stroke in\n2016. On the day of admission to the Park Clinic, normochromic\nnormocytic anemia (Hemoglobin 3 g/dL) was noticed, which is why the\ntransfer to our clinic was made.\n\nOn inpatient admission, the patient presented in slightly reduced\ngeneral condition. She reported having black stools once. In addition,\nMs. Miller had coffee ground-like emesis once. Dyspnea, angina pectoris\ncomplaints, and B symptoms were denied. There were no problems with\nmicturition. Recently, there were no abnormalities in bowel movements.\nSo far, no colonoscopy has been performed. There were no known\nintestinal diseases in the family.\n\n[Noxae]{.underline}: Ex-nicotine use (since 1996, previously cumulative\nca. 3 PY), occasional alcohol consumption (probably abstinent for about\n5 years).\n\nLaboratory results showed that the patient had elevated infectious\nparameters. The\n\nurinalysis was unremarkable. X-ray chest showed no clear picture of\npneumonia. In a first emergency esophagogastroduodenoscopy on\n05/28/2020, esophageal varices °III were found without clear signs of\nrisk. Furthermore, varices in the area of the cardia (GOV 1 after Sarin)\nwere seen. When the source of bleeding was inconclusive, it was referred\nto a banding initially waived. In a renewed esophagogastroduodenoscopy\nin the morning of 05/30/2020, 2 ampoules of Histoacryl were applied to\nthe cardia varices. In addition, the picture of an incipient\nportal-hypertensive gastropathy. Antibiotic intravenous therapy with\nceftriaxone was initiated. At 06/13/2020, a\nre-esophagogastroduodenoscopy took place, during which a renewed twofold\nbanding of the esophageal varices was performed with injection of 0.5 ml\nHistoacryl. Abdominal ultrasound showed a picture of liver cirrhosis\nwith splenomegaly and perihepatic ascites. In addition, the liver showed\nmultiple echo-poor nodes in the right lobe and a suspicious\n2.4x3.6x4.4cm echo-poor area with a halo in SII. This was followed by an\nMRI of the liver, in which the HCC in segment II was confirmed by\nimaging.\n\nMultiple additional arterial hypervascularized areas/round foci in all\nliver lobes without definite washout. There is no evidence of suspicious\nnodular changes on CT chest/abdomen/pelvis. At an in-house liver\nconference, systemic therapy (Lenvatinib or Sorafenib in Child B7) was\nrecommended.\n\nDue to the back pain, a holospinal MRI was performed, which showed a\nsubacute cover plate compression fracture in the thoracic vertebra 8 as\nwell as multiple older compression fractures of the thoracic spine and\nupper lumbar spine. The colleagues of neurosurgery were consulted, who\ngave the indication for surgery. On 06/14/2020, the planned surgery with\nkyphoplasty thoracic vertebra 8 under C-arm fluoroscopy could be\nperformed without complications. Postoperatively, the patient remained\ncirculatory stable.\n\nDue to auscultatory suspicion of aortic valve stenosis, further\nclarification was performed by cardiac echography, showing no\nhigher-grade valvular vitiation.\n\nWe are transferring Mrs. Miller in improved general condition to the\nSenior Citizens\\' Residence Seaview. If you have any questions, please\ndo not hesitate to contact us.\n\n**Addition:**\n\n**Ultrasound of the upper abdomen on 05/27/2020:**\n\nLimited assessable due to meteorism.\n\n**Liver**: Liver dimensions are within normal limits, measuring 15.9 cm\nin the craniocaudal axis. Echotexture demonstrates inhomogeneous\ngranularity. There is hepatic margin convexity and nodular surface\nappearance. Rarification of hepatic veins. Segment III reveals two\nhypoechoic lesions measuring 3 cm and 1 cm in diameter. Portal vein\ndemonstrates orthograde flow with a maximum velocity of 17 cm/s.\n\n**Gallbladder:** Gallbladder is partially contracted; its wall appears\nunremarkable without sonographic evidence of cholecystitis. No\ntenderness elicited upon sonographic examination.\n\n**Biliary Tract**: Intrahepatic bile ducts are patent. Common hepatic\nduct measures 6 mm in diameter. Common bile duct appears transiently\ndilated up to 9 mm and is otherwise unremarkable as far as can be\nvisualized prepapillary.\n\n**Pancreas**: Limited visualization of the pancreas; however, the\nvisible parenchyma appears homogeneously echoic.\n\n**Spleen**: Spleen is enlarged, measuring 13 x 4 cm, with homogeneous\nparenchyma.\n\n**Kidneys**: Kidneys are morphologically unremarkable, without evidence\nof pelvicalyceal system dilation.\n\n**Abdominal Vessels**: Aorta is partially visualized and appears within\nnormal calibers.\n\nIntestinal/Peritoneal Cavity: No evidence of free intraperitoneal fluid.\n\nUrinary Bladder/Genitalia: Urinary bladder is adequately distended,\nappearing unremarkable upon limited assessment. Uterus is not\nvisualized.\n\n**Virology from 05/28/2020:**\n\n- SARS CoV-2 PCR PCR negative Geq/ml\n\n- Findings: No detection of SARS-CoV-2 by PCR in the submitted\n material.\n\n**Chest X-ray a.p. from 05/28/2020:**\n\nLimited assessability in supine position, malrotation. The diaphragmatic\ncrests are smooth. The marginal sinuses are free of effusions and\ncalluses. Heart and mediastinum lie cryptically. The aorta is sclerosed.\nCranialization of the vessels as well as slightly elevated vascular\nmarkings in the supine position, especially in the right upper field.\nDystelectasis on the right. Sharply defined vertical shadowing in the\nleft upper field. The upper mediastinum is narrow, the trachea is in the\nmidline and is not constricted. Degenerative changes in the cervical\nspine. Overlying foreign material.\n\n**Assessment**: Sharply defined vertical shadowing in the left upper\nfield. Dystelectasis on the right side. Conventional radiographic\nexamination No evidence of a mass. No effusion.\n\n**Esophagogastroduodenoscopy of 05/28/2020:**\n\n**Esophagus**: Successful intubation of the esophageal orifice under\ndirect visualization. Multiple intraluminal protrusions noted in the\nupper third of the esophagus. Non-collapsible variceal strands observed\nupon air insufflation, beginning from the middle third. Whitish\nproliferations seen at multiple sites, not consistent with typical white\nnipple signs. No evidence of active bleeding on close inspection. Z-line\nobserved with isolated minor erosions. Cardiac sphincter fully\ncompetent.\n\n**Stomach**: Gastric lumen fully distended under air insufflation.\nCorpus predominantly contains hematin-laden food remnants. Mucosal\nsurface also stained with hematin but without visible active bleeding.\nPeristalsis noted throughout. Distinct coronary vasculature observed on\nthe lesser curvature. Pylorus unremarkable, offering no resistance to\npassage.\n\n**Duodenum**: Bulbus duodeni well-formed. Pars descendens duodeni\nvisualized clearly. Overall mucosa appears unremarkable, with scattered\nhematin remnants observed without an identifiable bleeding source.\n\n**Assessment**: Esophageal varices graded as °III, with no definitive\nhigh-risk stigmata. Varices also noted in the cardia, classified as GOV\n1 according to Sarin\\'s classification. Ligation of varices was not\nperformed due to the absence of an identifiable bleeding source and\nincomplete visualization of the gastric lumen.\n\n**Ultrasound of the abdomen on 05/29/2020:**\n\n**Quality of Exam**: Limited due to patient non-cooperation and\nmeteorism.\n\n**Liver**: Liver size is paradoxically reported both as normal at 15.9\ncm and enlarged at 18.7 cm. Margins are rounded. Echotexture is markedly\ninhomogeneous with nodular surface. Multiple hypoechoic nodules are\npresent in the right lobe, along with a suspicious hypoechoic area\nmeasuring 2.4 x 3.6 x 4.4 cm with peripheral halo in segment II. Hepatic\nveins are rarified. Portal vein shows orthograde flow with a vmax of 28\ncm/s.\n\n**Gallbladder**: Morphologically unremarkable with no wall thickening.\nCholelithiasis noted with concretions measuring at least 2 to 1.6 cm.\n\n**Biliary Tract:** Intrahepatic bile ducts are not dilated; Common\nhepatic duct measures up to 8.5 mm and common bile duct measures 6.6 mm\nin diameter.\n\n**Pancreas**: Partially visualized; adequacy of assessment is\ncompromised.\n\n**Spleen**: Enlarged with homogeneous internal echotexture.\n\n**Kidneys**: Morphologically unremarkable; no evidence of\nhydronephrosis.\n\n**Abdominal Vessels:** Aorta is not dilated.\n\n**Gastrointestinal**: Perihepatic ascites noted. Both small and large\nintestines appear unremarkable upon limited assessment.\n\n**Urinary Bladder/Genitalia:** Bladder is moderately filled and\nunremarkable in shape and size.\n\n**Assessment**: Limited study due to patient non-cooperation and\nmeteorism. Findings are suggestive of liver cirrhosis and grade I\nascites. Additional findings include suspected hepatic space-occupying\nlesions, splenomegaly, and cholelithiasis. Mild dilation of DHC and DC\nobserved without signs of intrahepatic cholestasis.\n\n**Virology from 06/01/2020:**\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HAV IgG 0.73 negative\n Anti HAV IgM \\<0.1 negative\n\n**Interpretation:** Serologically no evidence of fresh or expired\ninfection with\n\nHepatitis A virus, no immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n HBs antigen 0.21 negative\n Anti HBs \\<0.1 negative\n Anti HBc 0.1 negative\n\n**Interpretation:** Serologically no evidence of acute, chronic or\nexpired Hepatitis B virus infection. No immunity.\n\n **Parameter** **Result** **Interpretation**\n --------------- ------------ --------------------\n Anti HCV 0.06 negative\n\n**Interpretation:** Serologically no evidence of hepatitis C virus\ninfection. At possible fresh infection resubmission in 2-4 weeks and HCV\nPCR recommended.\n\n**MRI total spine plain from 06/04/2020:**\n\n**Technique**: T2 Dixon Sagittal and T2 Axial MRI Sequences. Coverage\nextends from the craniocervical junction to the sacrum.\n\n**Findings:**\n\n**General Spine:** Full extent from craniocervical junction to sacrum\nvisualized. Conus medullaris appropriately located at T12-L1 level.\nMyelon demonstrates uniform width and homogeneous signal. Evaluation of\nthoracolumbar transition and lumbar spine is compromised by artifact\nsuperimposition from ascites.\n\n**Cervical Spine:** Irregular alignment of the posterior vertebral body\nmargins noted, with evidence of disc protrusions and ligamentum flavum\nhypertrophy. Focal T2 hyperintensity observed at C5 level. No evidence\nof prevertebral soft tissue proliferation.\n\n**Thoracic Spine**: Maintained alignment of the posterior vertebral body\nmargins. Multiple anterior endplate compression fractures noted at T5,\nT8, T9, T11, T12 levels. Focal T2 hyperintensity near the anterior\nendplate of T8 involving the posterior margin, indicative of a\nnon-displaced fracture without spinal canal compromise. Hypertrophic\nfacet joint arthrosis at T10-T11 levels resulting in relative spinal\nnarrowing. Bilateral pleural effusions noted, more pronounced on the\nright, with a maximum width of approximately 2 cm. No evidence of\nsignificant neuroforaminal stenosis.\n\n**Lumbar Spine:** Maintained alignment of posterior vertebral body\nmargins. Known anterior endplate compression fractures at L1 and\nbaseplate compression fracture at L2. No evidence of pathological T2\nedema within the vertebral bodies, although assessment is limited due to\nsuperimposed artifacts from ascites. Spinal canal dimensions appear\nadequate throughout. Moderate fatty degeneration of sacral bone noted.\n\n**Assessment**: Evaluation limited due to ascites-related artifacts.\nSubacute anterior endplate compression fracture at T8, along with\nseveral other likely older compression fractures in the thoracic and\nupper lumbar spine. Bilateral pleural effusions observed. Multiple\nneuroforaminal narrowings as detailed above.\n\n**MR Liver plain + contast agent from 06/06/2020**\n\n**Findings:**\n\n1) [Lesion 1]{.underline}\n\n- Size of the lesion 41 mm\n\n- Segment 2\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: yes\n\n- Pseudocapsule: yes\n\n- Behavior delayed leaching: yes\n\n- pseudocapsule macrovascular invasion: no\n\n2) [Lesion 2]{.underline}\n\n- Size of the lesion 104 mm\n\n- Segment 5 / 7 / 8\n\n- Behavior arterial strongly enriching: yes\n\n- Portal venous early washing out: no\n\n- Pseudocapsule: no\n\n- Behavior delayed washing out: no\n\n- Pseudocapsule: no\n\n- Macrovascular invasion: yes\n\n**Comments:**\n\n- MRI with Gadovist intravenous.\n\n- Multiple other satellite foci in all liver segments.\n\n- Signs of liver cirrhosis with nodular liver parenchyma and\n hypertrophy of the left lobe.\n\n- Cholecystolithiasis and gallbladder hydrops. No cholestasis.\n\n- Varices of the esophagus and fundus. Splenomegaly. Ascites. Pleural\n effusions on both sides.\n\n- Lymph node (approximately 8 mm) between the small curvature of the\n Stomach and S1 of the liver.\n\n- Axial hernia.\n\n**Assessment:** Milan fulfilled**.** Dissiminated HCC foci in all\nsegments, the largest foci being in segments 5 / 7 / 8 localized. Portal\nhypertension with bypass circulation and splenomegaly. Ascites and\npleural effusions.\n\n**Microbiology from 06/09/2020:**\n\n[Material]{.underline}: Ascites in blood culture bottles\n\n[Microscopic]{.underline}: No cells, no germs\n\n- Anaerobic culture negative after 48 hours\n\n- So far, no growth in the anaerobic cultures. The cultures are\n incubated for a total of 5 days. In case of growth of anaerobes we\n will send you a follow-up report.\n\n- No growth after 48 hours\n\n**Esophagogastroduodenoscopy of 06/11/2020:**\n\n**Esophagus**: In the distal esophagus, multiple band-like ulcerations\nas well as residual varices with risk signs that may not completely pass\nair insufflation. Z-line without erosions.\n\n**Stomach**: Mosaic-like occupancy of the gastric mucosa. With inversion\nthe\n\nknown small-curved lateral cardiavarii, which is hard on palpation with\nclosed forceps after histoacryl injection. Directly next to it, another\ncardiavarice can now be seen, which has not yet been injected with\nhistoacryl and is soft on palpation.\n\n**Duodenum**: Endoscopic therapy: Injection of 0.5 mL Histoacryl (+0.5\nmL Lipoidol) in the new cardiavarice. Application of 3 rubber band\nligatures to the residual varices in the esophagus.\n\n**Assessment:** Residual varices in the esophagus, application of 3\nrubber band ligations; portal hypertensive gastropathy\n\n**Spine-whole: 2 planes from 06/13/2020**\n\nThe perpendicular of C7 protrudes about 15 mm laterally to the left of\nsacral vertebra 1 in the anterior-posterior image and about 9.3 cm in\nfront of sacral vertebra 1 in the lateral ray path. Slight left convex\nscoliosis thoracolumbally with thoracic counter-swing (Cobb angle \\< 10°\nin each case). The lungs are unremarkable as far as technically\nassessable.\n\n**Assessment**: decompensated positive sagittal spinal imbalance. There\nis no relevant lateral trunk overhang.\n\n**Critical Findings Report:**\n\nA conspicuous single cell population of cells with partial signet ring\ncell character is detected in the smears. A cell block is prepared from\nthe remaining liquid material for further typing of these cells. A\nfollow-up report will follow.\n\n**Thoracic spine in 2 planes from 06/15/2020:**\n\n**Findings**: Thoracic vertebra 8: Post-kyphoplasty status with notable\nimprovement in vertebral height, now measuring 21 mm compared to a\npreoperative height of 13 mm. Mild straightening of the vertebral column\nobserved at this level.\n\nThoracic vertebra 9: Known older anterior endplate collapse.\n\nThoracolumbar spine: Multisegmental height reduction in vertebral bodies\nconsistent with osteoporotic changes. No signs of contrast\nextravasation.\n\nAdditional Finding: Pre-existing calcified structure projecting onto the\nleft upper abdomen; likely unrelated to current surgical site.\n\n**Assessment**: Unremarkable postoperative imaging following kyphoplasty\nof T8. No evidence of postoperative sintering or newly identifiable\nfractures. Overall, the surgical intervention appears successful in\nincreasing vertebral height and stabilizing the fracture site.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 06/18/2020:**\n\n**Technique**: Multislice spiral CT of the chest, abdomen, and pelvis\nwas performed post-bolus intravenous injection of 120 ml of Imeron 400.\nImaging conducted in arterial, portal venous, and venous phases. Oral\ncontrast agent administered with Micropaque 1:7 in water and Gastrolux\n1:33 in water. Thin-slice reconstructions and secondary coronal and\nsagittal reformats were performed.\n\n**Chest**: Presence of struma nodosa. Bilateral minor pleural effusions\nwith adjacent atelectasis, more pronounced on the right and extending\ninto the interlobar region. No signs of infiltrative changes. Isolated\nsmall nodular opacities in the right lung. Few small bullae noted.\nMediastinal lymph nodes mildly enlarged up to 0.5 cm; axillary and hilar\nnodes are not enlarged. No pericardial effusion observed.\n\n**Abdomen/Pelvis**: Known esophageal and fundal varices present. Liver\ndemonstrates nodular changes in the context of known Child-Pugh B stage\ncirrhosis. A solid hepatic cellular carcinoma lesion in segment II and\ndiffuse HCC nodules in segments V/VII/VIII visualized, corroborating\nprior MRI findings. They show pronounced arterial enhancement and\ncentral washout. Splenomegaly noted. Adrenal glands unremarkable. Renal\nand urinary systems are inconspicuous. No intestinal motility\nabnormalities detected. Marked ascites present; no pathologically\nenlarged abdominal lymph nodes noted upon limited assessment.\n\n**Skeletal**: Moderate coxarthrosis bilaterally. An old, minimally\ndisplaced fracture of the right 7th rib noted. Advanced degenerative\nchanges in thoracic vertebrae 10, 12, and lumbar spine.\nPost-vertebroplasty status at thoracic vertebra 9. Hemangioma at\nthoracic vertebra 11.\n\n**Assessment**:\n\n- Marked ascites in the setting of liver cirrhosis with multifocal HCC\n lesions, as corroborated by prior MRI. No evidence of extrahepatic\n or lymphatic spread.\n\n- Bilateral minor pleural effusions with associated atelectasis.\n\n- Skeletal findings include moderate coxarthrosis and degenerative\n changes in the spine.\n\nOverall, the scan provides vital information that aligns with and\nelaborates upon existing clinical and imaging data.\n\n**Histology**:\n\n**Pathology from 06/19/2020:**\n\n[Clinical Data:]{.underline} Hepatocellular carcinoma, hydropic\ndecompensated liver cirrhosis Child B,\n\n[Extraction date:]{.underline} 06/13/2020\n\n[Material:]{.underline} 1 Liquid material 7 ml light yellow\n\n[Editing]{.underline}: Papanicolaou and MGG staining\n\n\\+ Protein precipitation\n\n\\+ Erythrocytes\n\n\\+ Lymphocytes\n\n(+) Granulocytes Eosinophils\n\n\\+ Histiocytic cell forms\n\n\\+ Mesothelium\n\n\\+ Active mesothelium\n\n**Other**: Single mononuclear cells with large, eccentric nuclei with\nnucleoli and a narrow cytoplasmic space, partly with signet ring cells.\n\n**Supplementary findings from 06/19/2020**\n\n[Processing]{.underline}: Cell block, HE\n\n**Microscopic:**\n\nAs announced, from the remaining liquid material a cell block was\nprepared. In the HE stain only isolated evidence of mononuclear Cells\nand some blood. No cell atypia.\n\n**Critical Findings Report:** After examination of the remaining liquid\nmaterial in the cell block no Extension of the initial findings in the\nabsence of further diagnostic cell material. The finding is thus based\nexclusively on the Smear material:\n\n- Detection of a single-cell population consisting of cells with\n partial signet ring cell character. Differentially it could be The\n mesothelium may be a reactive change of the approaching mesothelium.\n Cells of an epithelial neoplasia are not visible on the present\n material. to be ruled out with certainty.\n\n**Diagnostic classification:** Suspicious\n\n**Current Recommendations:**\n\n- An appointment at our outpatient clinic to start therapy was\n organized for 06/26/2020.\n\n- An appointment for a health department check-up with varicose vein\n status survey and, if necessary, repeat rubber band ligation has\n been scheduled for 07/22/2020. Please come to the endoscopy on this\n day at 08:30 am fasting with current lab results. incl. coagulation,\n signed consent form as well as SARS-CoV-2 PCR not older than 48h.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report to you on Mrs. Laura Miller, born 04/03/1967, whom we examined\non 06/08/2020 in the course of a consultation.\n\n**Consilar Request:**\n\n- Liver cirrhosis, Child-Pugh B, ethyltoxic genesis\n\n- HCC\n\n- Laboratory albumin: 2.6\n\n- Nutritional advice requested\n\n**Nutritional counseling in cirrhosis of the liver:**\n\n- Albumin at 2.6\n\n- 70kg at admission (stable weight in recent years).\n\n- Height: 1.72m\n\n- BMI falsified by ascites\n\n- Patient reports that she always a \\\"bad eater\\\"\n\n- She reports to eat less due to numerous medication intake\n\n- Patient is noticeably overwhelmed and seems very burdened by\n diagnosis\n\n**Assessment:**\n\n- Protein malnutrition with inadequate oral nutrition\n\n- Patient appears desperate and overwhelmed, questionable compliance\n\n**Recommendations: **\n\n- High-calorie food for more choices (already ordered)\n\n- High-calorie drinks (contains more protein)\n\n- Incorporate protein-rich snacks such as yogurt, sippy cups,\n crispbread\n\n- with cheese.\n\n- A high-energy, high-protein food choice was made with the patient\\'s\n discussed in detail\n\n- Contact details were handed out\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 08/21/2020 to\n08/23/2020.\n\n**Diagnoses**:\n\n- MRI of the liver: disseminated HCC foci in all segments, the largest\n foci is localized in segments 5 / 7 / 8\n\n<!-- -->\n\n- Hydropic, decompensated liver cirrhosis Child B, first diagnosis:\n 05/20, ethyltoxic genesis\n\n- Anemia requiring transfusion\n\n- EGD of 05/28/20: esophageal varices III° without risk signs, rubber\n band ligation; cardia varices I°, Histoacryl injection\n\n- EGD of 06/13/20: residual varices in the esophagus, application of 3\n rubber band ligations, injection of 0.5 ml. Histoacryl; portal\n hypertensive gastropathy\n\n- Transfusion of 2 ECs\n\n- Fresh osteoporotic thoracic vertebra 8 fracture\n\n- Kyphoplasty thoracic vertebra 8 under C-arm fluoroscopy\n\n- Portal hypertension with bypass circuits\n\n- Splenomegaly\n\n- Cholecystolithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- Status post stroke\n\n- Allergies: None known\n\n**Current Presentation:** Mrs. Miller presented electively for\ngastroscopy for variceal screening with continuation of banding therapy\ndue to esophageal variceal bleeding.\n\n**Medical History**: For a detailed medical history, we refer to\nprevious reports from our department. In summary, we present a liver\ncirrhosis due to ethyl toxicity leading to the development of multifocal\nHCC. Similar to the liver board decision of 06/13/20, a recommendation\nfor systemic therapy with Lenvatinib or Sorafenib was made in the\nsetting of partially compensated Child B7 cirrhosis with multifocal HCC\nin both lobes of the liver.\n\n**Therapy and Course:** Upon admission, the patient was in\nage-appropriate general condition and largely symptom-free. There were\nno signs of acute infection, jaundice, encephalopathic symptoms, or GI\nbleeding. No irregularities in bowel movements or urination were\nreported. The patient denied abdominal pain and dyspnea. There were no\nknown allergies.\n\nOn the day of admission, an uncomplicated gastroscopy was performed,\nincluding the application of 4 rubber band ligations for residual\nesophageal varices. Post-interventional pain was adequately controlled\nwith double-standard doses of Pantoprazole and intravenous analgesic\ntherapy. The further inpatient course was uneventful, and the patient\ntolerated the post-interventional diet without signs of GI bleeding.\n\nBased on laboratory findings and clinical evaluation, particularly with\nregressed ascites, a compensated Child A6 cirrhosis was confirmed.\nTherefore, a re-presentation at our interdisciplinary liver board was\ninitiated for discussion of potential treatment options in the context\nof compensated liver function.\n\nAs per the consensus recommendation from the liver board, a follow-up\ngastroscopy is scheduled within the next two weeks. Depending on the\nvariceal status, systemic therapy with Atezolizumab/Bevacizumab or\nLenvatinib will follow.\n\nThroughout the monitoring period, the patient remained stable in terms\nof circulation and hemoglobin levels. Therefore, on 08/23/20, we\ndischarged Mrs. Miller for outpatient follow-up care. The patient was\nthoroughly informed about reasons that necessitate immediate\nre-presentation. Please note the listed procedural appointments.\n\n**Physical Examination:** Awake, alert, oriented\n\n- Heart: Regular heart tones, no murmurs\n\n- Lungs: Clear vesicular breath sounds, no crackles or wheezes\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, palpable firm liver edge under the rib cage, no palpable\n spleen enlargement, non-painful renal angle\n\n- Extremities: Good peripheral pulses, no edema\n\n- Neurology: No focal neurological deficits.\n\n**EGD on 08/21/2020:**\n\n**Findings:**\n\n**Esophagus**: Unobstructed intubation of the esophagus under direct\nvision. Multiple variceal cords and scarring changes due to banding were\nobserved in the lower half of the esophagus. Z-line at 35 cm\ndiaphragmatic passage at 39 cm. Two variceal cords extend along the\nsmall curve into the stomach, two of the varices show alarm signs (red\nspots). 4 rubber band ligations were performed.\n\n**Stomach**: In the proximal corpus a picture of portal hypertensive\ngastropathy, otherwise unremarkable. No fundus varices.\n\n**Duodenum**: Good unfolding of the duodenal bulb, contact-sensitive\nmucosa. Good insight into the descending part of the duodenum. Overall,\nunremarkable mucosa.\n\n**Assessment:** Esophageal varices, Gastroesophageal varices Type I.\nBanding therapy.\n\n**Current Recommendations:**\n\n- Regular clinical and laboratory checks by the primary care\n physician.\n\n- In case of fever, acute deterioration of the general condition, or\n clinical signs of bleeding such as melena or hematemesis, we request\n immediate re-presentation, even at night and on weekends, through\n our interdisciplinary emergency department.\n\n- Decision of the liver board: Improvement of liver function with\n alcohol abstinence, but also progression of multifocal HCC over 2\n months without tumor-specific therapy. Consensus: Repeat EGD in 7-14\n days, depending on variceal status, Atezolizumab/Bevacizumab, or\n Lenvatinib.\n\n- Follow-up appointment on 09/11/20 in our HCC outpatient clinic for\n clinical control and explanation of the EGD.\n\n- Follow-up in our endoscopy for EGD to determine variceal status and\n possible banding -\\> Please bring a COVID PCR test (maximum 48 hours\n old) for inpatient admission.\n\nIf complaints persist or worsen, we recommend immediate re-presentation.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about Mrs. Laura Miller, born on\n04/03/1967, who was under our inpatient care from 09/18/2020 to\n09/20/2020.\n\n**Diagnoses:**\n\n- 4-time banding therapy with 4 rubber band ligations for residual\n esophageal varices without alarm signs\n\n- Hepatocellular Carcinoma (HCC)\n\n- MR Liver: Disseminated HCC lesions in all segments, with the largest\n lesion located in segments 5/7/8\n\n- Decompensated cirrhosis of the liver (Child B) since 05/20 due to\n ethyltoxic origin.\n\n- Transfusion-dependent anemia due to a history of variceal bleeding.\n\n- Osteoporotic thoracic vertebral fracture of vertebra BWK8 (OF3) with\n kyphoplasty.\n\n- Portal hypertension with portosystemic collaterals\n\n- Splenomegaly\n\n- Cholelithiasis\n\n- Arterial hypertension\n\n- Osteoporosis\n\n- History of stroke (2016)\n\n- Allergies: Amalgam\n\n**Presentation:** Mrs. Miller\\'s elective presentation was for a\nfollow-up examination for known esophageal varices.\n\n**Medical History:** For a detailed medical history, please refer to\nprevious reports from our department. In summary, in June 2020, the\npatient was diagnosed with decompensated liver cirrhosis attributed to\nethyltoxicity. MR imaging showed multifocal HCC. According to the liver\nboard decision on 06/15/20, initial therapy was recommended with\nLenvatinib or Sorafenib for partially compensated Child B7 cirrhosis\nwith multifocal HCC in both liver lobes. Despite improvement in liver\nfunction with alcohol cessation, there was a short-term progression of\nmultifocal HCC without tumor-specific therapy, leading to a\nrecommendation for a repeat variceal screening on 08/28/20. Depending on\nthe findings, therapy with Atezolizumab/Bevacizumab or Lenvatinib was\nadvised. The last EGD was performed on 08/21/20, revealing esophageal\nvarices with alarm signs, and a 4-time banding was performed.\n\n**Physical Examination upon Admission:** Blood pressure: 80/150 mmHg,\nheart rate 88/min, temperature 36.4°C, SpO2 97% in room air.\n\nPatient in good general condition and normal mental status. Mrs. Miller\nis fully oriented. Pupils are equal and reactive.\n\n- Cardiovascular: Clear heart sounds, no murmurs.\n\n- Lungs: Equal breath sounds bilaterally, no crackles, resonant\n percussion.\n\n- Abdomen: Soft, non-tender, no masses, normal bowel sounds in all\n quadrants, liver and spleen not palpable.\n\n- Extremities: No edema, good peripheral pulses. No focal neurological\n deficits.\n\n**Course and Therapy:** On the day of admission, the EGD was performed\nwithout complications. Residual varices without warning signs were\nobserved, and a 4-time rubber band ligation was performed. Portal\nhypertensive gastropathy was also diagnosed. After the procedure, the\npatient was transferred to our gastroenterological normal ward.\n\nThe post-interventional course was uneventful. There were no clinical or\nlaboratory signs of post-interventional bleeding. The diet was\nreintroduced without any issues. Therefore, on 09/20/2020, we discharged\nMrs. Miller for outpatient care. We request a follow-up appointment at\nour in-house HCC outpatient clinic. Additionally, we request a follow-up\nEGD with variceal control.\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nPatient: Miller, John, born 04/07/1961\n\nWe report to you about our common patient, Mr. John Miller, who is in\nour inpatient treatment since 07/30/2019.\n\n**Diagnoses:**\n\n\\- Suspected right cerebral glioblastoma (first diagnosis)\n\n\\- Symptoms: Aphasia, passive confusion\n\n**Patient history: **\n\nMr. Miller was admitted as an emergency. He was on the phone with a\nfriend when he suddenly began to exhibit speech difficulties and\nstruggled to find the right words. Consequently, his friend called 911.\n\nUpon the ambulance\\'s arrival, Mr. Miller was disoriented and exhibited\naggressive behavior. There was evidence of a torn door. He had blood on\nhis right forearm and around his mouth, but there were no indications of\na tongue bite or urinary incontinence.\n\nUpon admission, Mr. Miller was coherent and showed no speech issues. He\nattributed a mild weakness in his right arm to pre-existing pain in the\nupper arm. An immediate CT scan revealed a mass suggestive of a\nglioblastoma in the right cerebral hemisphere, leading to a\nneurosurgical consultation.\n\nGiven the possibility of an epileptic seizure, Mr. Miller was\nhospitalized and started on Levetiracetam. He is currently unaware of\nhis regular medications but takes antihypertensives and diabetes\nmedications, among others. His friend and brother have been notified and\nare ensuring that a detailed medication list is provided.\n\nAfter a brief stay in ward ABC, Mr. Miller was transferred to the\nneurosurgery team for further evaluation and treatment. We appreciate\nthe prompt transfer and are available for any further inquiries.\n\nPlanned Procedures:\n\n-Schedule EEG\n\n-Clarify routine medications\n\n**Surgery Report**\n\n**Diagnosis:** Suspected HGG (high-grade glioma) of the right hemisphere\n\n**Procedure:** Microsurgical navigation-guided resection of the tumor\nwith intraoperative neuromonitoring (stable MEPs) and intraoperative MRI\nusing 5-ALA. Pathology samples taken (Preliminary: HGG; Final to be\nconfirmed). Resection was followed by duragen placement, watertight\ndural closure, and multilayer wound closure, with skin sutures.\n\n**Time:**\n\n-Start: 11:12 am\n\n-Finish: 3:54 pm\n\n-Duration: 4 hours 42 minutes\n\n**Assessment:**\n\nMr. Miller presented with a seizure characterized by speech disturbance\nand disorientation. Imaging revealed a significant right hemispheral\nmass, likely representing a high-grade brain tumor. The need for\nsurgical resection was determined following discussions at our\ninterdisciplinary tumor board. After being informed about the procedure,\nalternative treatments, the operation\\'s urgency, benefits, and\npotential risks, Mr. Miller provided written consent following ample\ntime for consideration and the opportunity to ask further questions.\n\n**Procedure Details:**\n\nThe patient was positioned supine with his head secured in a Nova clamp.\nNavigation data were read, followed by skin preparation, and the\nsurgical field was sterilized and draped. An arch-shaped incision was\nmade, followed by hemostasis, deep tissue dissection, placement of a\nburr hole, and the creation of a large bone flap over the lesion. The\nbone flap was then elevated. Multiple washings were performed, followed\nby dural opening under microscopic visualization. A corticotomy was\ncarried out with bipolar forceps, CUSA, and suction to progressively\nreduce the tumor, utilizing 5-ALA fluorescence and continuous\nneurophysiological monitoring. An intraoperative MRI showed residual\ntumor, prompting further resection. Hemostasis was achieved, and the\nwound was closed using tabotamp, followed by duragen placement and dural\nsuturing. The bone flap was refixed using Dogbone plates. The wound area\nwas irrigated extensively once more, followed by subcutaneous and skin\nsutures.\n\n**Date:** 10/01/2019\n\n**Clinical Indication:**Suspected recurrence of GBM in the right\nhemisphere\n\n**Requested Imaging:**cMRI with or without contrast + DTI.\n\n**Findings:***Imaging Modality (GE 3.0T):* 3D FLAIR, DTI, SWI, T2\\*\nperfusion, 3D T1 with and without contrast, 3D T2,\nsubtraction.Following resection of a right hemispheric glioblastoma in\n08/19, and compared to the last two scans (external: 07/19, internal:\n08/19), there is a notable expansion of the prior detected flair\nhyperintense regions. These now span from the right parietal-subcortical\narea across the right basal ganglia to the right temporo-occipital/right\ntemporal pole. Specifically, at the dorsocranial edge of the resection\ncavity, the hyperintense regions appear to have grown since 08/19. These\ncoincide with hyperperfused regions in the T2\\* perfusion. Linear SWI\nsignal changes are suggestive of mild post-surgical bleeding. No\nsignificant postoperative hemorrhage or territorial ischemia is\ndetected. A normal venous sinus drainage is observed. Right temporal\nhorn appears congested, possibly due to CSF trapping.\n\n**Assessment:**\n\nFollowing the resection of the right hemispheric glioblastoma in 08/19:\n\n-Markedly progressive flair edema and evolving barrier disturbance.\nRegions especially towards the dorsal side of the resection cavity show\nthis alongside associated hyperperfusion. With the recent PET imaging\nfrom 10/19, there is an indication of progressive disease as per RANO\ncriteria.\n\n-Long-term progressive congestion of the right temporal horn, likely CSF\ntrapping.\n\n**Surgery Report****Diagnosis:**Tumor recurrence after resection of a\nglioblastoma (IDH wild type, WHO CNS grade 4) of the right hemisphere in\n08/2019. The patient underwent combined radiochemotherapy at the local\nclinical center.\n\n**Procedure:**Navigated, microsurgical resection supported by 5-ALA,\nwith stable MEPs through the previous right temporal access. iMRI\nconducted between 11:10 and 11:50. Used Duragen/TachoSil, dog bones for\nclosure, followed by layered wound closure and skin sutures.\n\n**Timing:**\n\n-Incision: 09:23 am on 10/12/19\n\n-Suture: 12:32 pm on 10/12/19\n\n**Assessment:**The patient had previously undergone surgery for a\nglioblastoma and a recurrence was detected on imaging. The tumor board\nhad already deliberated on the surgery. The patient was informed about\nthe surgical procedure, particularly about conducting an extensive\nresection caudally without impacting function post-mapping. The patient\nconsented, understanding the potential for longer progression-free\nsurvival.\n\n**Procedure Details:**The patient was placed in a supine position with\nthe head turned to the side and fixed using the Noras clamp. The right\nshoulder was padded. The surgical area was prepared by trimming hair\naround the previous scar, followed by sterilization and draping. After a\nteam time-out, prophylactic antibiotics were administered. The previous\nscar was reopened and old plates were removed. The microscope was then\nswung into position and the dura was opened. Navigation proceeded\nbeneath the labbé vein, with tumor resection as guided by ALA\nfluorescence. Post-tumor removal, extensive hemostasis was achieved\nusing absorbent cotton and TABOTAMP. Intraoperative MRI confirmed a\ncomplete resection of the tumor. The dura was sealed using DuraGen,\nensuring a watertight closure. The bone flap was reinserted, followed by\nsubcutaneous suturing, skin suturing, and sterile dressing of the wound.\n\n\n\n\n### text_1\n**Dear colleague, **\n\nWe write to update you regarding our shared patient, Mr. John Miller,\nborn on 07/04/1961, who visited us on 12/02/2019.\n\n**Diagnosis:**Glioblastoma recurrence, IDH 1 wild type.\n\n**Tumor Location:**Right hemisphere including temporal regions.\n\n**Clinical History & Treatment:**\n\n-07/2019: Mr. Miller experienced speech disturbances and confusion.\n\n-08/01/2019: Brain PET-MRI revealed a suspected malignancy in the right\nhemisphere, including temporal areas.\n\n-08/11/2019: Glioblastoma was resected at our facility.\n\n-08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy\nwith a boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local\nclinical center.\n\n-10/01/2019: cMRI with suspected recurrence.\n\n-10/12/2019: A recurrent resection was performed at our facility.\n\n-11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n**Recent Evaluation (12/01/2019):**Mr. Miller visited our facility with\nhis brother. Our assessment, based on CTCAE criteria, indicated that he\nis in a fair but stable general and nutritional health (KPS 70-80%,\nweight undisclosed, height 175 cm). Neurological and general evaluations\nrevealed a degree of aphasia, mainly with word-finding difficulty, and\nshort-term memory impairment. However, he remains fully oriented and\nindependent in daily life.\n\n**Additional Observations:**\n\nHis surgical wound has healed well.\n\n**Pre-existing Conditions:** Arterial hypertension, Diabetes Mellitus\nType II\n\n**Allergies:** None\n\n**Current Medications:** Antihypertensive drugs and insulin.\n\nPostoperatively, Mr. Miller remains in good health. A recent brain MRI\nnoted that the suspected recurring GBM lesion near the superior border\nof the surgical site was entirely resected. Furthermore, CT scans at the\nanterior medial and lateral edges suggest that a complete resection was\nmost likely achieved.\n\nGiven the presumed complete resection of the glioblastoma recurrence, we\nhave recommended Mr. Miller for a neuro-oncology review and a follow-up\nwith PET-MRI in three months.\n\n**Next Steps:**\n\n-He has a scheduled appointment in neuro-oncology on 01/23/2020 at 10:00\nAM.\n\n-A follow-up PET-MRI is set for 01/29/2020 at 12:45 PM. We have advised\nMr. Miller to fast for 4 hours prior and to bring a referral from his\nprimary care physician, along with a recent creatinine test result.\n\n-A review of these findings will be held in our outpatient department on\n01/30/2020 at 2:00 PM.\n\nThank you for your continued care and collaboration. Please do not\nhesitate to reach out for any additional information.\n\nWarm regards,\n\n\n\n### text_2\n**Dear colleague, **\n\nRegarding our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nGlioblastoma recurrence, IDH 1 wild type\n\n**Tumor Location**:\n\nRight hemisphere/temporal.\n\n**Medical History**:\n\n07/2019: Onset of speech arrest and confusion.\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\nMr. Miller came in on 12/01/2019 with his brother. Clinical examination\nfindings are as follows:\n\n-General health: Stable with reduced vitality.\n\n-Nutritional status: Stable (KPS 70-80%, weight in kg, height 169 cm).\n\n-No evident motor, sensory, visual, or cranial nerve deficits.\n\n-Neurocognitive deficits: Short-term memory issues.\n\n-Aphasia: Grade II (mainly word-finding disorders). The patient is fully\noriented and independent in daily life.\n\n-No evidence of recurrence in PET-MRI. Next imaging scheduled in\n03/2020.\n\n**Past Medical Conditions**:\n\n-Hypertension\n\n-Type II Diabetes Mellitus\n\n**Allergies**: None.\n\n**Medications**:\n\n-Antihypertensive medications\n\n-Insulin\n\nBest Regards,\n\n\n\n\n### text_3\n**Dear colleague, **\n\nUpdating you on our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nRecurrent Glioblastoma, IDH 1 wild type (ICD-10: 71.8).\n\n**Molecular Pathology**:\n\nNo p.R132H mutation in IDH.\n\nNo combined 1p/19q loss.\n\nSuspected CDKN2A/B deletion.\n\n**Medical History**:\n\nNo pain or B symptoms.\n\nIntermittent dizziness and headaches since the last check-up.\n\n**Neurological Findings**:\n\nPatient is alert and oriented.\n\nWeight: 80 kg (total loss: 15 kg), Height: 175 cm.\n\nKarnofsky Performance Score: 80%.\n\nMotor function and sensory assessments were unremarkable.\n\n**Allergies**: None.\n\n**Medications**:\n\nLisinopril 10mg once daily in the morning\n\nBisoprolol 2.5mg once daily at bedtime\n\nJanuvia 50mg twice daily\n\nAllopurinol 100mg once daily in the morning\n\nEzetimibe 10mg once daily at bedtime\n\nLevetiracetam 1000mg once daily in the morning Insulin as per regimen\n\n**Secondary Diagnoses**:\n\nHypertension\n\nType II Diabetes Mellitus\n\n**Medical Course**:\n\nDetails from 07/2019 through 03/2020 provided, including surgeries,\nradiochemotherapies, and diagnostics.\n\nIn summary, Mr. Miller\\'s glioblastoma diagnosis in 07/2019 led to\nvarious treatments, including radiochemotherapy and surgeries. His\nrecent PET/MRI on 01/2020 indicates potential recurrent areas.\n\nBest regards,\n\n**Patient:** John Miller\n\n**DOB:** 04/07/1961\n\n**Admission Date:** 04/11/2020\n\n**Discharge Date:** 04/18/2020\n\n**Admission Diagnosis:**\n\nRecurrent tumor in the hippocampal region and along the prior resection\ncavity.\n\nHistory of glioblastoma (IDH wild type, WHO CNS grade 4) in the right\nhemisphere, resected on 08/2019.\n\nHistory of combined radiochemotherapy with Temodar (Temozolomide) from\nAugust to September 2019 at the local clinical center.\n\nSubsequent first re-resection in 10/2019.\n\n**Presenting Complaint:**\n\nMr. Miller presented to the neurosurgical outpatient department\naccompanied by his wife. Recent imaging indicated a potential recurrence\nof the glioblastoma. The neuro-oncological board on 04/12/2020\nrecommended a re-resection.\n\n**Physical eon Admission:**\n\nAlert, oriented x4, cooperative.\n\nNon-fluent aphasia.\n\nCranial nerves intact.\n\nNo sensory or motor deficits in the extremities.\n\nSurgical scar clean and dry.\n\nNo signs of neurogenic bladder or rectal dysfunction.\n\nKPSS 70%.\n\n**Medications on Admission:**\n\n-Lisinopril 10mg daily\n\n-Bisoprolol 2.5mg nightly\n\n-Januvia 50mg twice daily\n\n-Allopurinol 100mg daily\n\n-Atorvastatin 40mg nightly\n\n-Ezetimibe 10mg nightly\n\n-Levetiracetam 1000mg twice daily\n\n-Actraphane insulin as prescribed\n\n**Surgical Intervention (04/12/2020):**\n\nNavigated microsurgical resection of tumor spots assisted with 5-ALA.\nStable MEPs were maintained. An intraoperative MRI (iMRI) was utilized.\nPost-resection, the surgical area was managed using Tabotamp, Duragen,\nTachoSil, and dog-bone plates, concluding with layered wound closure.\n\n**Postoperative Course:**\n\nUncomplicated recovery.\n\nPost-op MRI showed no residual tumor.\n\nSurgical site remained clean, dry, and showed no signs of infection or\nirritation.\n\n**Discharge Diagnosis:**\n\nRecurrence of known glioblastoma, WHO CNS grade 4.\n\n**Interdisciplinary Neuro-oncological Tumor Board Recommendation\n(04/20/2020):**\n\nMolecular tumor board review.\n\nOffer reinitiation of Temozolomide chemotherapy.\n\n**Physical Examination on Discharge:**\n\nSimilar to admission, with suture in place and wound site in good\ncondition.\n\nKPSS 70%.\n\n**Medications on Discharge:**\n\n-Allopurinol 100mg daily (morning)\n\n-Atorvastatin 40mg nightly (evening)\n\n-Bisoprolol 2.5mg nightly (evening)\n\n-Ezetimibe 10mg nightly (evening)\n\n-Sitagliptin (Januvia) 50mg twice daily (morning and evening)\n\n-Levetiracetam (Keppra) 1000mg twice daily (morning and evening)\n\n-Lisinopril 10mg daily (morning)\n\n-Acetaminophen 500mg as needed for pain or fever\n\n-Actraphane insulin as prescribed\n\n**Surgery Report **\n\n**Diagnosis**:\n\nTumor recurrence in the right hippocampal region and along the resection\ncavity post glioblastoma resection on 8/11/2019.\n\nPrevious treatments include radiochemotherapy at our clinic. Local\ntherapy center (from August to September 2019) and re-resection on\n10/12/2019.\n\n**Surgery Type**:\n\nRe-opening of the temporal region with navigation, microsurgery using\n5-ALA assistance, iMRI, and re-resection, among other procedures.\n\n**Procedure Details**:\n\nStart: 11:50 pm on 04/12/2020\n\nEnd: 4:00 pm on 04/12/2020\n\nDuration: 4 hours 10 minutes.\n\n**Assessment**:\n\nEvidence of recurrent glioblastoma areas warranted another biopsy and\nresection. After informing Mr. Miller about the procedure\\'s risks and\nbenefits, he provided written consent.\n\n**Operation**:\n\nDetails on the positioning, pre-operative preparations, resection, and\npost-operative procedures are provided.\n\nBest regards,\n\nMEDICAL HISTORY:\n\nMr. Miller underwent surgery because of tumor recurrence in the right\nhemisphere last November to treat a right temporal glioblastoma. He\npresented to our private outpatient clinic due to a wound complication,\nspecifically a wound dehiscence measuring about 1 cm. On closer\nexamination, pus was noted. Despite being symptom-free otherwise, a\nconsultation with Dr. Doe was scheduled. After discussion, it was\ndecided to clean the wound, trim the deteriorated wound edges, and clean\nthe bone flap with an antibiotic solution before reinserting it. The\npatient was thoroughly educated about the nature and risks of the\nprocedure and gave consent.\n\nOPERATION:\n\nThe patient was placed in a supine position. The hair surrounding the\nsurgical site was trimmed, followed by skin disinfection and sterile\ndraping. The bicoronal skin incision was reopened. Deteriorated wound\nedges were excised and the wound was extensively cleaned with\nirrigation. The bone flap was removed and immersed in a Refobacin\nsolution. The epidural pannus tissue was removed. The dura was\ncompletely sutured. Multiple samples were collected both subgaleally and\nepidurally. A sponge was applied, followed by the reinsertion of the\nbone flap using a dog bone miniplate fixation and local application of\nvancomycin powder. A subgaleal drain was placed, and the skin was closed\nusing Donati continuous sutures. A sterile staple dressing was applied,\nand the patient was transferred to recovery.\n\nCLINICAL NOTES:\n\nEpidural pannus suggestive of infection. Past surgical history includes\nglioblastoma removal in 8/11/2019 and subsequent surgeries because of\nrecurrence, the last of these in 04/12/2020. Nature and type of growth?\n\nMACROSCOPIC EXAMINATION:\n\nFixed tissue samples measuring 1.2 x 1.0 x 0.4 cm were entirely\nembedded.\n\nSTAINING: 1 block, Hematoxylin & Eosin (HE), Periodic Acid Schiff (PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology shows entirely necrotic tissue and some bony fragments. No\nmicroorganisms were detected in the PAS stain.\n\nFINDINGS:\n\nFully necrotic tissue. No signs of inflammation or malignancy in the\navailable samples.\n\nOPERATIVE REPORT:\n\nDiagnosis: Wound healing disruption high on the forehead, following a\nresection of recurrent gioblastoma in the right hemisphere in\n04/12/2020.\n\nProcedure: Wound revision, thorough wound cleaning, reinsertion of the\nautologous bone flap.\n\nTime of incision: 3:30 PM, 06/01/2020\n\nTime of suture completion: 4:35, 06/01/2020\n\nDuration: 65 minutes\n\nPATIENT HISTORY:\n\nThe patient had two prior surgeries with our team. The most recent was a\nrevision due to a wound healing complication. The patient was informed\nabout the procedure\\'s nature, extent, risks, and potential outcomes,\nand was given ample opportunity to ask questions. After thoughtful\nconsideration, written consent was obtained.\n\nOPERATION:\n\nThe patient was positioned supine with the head in a neutral position.\nThe surgical area was sterilized and draped. Antibiotic prophylaxis was\nadministered, and a timeout procedure was conducted. The old wound was\nreopened and slightly extended by about 1 cm in both directions. The\nbone flap was removed, inspected, and cleaned. It was then reinserted\nafter refreshing the bone edges. The wound edges were refreshed, and the\nwound was irrigated again before closure.\n\nSUMMARY:\n\nSuccessful wound revision without complications for a wound healing\ncomplication post-glioblastoma surgery.\n\nCLINICAL NOTES:\n\nComplication in wound healing after glioblastoma removal and radiation\ntherapy. Possible inflammation? Evaluate for pus. Nature and type of\ngrowth?\n\nMACROSCOPIC EXAMINATION:\n\nSubcutaneous tissue samples, 1.2 x 1.0 x 0.4 cm, were completely\nembedded after being cut into two.\n\nEpidural tissue samples, 5.6 x 5.3 x 1.0 cm, were partially embedded.\n\nSTAINING: 2 blocks, Hematoxylin & Eosin (HE), Periodic Acid Schiff\n(PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology displays connective tissue surrounded by a pronounced\ninflammatory infiltrate, comprised of neutrophils, lymphocytes, and\nnumerous eosinophils. Additionally, budding capillaries were seen. No\nspecific findings in the PAS stain.\n\nHistologically, connective tissue infiltrated by predominantly\nlymphocytic inflammation was observed. Eosinophils and abundant necrotic\ntissue were also seen. Additionally, polarizable material was noted,\noccasionally engulfed by multinucleated giant cells. Hemorrhagic signs\nwere indicated by hemosiderin deposits. No specific findings in the PAS\nstain.\n\nFINDINGS:\n\n1 & 2. Soft tissue displays acute phlegmonous inflammation and chronic\ngranulating inflammation.\n\n**Brief report (07/15/2020): **\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 06/01/2020.\n\nWound healing disorder right parietal at the site of previous right-side\nglioblastoma, last revision 04/12/2020.\n\n-Single right body focal seizure 04/20/2020, single generalized seizure\n05/12/2020\n\n-Previous resection on 10/12/2019\n\n-Wound healing disorder with subsequent wound revision (06/2020)\n\n-Last cMRI on 05/03/2020: no recurrence observed.\n\nSecondary diagnoses:\n\nHypothyroidism\n\nSurgery type: injection of Ropivacaine, smear for microbiology,\nreadaptation of three small wound dehiscence, tobacco bag suture,\noverlay polyhexanide gel, plaster application\n\nInstructions: Return next Tuesday for wound check. Sutures to remain in\nplace for 10 days. Check microbiology results on Thursday. Clinically,\nno signs of infection observed.\n\nSurgical report:\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 04/20/2020.\n\nASSESSMENT:\n\nThe patient was presented at the emergency unit after observing a small\nwound dehiscence after the aforementioned surgery for a wound healing\ndisorder. The treating surgeon recommended a second local wound revision\nattempting to readapt the wound with a minor surgery. The patient\nprovided written consent for the procedure. The intervention was\nconducted with standard coagulation parameters.\n\nSURGERY:\n\nSterile preparation and draping of the surgical area. Initial injection\nof Ropivacaine. This was followed by swab collection for microbiology.\nThe wound edges were excised and the wound dehiscence was readapted\nusing a tobacco bag suture. Afterward, polyhexanide gel was applied,\nfollowed by a sterile plaster dressing.\n\nSurgery report:\n\nDiagnosis: significant scalp wound healing disorder in the prior\nsurgical access area post-resection and irradiation of a glioblastoma\nmultiforme.\n\nOperating time: 49 minutes\n\n\n\n### text_4\n**Dear colleague, **\n\nwe report on Mr. Miller, John, born 04/07/1961, who was in our inpatient\ntreatment from 09/12/2020 to 10/07/2020.\n\nDischarge diagnosis: Recurrence of the pre-described glioblastoma right\ninsular, WHO CNS grade 4 (IDH wild type, MGMT methylated).\n\nPhysical examination on admission:\n\nPatient awake, fully oriented, cooperative. Non-fluent aphasia. Speech\nclear and fluent. Latent left hemisymptomatic with strength grades 4+/5,\nstance and gait unsteady. Cranial nerve status regular. Scar conditions\nnon-irritant except for frontal superficial erosion at frontal wound\npole of pterional approach. Karnofsky 70%.\n\nMedication on Admission:\n\nLevothyroxine sodium 50 μg/1 pc (Synthroid® 50 micrograms, tablets)\n1-0-0-0\n\nLorazepam 0.5 mg/1 pc (Ativan® 0.5 mg, tablets) 1-1-1-1\n\nLacosamide 100 mg/1 pc (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\n**Imaging: **\n\ncMRI +/- contrast agent dated 09/15/2020: There is a contrast enhancing\nformation on the right temporo-mesial with approach to the insular\ncistern with suspected tumor recurrence.\n\nPET dated 09/10/2020 (external): Significant tracer multinodulation with\nactive areas in the islet region is seen.\n\n**Surgery of 09/18/2020: **\n\nReopening of existing skin incision and extension of craniotomy\ncranially, microsurgical navigated tumor resection right insular (IONM:\nMEP waste lower extremity with incomplete recovery) CUSA; extensive\nhemostasis, intraoperative MRI, sutures, reimplantation of bone flap\nwith multilayer wound closure. Skin suture.\n\nHistopathological report:\n\nRecurrence of pre-described glioblastoma, WHO CNS grade 4 (IDH wild\ntype, MGMT methylated).\n\nCourse:\n\nThe patient initially presented postoperatively with left hemiplegia in\nthe sense of SMA. This regressed significantly during the inpatient\nstay. Postoperative imaging revealed a regular resection finding. In\ncase of a possible adjustment disorder, the patient was treated with\nsertraline and lorazepam. The wound was dry and non-irritant during the\ninpatient stay. The patient received regular physiotherapeutic exercise.\nThe patient\\'s case was discussed in our neuro-oncological tumor board\non 09/29/2020, where the decision was made for adjuvant definitive\nradiochemotherapy. An inpatient transfer was offered by the colleagues\nof radiotherapy.\n\nProcedure:\n\nWe transfer Mr. Miller today in good clinical general condition to your\nfurther treatment and thank you for the kind takeover. We ask for\nregular wound controls as well as regular ECG controls to exclude a\nQTc-time prolongation under sertraline. Furthermore, the medication with\nlorazepam should be further phased out in the course of time. In case of\nacute neurological deterioration, a re-presentation in our neurosurgical\noutpatient clinic or surgical emergency room is possible at any time.\n\nClinical examination findings at discharge:\n\nPatient awake, fully oriented, cooperative. Speech clear and fluent.\nCranial nerve status without pathological findings. Hemiparesis\nleft-sided strength grade 4/5, right-sided no sensorimotor deficit.\nStance and gait unsteady. Non-fluent aphasia. Wound dry, without\nirritation. Karnofsky 70%.\n\n**Medication at Discharge:**\n\nLevothyroxine sodium 50 μg (Synthroid® 50 micrograms, tablets) 1-0-0-0\n\nLorazepam 0.5 mg (Ativan® 0.5 mg, tablets) as needed\n\nLacosamide 100 mg (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\nAcetaminophen 500 mg (Tylenol® 500 mg tablets) 1-1-1-1\n\nSertraline 50 mg (Zoloft® 50 mg film-coated tablets) by regimen\n\n**Magnetic Resonance Imaging (MRI) Report**\n\nDate of Examination: 02/02/2021\n\nClinical Indication: Multifocal glioblastoma WHO grade IV, IDH wild\ntype, MGMT methylated.\n\nClinical Query: Hemiparesis on the right side. Is there a structural\ncorrelate? Tumor progression?\n\n**Previous Imaging**: Multiple prior studies. The most recent contrasted\nMRI was on 09/15/2020.\n\n**Findings**:\n\n**Imaging Device**: GE 3T; Protocol: 3D FLAIR, 3D T1 Mprage with and\nwithout contrast, SWI, DWI, 3D T2, axial T2\\*, perfusion, DTI.\n\n1. **Report: **\n\n Known multimodal pretreated GBM since 2019, recently post-surgical\n resection for tumor progression in the frontotemporal region on\n 09/18/2020. Also noted is a post-surgical resection of additional\n foci in the right insular region. The resection cavity in the right\n frontal, insular, and temporal regions appears unchanged in size and\n configuration. Residual blood products are noted within.\n\n There are increased areas of contrast enhancement compared to the\n immediate post-operative images. There is a minor growth in a\n nodular enhancement posterior to the right middle cerebral artery.\n Adjacent to this, there\\'s a new nodular enhancement, which could be\n a postoperative reactive change or a new tumor lesion.\n\n Ongoing diffusion abnormalities are observed in the right caput\n nuclei caudatus, putamen, and globus pallidus, especially pronounced\n in posterior sections.\n\n Persistent FLAIR-hyperintense peritumoral edema in the right\n hemisphere remains unchanged. The midline shift is approximately 9mm\n to the left, which remains unchanged.\n\n Post-operative swelling and fluid accumulation are noted at the\n surgical entry point. The bone flap is in place. The width of both\n the internal and external CSF spaces remains constant, with no\n evidence of obstruction.\n\n The orbital contents are symmetrical. Paranasal sinuses and mastoid\n air cells are aerated appropriately.\n\n**Impression**:\n\nResidual tumor segments along the right middle cerebral artery showing\ngrowth. Adjacent to it, a new nodular area of contrast enhancement\nsuggests either a postoperative change or a new tumor lesion.\n\nPreviously identified ischemic changes in the right caput nuclei\ncaudatus, putamen, and globus pallidus. Persistent brain edema with a\nleftward midline shift of approximately 9mm remains unchanged.\n\n\n\n### text_5\n**Dear colleague, **\n\nHerewith we report on our common patient Mr. John Miller, born\n04/07/1961, who was at our clinic between 02/04/2021 to 04/22/2021.\n\n-Recurrent manifestation of a glioblastoma\n\n-Stage: WHO CNS grade 4\n\n**Histology:**\n\nRecurrence of the pre-described glioblastoma, WHO CNS grade 4.\n\nMolecular pathological findings:\n\nIDH status: no p.R132H mutation (immunohistochemical).\n\nATRX: preservation of nuclear expression (immunohistochemical).\n\np53: technically not evaluable (immunohistochemical).\n\n1p/19q status: no combined loss (850k methylation analysis).\n\nCDKN2A/B: Deleted (850k methylation analysis).\n\nMGMT promoter: Methylated (850k methylation analysis).\n\nTumor localization: Islet/frontal right\n\nSecondary diagnoses:\n\nSymptomatic epilepsy\n\nHypothyroidism\n\nNausea\n\nLeukopenia I° (CTCAE)\n\nAnemia II° (CTCAE)\n\nPrevious course / therapies:\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n03/2020: Suspected recurrence\n\n04/2020: Revision surgery\n\n06-07/2020 Wound revisions and flap plasty for atrophic wound healing\ndisorder\n\n02/2021: Suspected recurrence with new FLAIR-positive tumor\nmanifestation insular on the right side. Stereotactic biopsy with\nevidence of glioblastoma.\n\nPathology: Renewed manifestation of a glioblastoma.\n\nRecommended radiochemotherapy.\n\nAccording to the interdisciplinary neuro-oncology board of 01/26/2021,\nwe gave the indication for adjuvant radiochemotherapy for the recurrence\nof glioblastoma.\n\n**Radiochemotherapy: **\n\nTechnique:\n\n1\\) Percutaneous intensity-modulated radiotherapy was administered to the\nformer recurrence tumor region in the frontal/insular right after CT-\nand MRI-guided radiation planning with 6 MV-photons in helical\ntomotherapy technique with a single dose of 2 Gy up to a total dose of\n60 Gy with 5 fractions per week. Daily position controls by CT.\n\n2\\) Subsequently, local dose saturation of the macroscopic tumor remnant\nwas performed.\n\nInsular right stereotactic ablative radiosurgery at the gamma knee to\nsaturate the macroscopic GammaKnife (Cobalt-60: 1.17 MeV and 1.33 MeV\nphotons) in mask fixation after CT- and MRI-guided radiotherapy planning\nunder image-guided setting (ConeBeam-CT) with a dose of 6 Gy in 2 Gy\nsingle dose to the 68% isodose up to a total cumulative dose of 66 Gy.\n\nChemotherapy:\n\nConcurrent chemotherapy with 75mg/m²KOF temozolomide daily (120 mg\ndaily).\n\nAbsolute dose: 5000 mg.\n\nTreatment Period:\n\nRadiotherapy 03/09/2021 -- 04/21/2021\n\nChemotherapy 03/09/2021 -- 04/21/2021\n\n**Course under therapy:**\n\nWe took over Mr. Miller on 03/06/2021 in reduced general and slightly\nreduced nutritional condition (Kanofsky index: 70 %, BMI: 18.5 kg/m²)\nfrom the Clinic for Neurosurgery for adjuvant re-radiochemotherapy on\nour radiooncology ward. At the time of admission, the patient had arm\n\nright hemiparesis (strength grades arm: 2/5, leg: 3/5). The patient was\nambulatory with assistance. Cranial nerve status was unremarkable.\nHeadache, nausea or dizziness were denied.\n\nOn 09/03/2021, combined re-radiochemotherapy was initiated.\n\nDuring the course of therapy with temozolomide, mild nausea occurred,\nwhich was treated with ondansetron 4mg as needed and dimenhydrinate\nSustained-release tablets 150 mg as needed. Under this treatment the\nsymptoms clearly regressed. Mild constipation was treated. Laboratory\ntests revealed mild leukopenia I° and anemia II° (CTCAE).\n\nOtherwise, the re-radiochemotherapy was very well tolerated overall.\n\nMr. Miller received physiotherapeutic exercise and psychotherapy during\nthe entire physiotherapeutic training and psycho-oncological support.\nUnder the physiotherapeutic treatment, his motor skills improved\nsignificantly. At the end of the therapy, the patient was also mobile\noutside the\n\nhouse without any aids.\n\nOn 04/22/2021 we discharged Mr. Miller to the outpatient care by his\nfamily doctor.\n\n04/11/2021: MR brain post contrast\n\nAfter renewed radiochemotherapy for a glioblastoma recurrence, a\nresidual suspicious barrier disturbance adjacent to the adjacent to the\nright cerebral artery. Stable nodular contrast enhancement\n\nPostoperative/reactive changes as described above. MR perfusion\nsequences show residual, contrast-absorbing tumor portions along the\nright A. cerebri media. Lateral to this, new nodular contrast-absorbing\nlesion, possibly postoperative reactive change. Previously known\nischemia at the right caput nuclei caudatii, putamen, and globus\npallidus. Unchanged medullary edema with midline shift to the left by\napproximately 9mm.\n\nLast lab:\n\nMCHC 29.4 g/dL (32 - 36) 04/20/2021\n\nMCH 25 pg (27 - 32) 04/20/2021\n\nLeukocytes 3.32 G/l (4.0 - 9.0) 04/20/2021\n\nHematocrit 31.6 % (37 - 43) 04/20/2021\n\nHemoglobin 9.3 g/dL (12 - 16) 04/20/2021\n\nErythrocytes 3.7 T/l (4.1 - 5.4) 04/20/2021\n\nUric acid 2.2 mg/dl (2.5 - 5.5) 04/20/2021\n\n**Further Procedure:**\n\nFurther skin care and behavior regarding side effects were explained to\nthe patient in detail.\n\nA first radiooncological control appointment was scheduled for\n06/05/2021 at 12:00 AM in our outpatient clinic. Prior to this, on\n06/02/2021 at 10:30 AM, an imaging exam (brain MRI) is scheduled.\n\nA further neuro-oncological connection is planned close to home via the\ntreating oncologist.\n\nAfter radiation therapy, we recommend annual ophthalmological check-ups\nand annual endocrinologic.\n\nwith testing of the hypothalamic-pituitary hormone axes.\n\n\n\n### text_6\n**Dear colleague, **\n\nThis is a report on our mutual patient, Mr. John Miller, born\n04/07/1961:\n\nDiagnosis:\n\nRecurrent manifestation of glioblastoma\n\nWHO CNS grade 4\n\nTumor localization: Right isle/frontal\n\nSecondary diagnoses: Symptomatic epilepsy\n\nHypothyroidism Previous\n\nTreatments / Therapies\n\nResection and revisions\n\nAdjuvant radiochemotherapy\n\nTwo wound revisions and flap plasty for atrophic wound healing disorder\n\nNew FLAIR-positive tumor manifestation insular on the right side\n(02/2021)\n\nStereotactic biopsy with histopathology with evidence of glioblastoma\n\nTumor Board: Recommended new radiochemotherapy up to a total dose of 60\nGy à 2 Gy single dose. Subsequent local dose saturation of the\nmacroscopic tumor remnant as radiosurgery on GammaKnife with a dose of 6\nGy à 2 Gy single dose (\\@68% isodose).\n\n03-4/2021 Repeat stereotactic RTx in the area of the basal ganglia and\nthe resection cavity right frontal on the Gamma Knife with 46 Gy à 2 Gy;\n3 doses of Bevacizumab 7.5 mg/kg i.v.\n\n**Summary:**\n\nOn 07/03/2023, we conducted an initial telephone follow-up with the\npatient, Mr. Miller, for a radio-oncology consultation. Presently, Mr.\nMiller is undergoing rehabilitation, from which he feels he is deriving\nsubstantial benefits. His recent radiotherapy was well-received without\nany complications. Since the onset of his symptoms, there have been no\nnew developments. Symptoms related to intracranial pressure or new\nneurological deficits were denied. Fortunately, while on anticonvulsant\ntherapy with Lacosamide, Mr. Miller experienced no epileptic seizures.\nHis skin condition is normal. However, Mr. Miller did mention some\ncognitive challenges that minimally impact his daily activities,\nalongside feelings of fatigue and grade I CTCAE symptoms. The cMRI scan\nfrom 06/02/2021 revealed a notable reduction in the barrier disturbance\nof the right-sided basal ganglia. This was accompanied by small, mildly\nhyperperfused residual findings near the third ventricle. Moreover, the\npinpoint contrast enhancement in the left parietal lobe appeared\nunchanged, suggesting it is a scarring reaction. In collaboration with\nthe neurooncology team, Mr. Miller has discussed starting chemotherapy.\nThe next imaging assessment is scheduled for mid-September. We have also\nscheduled another radio-oncologic follow-up with Mr. Miller for\nSeptember 28th, per his preference, via telephone. For patient safety,\nMr. Miller is prohibited from operating private or commercial vehicles\nfor 3 months post-intracerebral radiotherapy. This duration may extend\nif there are existing or progressing brain conditions. Following\nradiotherapy, we are mandated by the Radiation Protection Act to\nfacilitate regular checks. Hence, we encourage enrollment in the\naftercare calendar, prompt reporting of any significant findings, and\nattendance of scheduled follow-ups. Alongside these, regular oncological\ncheck-ups by specialist practitioners are mandatory. Mr. Miller has been\nduly informed of all these requirements.\n\n\n\n\nHere is the query:\nWhich molecular pathological finding was technically not evaluable (immunohistochemical) for Mr. Miller?\n\nChoose the correct answer from the following options:\nA. ATRX\nB. IDH status\nC. p53\nD. CDKN2A/B\nE. MGMT promoter\n\n\nYour response:\n", "role": "user" }, { "content": "p53", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nPatient: Miller, John, born 04/07/1961\n\nWe report to you about our common patient, Mr. John Miller, who is in\nour inpatient treatment since 07/30/2019.\n\n**Diagnoses:**\n\n\\- Suspected right cerebral glioblastoma (first diagnosis)\n\n\\- Symptoms: Aphasia, passive confusion\n\n**Patient history: **\n\nMr. Miller was admitted as an emergency. He was on the phone with a\nfriend when he suddenly began to exhibit speech difficulties and\nstruggled to find the right words. Consequently, his friend called 911.\n\nUpon the ambulance\\'s arrival, Mr. Miller was disoriented and exhibited\naggressive behavior. There was evidence of a torn door. He had blood on\nhis right forearm and around his mouth, but there were no indications of\na tongue bite or urinary incontinence.\n\nUpon admission, Mr. Miller was coherent and showed no speech issues. He\nattributed a mild weakness in his right arm to pre-existing pain in the\nupper arm. An immediate CT scan revealed a mass suggestive of a\nglioblastoma in the right cerebral hemisphere, leading to a\nneurosurgical consultation.\n\nGiven the possibility of an epileptic seizure, Mr. Miller was\nhospitalized and started on Levetiracetam. He is currently unaware of\nhis regular medications but takes antihypertensives and diabetes\nmedications, among others. His friend and brother have been notified and\nare ensuring that a detailed medication list is provided.\n\nAfter a brief stay in ward ABC, Mr. Miller was transferred to the\nneurosurgery team for further evaluation and treatment. We appreciate\nthe prompt transfer and are available for any further inquiries.\n\nPlanned Procedures:\n\n-Schedule EEG\n\n-Clarify routine medications\n\n**Surgery Report**\n\n**Diagnosis:** Suspected HGG (high-grade glioma) of the right hemisphere\n\n**Procedure:** Microsurgical navigation-guided resection of the tumor\nwith intraoperative neuromonitoring (stable MEPs) and intraoperative MRI\nusing 5-ALA. Pathology samples taken (Preliminary: HGG; Final to be\nconfirmed). Resection was followed by duragen placement, watertight\ndural closure, and multilayer wound closure, with skin sutures.\n\n**Time:**\n\n-Start: 11:12 am\n\n-Finish: 3:54 pm\n\n-Duration: 4 hours 42 minutes\n\n**Assessment:**\n\nMr. Miller presented with a seizure characterized by speech disturbance\nand disorientation. Imaging revealed a significant right hemispheral\nmass, likely representing a high-grade brain tumor. The need for\nsurgical resection was determined following discussions at our\ninterdisciplinary tumor board. After being informed about the procedure,\nalternative treatments, the operation\\'s urgency, benefits, and\npotential risks, Mr. Miller provided written consent following ample\ntime for consideration and the opportunity to ask further questions.\n\n**Procedure Details:**\n\nThe patient was positioned supine with his head secured in a Nova clamp.\nNavigation data were read, followed by skin preparation, and the\nsurgical field was sterilized and draped. An arch-shaped incision was\nmade, followed by hemostasis, deep tissue dissection, placement of a\nburr hole, and the creation of a large bone flap over the lesion. The\nbone flap was then elevated. Multiple washings were performed, followed\nby dural opening under microscopic visualization. A corticotomy was\ncarried out with bipolar forceps, CUSA, and suction to progressively\nreduce the tumor, utilizing 5-ALA fluorescence and continuous\nneurophysiological monitoring. An intraoperative MRI showed residual\ntumor, prompting further resection. Hemostasis was achieved, and the\nwound was closed using tabotamp, followed by duragen placement and dural\nsuturing. The bone flap was refixed using Dogbone plates. The wound area\nwas irrigated extensively once more, followed by subcutaneous and skin\nsutures.\n\n**Date:** 10/01/2019\n\n**Clinical Indication:**Suspected recurrence of GBM in the right\nhemisphere\n\n**Requested Imaging:**cMRI with or without contrast + DTI.\n\n**Findings:***Imaging Modality (GE 3.0T):* 3D FLAIR, DTI, SWI, T2\\*\nperfusion, 3D T1 with and without contrast, 3D T2,\nsubtraction.Following resection of a right hemispheric glioblastoma in\n08/19, and compared to the last two scans (external: 07/19, internal:\n08/19), there is a notable expansion of the prior detected flair\nhyperintense regions. These now span from the right parietal-subcortical\narea across the right basal ganglia to the right temporo-occipital/right\ntemporal pole. Specifically, at the dorsocranial edge of the resection\ncavity, the hyperintense regions appear to have grown since 08/19. These\ncoincide with hyperperfused regions in the T2\\* perfusion. Linear SWI\nsignal changes are suggestive of mild post-surgical bleeding. No\nsignificant postoperative hemorrhage or territorial ischemia is\ndetected. A normal venous sinus drainage is observed. Right temporal\nhorn appears congested, possibly due to CSF trapping.\n\n**Assessment:**\n\nFollowing the resection of the right hemispheric glioblastoma in 08/19:\n\n-Markedly progressive flair edema and evolving barrier disturbance.\nRegions especially towards the dorsal side of the resection cavity show\nthis alongside associated hyperperfusion. With the recent PET imaging\nfrom 10/19, there is an indication of progressive disease as per RANO\ncriteria.\n\n-Long-term progressive congestion of the right temporal horn, likely CSF\ntrapping.\n\n**Surgery Report****Diagnosis:**Tumor recurrence after resection of a\nglioblastoma (IDH wild type, WHO CNS grade 4) of the right hemisphere in\n08/2019. The patient underwent combined radiochemotherapy at the local\nclinical center.\n\n**Procedure:**Navigated, microsurgical resection supported by 5-ALA,\nwith stable MEPs through the previous right temporal access. iMRI\nconducted between 11:10 and 11:50. Used Duragen/TachoSil, dog bones for\nclosure, followed by layered wound closure and skin sutures.\n\n**Timing:**\n\n-Incision: 09:23 am on 10/12/19\n\n-Suture: 12:32 pm on 10/12/19\n\n**Assessment:**The patient had previously undergone surgery for a\nglioblastoma and a recurrence was detected on imaging. The tumor board\nhad already deliberated on the surgery. The patient was informed about\nthe surgical procedure, particularly about conducting an extensive\nresection caudally without impacting function post-mapping. The patient\nconsented, understanding the potential for longer progression-free\nsurvival.\n\n**Procedure Details:**The patient was placed in a supine position with\nthe head turned to the side and fixed using the Noras clamp. The right\nshoulder was padded. The surgical area was prepared by trimming hair\naround the previous scar, followed by sterilization and draping. After a\nteam time-out, prophylactic antibiotics were administered. The previous\nscar was reopened and old plates were removed. The microscope was then\nswung into position and the dura was opened. Navigation proceeded\nbeneath the labbé vein, with tumor resection as guided by ALA\nfluorescence. Post-tumor removal, extensive hemostasis was achieved\nusing absorbent cotton and TABOTAMP. Intraoperative MRI confirmed a\ncomplete resection of the tumor. The dura was sealed using DuraGen,\nensuring a watertight closure. The bone flap was reinserted, followed by\nsubcutaneous suturing, skin suturing, and sterile dressing of the wound.\n\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe write to update you regarding our shared patient, Mr. John Miller,\nborn on 07/04/1961, who visited us on 12/02/2019.\n\n**Diagnosis:**Glioblastoma recurrence, IDH 1 wild type.\n\n**Tumor Location:**Right hemisphere including temporal regions.\n\n**Clinical History & Treatment:**\n\n-07/2019: Mr. Miller experienced speech disturbances and confusion.\n\n-08/01/2019: Brain PET-MRI revealed a suspected malignancy in the right\nhemisphere, including temporal areas.\n\n-08/11/2019: Glioblastoma was resected at our facility.\n\n-08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy\nwith a boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local\nclinical center.\n\n-10/01/2019: cMRI with suspected recurrence.\n\n-10/12/2019: A recurrent resection was performed at our facility.\n\n-11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n**Recent Evaluation (12/01/2019):**Mr. Miller visited our facility with\nhis brother. Our assessment, based on CTCAE criteria, indicated that he\nis in a fair but stable general and nutritional health (KPS 70-80%,\nweight undisclosed, height 175 cm). Neurological and general evaluations\nrevealed a degree of aphasia, mainly with word-finding difficulty, and\nshort-term memory impairment. However, he remains fully oriented and\nindependent in daily life.\n\n**Additional Observations:**\n\nHis surgical wound has healed well.\n\n**Pre-existing Conditions:** Arterial hypertension, Diabetes Mellitus\nType II\n\n**Allergies:** None\n\n**Current Medications:** Antihypertensive drugs and insulin.\n\nPostoperatively, Mr. Miller remains in good health. A recent brain MRI\nnoted that the suspected recurring GBM lesion near the superior border\nof the surgical site was entirely resected. Furthermore, CT scans at the\nanterior medial and lateral edges suggest that a complete resection was\nmost likely achieved.\n\nGiven the presumed complete resection of the glioblastoma recurrence, we\nhave recommended Mr. Miller for a neuro-oncology review and a follow-up\nwith PET-MRI in three months.\n\n**Next Steps:**\n\n-He has a scheduled appointment in neuro-oncology on 01/23/2020 at 10:00\nAM.\n\n-A follow-up PET-MRI is set for 01/29/2020 at 12:45 PM. We have advised\nMr. Miller to fast for 4 hours prior and to bring a referral from his\nprimary care physician, along with a recent creatinine test result.\n\n-A review of these findings will be held in our outpatient department on\n01/30/2020 at 2:00 PM.\n\nThank you for your continued care and collaboration. Please do not\nhesitate to reach out for any additional information.\n\nWarm regards,\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nRegarding our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nGlioblastoma recurrence, IDH 1 wild type\n\n**Tumor Location**:\n\nRight hemisphere/temporal.\n\n**Medical History**:\n\n07/2019: Onset of speech arrest and confusion.\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\nMr. Miller came in on 12/01/2019 with his brother. Clinical examination\nfindings are as follows:\n\n-General health: Stable with reduced vitality.\n\n-Nutritional status: Stable (KPS 70-80%, weight in kg, height 169 cm).\n\n-No evident motor, sensory, visual, or cranial nerve deficits.\n\n-Neurocognitive deficits: Short-term memory issues.\n\n-Aphasia: Grade II (mainly word-finding disorders). The patient is fully\noriented and independent in daily life.\n\n-No evidence of recurrence in PET-MRI. Next imaging scheduled in\n03/2020.\n\n**Past Medical Conditions**:\n\n-Hypertension\n\n-Type II Diabetes Mellitus\n\n**Allergies**: None.\n\n**Medications**:\n\n-Antihypertensive medications\n\n-Insulin\n\nBest Regards,\n\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nUpdating you on our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nRecurrent Glioblastoma, IDH 1 wild type (ICD-10: 71.8).\n\n**Molecular Pathology**:\n\nNo p.R132H mutation in IDH.\n\nNo combined 1p/19q loss.\n\nSuspected CDKN2A/B deletion.\n\n**Medical History**:\n\nNo pain or B symptoms.\n\nIntermittent dizziness and headaches since the last check-up.\n\n**Neurological Findings**:\n\nPatient is alert and oriented.\n\nWeight: 80 kg (total loss: 15 kg), Height: 175 cm.\n\nKarnofsky Performance Score: 80%.\n\nMotor function and sensory assessments were unremarkable.\n\n**Allergies**: None.\n\n**Medications**:\n\nLisinopril 10mg once daily in the morning\n\nBisoprolol 2.5mg once daily at bedtime\n\nJanuvia 50mg twice daily\n\nAllopurinol 100mg once daily in the morning\n\nEzetimibe 10mg once daily at bedtime\n\nLevetiracetam 1000mg once daily in the morning Insulin as per regimen\n\n**Secondary Diagnoses**:\n\nHypertension\n\nType II Diabetes Mellitus\n\n**Medical Course**:\n\nDetails from 07/2019 through 03/2020 provided, including surgeries,\nradiochemotherapies, and diagnostics.\n\nIn summary, Mr. Miller\\'s glioblastoma diagnosis in 07/2019 led to\nvarious treatments, including radiochemotherapy and surgeries. His\nrecent PET/MRI on 01/2020 indicates potential recurrent areas.\n\nBest regards,\n\n**Patient:** John Miller\n\n**DOB:** 04/07/1961\n\n**Admission Date:** 04/11/2020\n\n**Discharge Date:** 04/18/2020\n\n**Admission Diagnosis:**\n\nRecurrent tumor in the hippocampal region and along the prior resection\ncavity.\n\nHistory of glioblastoma (IDH wild type, WHO CNS grade 4) in the right\nhemisphere, resected on 08/2019.\n\nHistory of combined radiochemotherapy with Temodar (Temozolomide) from\nAugust to September 2019 at the local clinical center.\n\nSubsequent first re-resection in 10/2019.\n\n**Presenting Complaint:**\n\nMr. Miller presented to the neurosurgical outpatient department\naccompanied by his wife. Recent imaging indicated a potential recurrence\nof the glioblastoma. The neuro-oncological board on 04/12/2020\nrecommended a re-resection.\n\n**Physical eon Admission:**\n\nAlert, oriented x4, cooperative.\n\nNon-fluent aphasia.\n\nCranial nerves intact.\n\nNo sensory or motor deficits in the extremities.\n\nSurgical scar clean and dry.\n\nNo signs of neurogenic bladder or rectal dysfunction.\n\nKPSS 70%.\n\n**Medications on Admission:**\n\n-Lisinopril 10mg daily\n\n-Bisoprolol 2.5mg nightly\n\n-Januvia 50mg twice daily\n\n-Allopurinol 100mg daily\n\n-Atorvastatin 40mg nightly\n\n-Ezetimibe 10mg nightly\n\n-Levetiracetam 1000mg twice daily\n\n-Actraphane insulin as prescribed\n\n**Surgical Intervention (04/12/2020):**\n\nNavigated microsurgical resection of tumor spots assisted with 5-ALA.\nStable MEPs were maintained. An intraoperative MRI (iMRI) was utilized.\nPost-resection, the surgical area was managed using Tabotamp, Duragen,\nTachoSil, and dog-bone plates, concluding with layered wound closure.\n\n**Postoperative Course:**\n\nUncomplicated recovery.\n\nPost-op MRI showed no residual tumor.\n\nSurgical site remained clean, dry, and showed no signs of infection or\nirritation.\n\n**Discharge Diagnosis:**\n\nRecurrence of known glioblastoma, WHO CNS grade 4.\n\n**Interdisciplinary Neuro-oncological Tumor Board Recommendation\n(04/20/2020):**\n\nMolecular tumor board review.\n\nOffer reinitiation of Temozolomide chemotherapy.\n\n**Physical Examination on Discharge:**\n\nSimilar to admission, with suture in place and wound site in good\ncondition.\n\nKPSS 70%.\n\n**Medications on Discharge:**\n\n-Allopurinol 100mg daily (morning)\n\n-Atorvastatin 40mg nightly (evening)\n\n-Bisoprolol 2.5mg nightly (evening)\n\n-Ezetimibe 10mg nightly (evening)\n\n-Sitagliptin (Januvia) 50mg twice daily (morning and evening)\n\n-Levetiracetam (Keppra) 1000mg twice daily (morning and evening)\n\n-Lisinopril 10mg daily (morning)\n\n-Acetaminophen 500mg as needed for pain or fever\n\n-Actraphane insulin as prescribed\n\n**Surgery Report **\n\n**Diagnosis**:\n\nTumor recurrence in the right hippocampal region and along the resection\ncavity post glioblastoma resection on 8/11/2019.\n\nPrevious treatments include radiochemotherapy at our clinic. Local\ntherapy center (from August to September 2019) and re-resection on\n10/12/2019.\n\n**Surgery Type**:\n\nRe-opening of the temporal region with navigation, microsurgery using\n5-ALA assistance, iMRI, and re-resection, among other procedures.\n\n**Procedure Details**:\n\nStart: 11:50 pm on 04/12/2020\n\nEnd: 4:00 pm on 04/12/2020\n\nDuration: 4 hours 10 minutes.\n\n**Assessment**:\n\nEvidence of recurrent glioblastoma areas warranted another biopsy and\nresection. After informing Mr. Miller about the procedure\\'s risks and\nbenefits, he provided written consent.\n\n**Operation**:\n\nDetails on the positioning, pre-operative preparations, resection, and\npost-operative procedures are provided.\n\nBest regards,\n\nMEDICAL HISTORY:\n\nMr. Miller underwent surgery because of tumor recurrence in the right\nhemisphere last November to treat a right temporal glioblastoma. He\npresented to our private outpatient clinic due to a wound complication,\nspecifically a wound dehiscence measuring about 1 cm. On closer\nexamination, pus was noted. Despite being symptom-free otherwise, a\nconsultation with Dr. Doe was scheduled. After discussion, it was\ndecided to clean the wound, trim the deteriorated wound edges, and clean\nthe bone flap with an antibiotic solution before reinserting it. The\npatient was thoroughly educated about the nature and risks of the\nprocedure and gave consent.\n\nOPERATION:\n\nThe patient was placed in a supine position. The hair surrounding the\nsurgical site was trimmed, followed by skin disinfection and sterile\ndraping. The bicoronal skin incision was reopened. Deteriorated wound\nedges were excised and the wound was extensively cleaned with\nirrigation. The bone flap was removed and immersed in a Refobacin\nsolution. The epidural pannus tissue was removed. The dura was\ncompletely sutured. Multiple samples were collected both subgaleally and\nepidurally. A sponge was applied, followed by the reinsertion of the\nbone flap using a dog bone miniplate fixation and local application of\nvancomycin powder. A subgaleal drain was placed, and the skin was closed\nusing Donati continuous sutures. A sterile staple dressing was applied,\nand the patient was transferred to recovery.\n\nCLINICAL NOTES:\n\nEpidural pannus suggestive of infection. Past surgical history includes\nglioblastoma removal in 8/11/2019 and subsequent surgeries because of\nrecurrence, the last of these in 04/12/2020. Nature and type of growth?\n\nMACROSCOPIC EXAMINATION:\n\nFixed tissue samples measuring 1.2 x 1.0 x 0.4 cm were entirely\nembedded.\n\nSTAINING: 1 block, Hematoxylin & Eosin (HE), Periodic Acid Schiff (PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology shows entirely necrotic tissue and some bony fragments. No\nmicroorganisms were detected in the PAS stain.\n\nFINDINGS:\n\nFully necrotic tissue. No signs of inflammation or malignancy in the\navailable samples.\n\nOPERATIVE REPORT:\n\nDiagnosis: Wound healing disruption high on the forehead, following a\nresection of recurrent gioblastoma in the right hemisphere in\n04/12/2020.\n\nProcedure: Wound revision, thorough wound cleaning, reinsertion of the\nautologous bone flap.\n\nTime of incision: 3:30 PM, 06/01/2020\n\nTime of suture completion: 4:35, 06/01/2020\n\nDuration: 65 minutes\n\nPATIENT HISTORY:\n\nThe patient had two prior surgeries with our team. The most recent was a\nrevision due to a wound healing complication. The patient was informed\nabout the procedure\\'s nature, extent, risks, and potential outcomes,\nand was given ample opportunity to ask questions. After thoughtful\nconsideration, written consent was obtained.\n\nOPERATION:\n\nThe patient was positioned supine with the head in a neutral position.\nThe surgical area was sterilized and draped. Antibiotic prophylaxis was\nadministered, and a timeout procedure was conducted. The old wound was\nreopened and slightly extended by about 1 cm in both directions. The\nbone flap was removed, inspected, and cleaned. It was then reinserted\nafter refreshing the bone edges. The wound edges were refreshed, and the\nwound was irrigated again before closure.\n\nSUMMARY:\n\nSuccessful wound revision without complications for a wound healing\ncomplication post-glioblastoma surgery.\n\nCLINICAL NOTES:\n\nComplication in wound healing after glioblastoma removal and radiation\ntherapy. Possible inflammation? Evaluate for pus. Nature and type of\ngrowth?\n\nMACROSCOPIC EXAMINATION:\n\nSubcutaneous tissue samples, 1.2 x 1.0 x 0.4 cm, were completely\nembedded after being cut into two.\n\nEpidural tissue samples, 5.6 x 5.3 x 1.0 cm, were partially embedded.\n\nSTAINING: 2 blocks, Hematoxylin & Eosin (HE), Periodic Acid Schiff\n(PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology displays connective tissue surrounded by a pronounced\ninflammatory infiltrate, comprised of neutrophils, lymphocytes, and\nnumerous eosinophils. Additionally, budding capillaries were seen. No\nspecific findings in the PAS stain.\n\nHistologically, connective tissue infiltrated by predominantly\nlymphocytic inflammation was observed. Eosinophils and abundant necrotic\ntissue were also seen. Additionally, polarizable material was noted,\noccasionally engulfed by multinucleated giant cells. Hemorrhagic signs\nwere indicated by hemosiderin deposits. No specific findings in the PAS\nstain.\n\nFINDINGS:\n\n1 & 2. Soft tissue displays acute phlegmonous inflammation and chronic\ngranulating inflammation.\n\n**Brief report (07/15/2020): **\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 06/01/2020.\n\nWound healing disorder right parietal at the site of previous right-side\nglioblastoma, last revision 04/12/2020.\n\n-Single right body focal seizure 04/20/2020, single generalized seizure\n05/12/2020\n\n-Previous resection on 10/12/2019\n\n-Wound healing disorder with subsequent wound revision (06/2020)\n\n-Last cMRI on 05/03/2020: no recurrence observed.\n\nSecondary diagnoses:\n\nHypothyroidism\n\nSurgery type: injection of Ropivacaine, smear for microbiology,\nreadaptation of three small wound dehiscence, tobacco bag suture,\noverlay polyhexanide gel, plaster application\n\nInstructions: Return next Tuesday for wound check. Sutures to remain in\nplace for 10 days. Check microbiology results on Thursday. Clinically,\nno signs of infection observed.\n\nSurgical report:\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 04/20/2020.\n\nASSESSMENT:\n\nThe patient was presented at the emergency unit after observing a small\nwound dehiscence after the aforementioned surgery for a wound healing\ndisorder. The treating surgeon recommended a second local wound revision\nattempting to readapt the wound with a minor surgery. The patient\nprovided written consent for the procedure. The intervention was\nconducted with standard coagulation parameters.\n\nSURGERY:\n\nSterile preparation and draping of the surgical area. Initial injection\nof Ropivacaine. This was followed by swab collection for microbiology.\nThe wound edges were excised and the wound dehiscence was readapted\nusing a tobacco bag suture. Afterward, polyhexanide gel was applied,\nfollowed by a sterile plaster dressing.\n\nSurgery report:\n\nDiagnosis: significant scalp wound healing disorder in the prior\nsurgical access area post-resection and irradiation of a glioblastoma\nmultiforme.\n\nOperating time: 49 minutes\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nwe report on Mr. Miller, John, born 04/07/1961, who was in our inpatient\ntreatment from 09/12/2020 to 10/07/2020.\n\nDischarge diagnosis: Recurrence of the pre-described glioblastoma right\ninsular, WHO CNS grade 4 (IDH wild type, MGMT methylated).\n\nPhysical examination on admission:\n\nPatient awake, fully oriented, cooperative. Non-fluent aphasia. Speech\nclear and fluent. Latent left hemisymptomatic with strength grades 4+/5,\nstance and gait unsteady. Cranial nerve status regular. Scar conditions\nnon-irritant except for frontal superficial erosion at frontal wound\npole of pterional approach. Karnofsky 70%.\n\nMedication on Admission:\n\nLevothyroxine sodium 50 μg/1 pc (Synthroid® 50 micrograms, tablets)\n1-0-0-0\n\nLorazepam 0.5 mg/1 pc (Ativan® 0.5 mg, tablets) 1-1-1-1\n\nLacosamide 100 mg/1 pc (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\n**Imaging: **\n\ncMRI +/- contrast agent dated 09/15/2020: There is a contrast enhancing\nformation on the right temporo-mesial with approach to the insular\ncistern with suspected tumor recurrence.\n\nPET dated 09/10/2020 (external): Significant tracer multinodulation with\nactive areas in the islet region is seen.\n\n**Surgery of 09/18/2020: **\n\nReopening of existing skin incision and extension of craniotomy\ncranially, microsurgical navigated tumor resection right insular (IONM:\nMEP waste lower extremity with incomplete recovery) CUSA; extensive\nhemostasis, intraoperative MRI, sutures, reimplantation of bone flap\nwith multilayer wound closure. Skin suture.\n\nHistopathological report:\n\nRecurrence of pre-described glioblastoma, WHO CNS grade 4 (IDH wild\ntype, MGMT methylated).\n\nCourse:\n\nThe patient initially presented postoperatively with left hemiplegia in\nthe sense of SMA. This regressed significantly during the inpatient\nstay. Postoperative imaging revealed a regular resection finding. In\ncase of a possible adjustment disorder, the patient was treated with\nsertraline and lorazepam. The wound was dry and non-irritant during the\ninpatient stay. The patient received regular physiotherapeutic exercise.\nThe patient\\'s case was discussed in our neuro-oncological tumor board\non 09/29/2020, where the decision was made for adjuvant definitive\nradiochemotherapy. An inpatient transfer was offered by the colleagues\nof radiotherapy.\n\nProcedure:\n\nWe transfer Mr. Miller today in good clinical general condition to your\nfurther treatment and thank you for the kind takeover. We ask for\nregular wound controls as well as regular ECG controls to exclude a\nQTc-time prolongation under sertraline. Furthermore, the medication with\nlorazepam should be further phased out in the course of time. In case of\nacute neurological deterioration, a re-presentation in our neurosurgical\noutpatient clinic or surgical emergency room is possible at any time.\n\nClinical examination findings at discharge:\n\nPatient awake, fully oriented, cooperative. Speech clear and fluent.\nCranial nerve status without pathological findings. Hemiparesis\nleft-sided strength grade 4/5, right-sided no sensorimotor deficit.\nStance and gait unsteady. Non-fluent aphasia. Wound dry, without\nirritation. Karnofsky 70%.\n\n**Medication at Discharge:**\n\nLevothyroxine sodium 50 μg (Synthroid® 50 micrograms, tablets) 1-0-0-0\n\nLorazepam 0.5 mg (Ativan® 0.5 mg, tablets) as needed\n\nLacosamide 100 mg (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\nAcetaminophen 500 mg (Tylenol® 500 mg tablets) 1-1-1-1\n\nSertraline 50 mg (Zoloft® 50 mg film-coated tablets) by regimen\n\n**Magnetic Resonance Imaging (MRI) Report**\n\nDate of Examination: 02/02/2021\n\nClinical Indication: Multifocal glioblastoma WHO grade IV, IDH wild\ntype, MGMT methylated.\n\nClinical Query: Hemiparesis on the right side. Is there a structural\ncorrelate? Tumor progression?\n\n**Previous Imaging**: Multiple prior studies. The most recent contrasted\nMRI was on 09/15/2020.\n\n**Findings**:\n\n**Imaging Device**: GE 3T; Protocol: 3D FLAIR, 3D T1 Mprage with and\nwithout contrast, SWI, DWI, 3D T2, axial T2\\*, perfusion, DTI.\n\n1. **Report: **\n\n Known multimodal pretreated GBM since 2019, recently post-surgical\n resection for tumor progression in the frontotemporal region on\n 09/18/2020. Also noted is a post-surgical resection of additional\n foci in the right insular region. The resection cavity in the right\n frontal, insular, and temporal regions appears unchanged in size and\n configuration. Residual blood products are noted within.\n\n There are increased areas of contrast enhancement compared to the\n immediate post-operative images. There is a minor growth in a\n nodular enhancement posterior to the right middle cerebral artery.\n Adjacent to this, there\\'s a new nodular enhancement, which could be\n a postoperative reactive change or a new tumor lesion.\n\n Ongoing diffusion abnormalities are observed in the right caput\n nuclei caudatus, putamen, and globus pallidus, especially pronounced\n in posterior sections.\n\n Persistent FLAIR-hyperintense peritumoral edema in the right\n hemisphere remains unchanged. The midline shift is approximately 9mm\n to the left, which remains unchanged.\n\n Post-operative swelling and fluid accumulation are noted at the\n surgical entry point. The bone flap is in place. The width of both\n the internal and external CSF spaces remains constant, with no\n evidence of obstruction.\n\n The orbital contents are symmetrical. Paranasal sinuses and mastoid\n air cells are aerated appropriately.\n\n**Impression**:\n\nResidual tumor segments along the right middle cerebral artery showing\ngrowth. Adjacent to it, a new nodular area of contrast enhancement\nsuggests either a postoperative change or a new tumor lesion.\n\nPreviously identified ischemic changes in the right caput nuclei\ncaudatus, putamen, and globus pallidus. Persistent brain edema with a\nleftward midline shift of approximately 9mm remains unchanged.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nHerewith we report on our common patient Mr. John Miller, born\n04/07/1961, who was at our clinic between 02/04/2021 to 04/22/2021.\n\n-Recurrent manifestation of a glioblastoma\n\n-Stage: WHO CNS grade 4\n\n**Histology:**\n\nRecurrence of the pre-described glioblastoma, WHO CNS grade 4.\n\nMolecular pathological findings:\n\nIDH status: no p.R132H mutation (immunohistochemical).\n\nATRX: preservation of nuclear expression (immunohistochemical).\n\np53: technically not evaluable (immunohistochemical).\n\n1p/19q status: no combined loss (850k methylation analysis).\n\nCDKN2A/B: Deleted (850k methylation analysis).\n\nMGMT promoter: Methylated (850k methylation analysis).\n\nTumor localization: Islet/frontal right\n\nSecondary diagnoses:\n\nSymptomatic epilepsy\n\nHypothyroidism\n\nNausea\n\nLeukopenia I° (CTCAE)\n\nAnemia II° (CTCAE)\n\nPrevious course / therapies:\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n03/2020: Suspected recurrence\n\n04/2020: Revision surgery\n\n06-07/2020 Wound revisions and flap plasty for atrophic wound healing\ndisorder\n\n02/2021: Suspected recurrence with new FLAIR-positive tumor\nmanifestation insular on the right side. Stereotactic biopsy with\nevidence of glioblastoma.\n\nPathology: Renewed manifestation of a glioblastoma.\n\nRecommended radiochemotherapy.\n\nAccording to the interdisciplinary neuro-oncology board of 01/26/2021,\nwe gave the indication for adjuvant radiochemotherapy for the recurrence\nof glioblastoma.\n\n**Radiochemotherapy: **\n\nTechnique:\n\n1\\) Percutaneous intensity-modulated radiotherapy was administered to the\nformer recurrence tumor region in the frontal/insular right after CT-\nand MRI-guided radiation planning with 6 MV-photons in helical\ntomotherapy technique with a single dose of 2 Gy up to a total dose of\n60 Gy with 5 fractions per week. Daily position controls by CT.\n\n2\\) Subsequently, local dose saturation of the macroscopic tumor remnant\nwas performed.\n\nInsular right stereotactic ablative radiosurgery at the gamma knee to\nsaturate the macroscopic GammaKnife (Cobalt-60: 1.17 MeV and 1.33 MeV\nphotons) in mask fixation after CT- and MRI-guided radiotherapy planning\nunder image-guided setting (ConeBeam-CT) with a dose of 6 Gy in 2 Gy\nsingle dose to the 68% isodose up to a total cumulative dose of 66 Gy.\n\nChemotherapy:\n\nConcurrent chemotherapy with 75mg/m²KOF temozolomide daily (120 mg\ndaily).\n\nAbsolute dose: 5000 mg.\n\nTreatment Period:\n\nRadiotherapy 03/09/2021 -- 04/21/2021\n\nChemotherapy 03/09/2021 -- 04/21/2021\n\n**Course under therapy:**\n\nWe took over Mr. Miller on 03/06/2021 in reduced general and slightly\nreduced nutritional condition (Kanofsky index: 70 %, BMI: 18.5 kg/m²)\nfrom the Clinic for Neurosurgery for adjuvant re-radiochemotherapy on\nour radiooncology ward. At the time of admission, the patient had arm\n\nright hemiparesis (strength grades arm: 2/5, leg: 3/5). The patient was\nambulatory with assistance. Cranial nerve status was unremarkable.\nHeadache, nausea or dizziness were denied.\n\nOn 09/03/2021, combined re-radiochemotherapy was initiated.\n\nDuring the course of therapy with temozolomide, mild nausea occurred,\nwhich was treated with ondansetron 4mg as needed and dimenhydrinate\nSustained-release tablets 150 mg as needed. Under this treatment the\nsymptoms clearly regressed. Mild constipation was treated. Laboratory\ntests revealed mild leukopenia I° and anemia II° (CTCAE).\n\nOtherwise, the re-radiochemotherapy was very well tolerated overall.\n\nMr. Miller received physiotherapeutic exercise and psychotherapy during\nthe entire physiotherapeutic training and psycho-oncological support.\nUnder the physiotherapeutic treatment, his motor skills improved\nsignificantly. At the end of the therapy, the patient was also mobile\noutside the\n\nhouse without any aids.\n\nOn 04/22/2021 we discharged Mr. Miller to the outpatient care by his\nfamily doctor.\n\n04/11/2021: MR brain post contrast\n\nAfter renewed radiochemotherapy for a glioblastoma recurrence, a\nresidual suspicious barrier disturbance adjacent to the adjacent to the\nright cerebral artery. Stable nodular contrast enhancement\n\nPostoperative/reactive changes as described above. MR perfusion\nsequences show residual, contrast-absorbing tumor portions along the\nright A. cerebri media. Lateral to this, new nodular contrast-absorbing\nlesion, possibly postoperative reactive change. Previously known\nischemia at the right caput nuclei caudatii, putamen, and globus\npallidus. Unchanged medullary edema with midline shift to the left by\napproximately 9mm.\n\nLast lab:\n\nMCHC 29.4 g/dL (32 - 36) 04/20/2021\n\nMCH 25 pg (27 - 32) 04/20/2021\n\nLeukocytes 3.32 G/l (4.0 - 9.0) 04/20/2021\n\nHematocrit 31.6 % (37 - 43) 04/20/2021\n\nHemoglobin 9.3 g/dL (12 - 16) 04/20/2021\n\nErythrocytes 3.7 T/l (4.1 - 5.4) 04/20/2021\n\nUric acid 2.2 mg/dl (2.5 - 5.5) 04/20/2021\n\n**Further Procedure:**\n\nFurther skin care and behavior regarding side effects were explained to\nthe patient in detail.\n\nA first radiooncological control appointment was scheduled for\n06/05/2021 at 12:00 AM in our outpatient clinic. Prior to this, on\n06/02/2021 at 10:30 AM, an imaging exam (brain MRI) is scheduled.\n\nA further neuro-oncological connection is planned close to home via the\ntreating oncologist.\n\nAfter radiation therapy, we recommend annual ophthalmological check-ups\nand annual endocrinologic.\n\nwith testing of the hypothalamic-pituitary hormone axes.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nThis is a report on our mutual patient, Mr. John Miller, born\n04/07/1961:\n\nDiagnosis:\n\nRecurrent manifestation of glioblastoma\n\nWHO CNS grade 4\n\nTumor localization: Right isle/frontal\n\nSecondary diagnoses: Symptomatic epilepsy\n\nHypothyroidism Previous\n\nTreatments / Therapies\n\nResection and revisions\n\nAdjuvant radiochemotherapy\n\nTwo wound revisions and flap plasty for atrophic wound healing disorder\n\nNew FLAIR-positive tumor manifestation insular on the right side\n(02/2021)\n\nStereotactic biopsy with histopathology with evidence of glioblastoma\n\nTumor Board: Recommended new radiochemotherapy up to a total dose of 60\nGy à 2 Gy single dose. Subsequent local dose saturation of the\nmacroscopic tumor remnant as radiosurgery on GammaKnife with a dose of 6\nGy à 2 Gy single dose (\\@68% isodose).\n\n03-4/2021 Repeat stereotactic RTx in the area of the basal ganglia and\nthe resection cavity right frontal on the Gamma Knife with 46 Gy à 2 Gy;\n3 doses of Bevacizumab 7.5 mg/kg i.v.\n\n**Summary:**\n\nOn 07/03/2023, we conducted an initial telephone follow-up with the\npatient, Mr. Miller, for a radio-oncology consultation. Presently, Mr.\nMiller is undergoing rehabilitation, from which he feels he is deriving\nsubstantial benefits. His recent radiotherapy was well-received without\nany complications. Since the onset of his symptoms, there have been no\nnew developments. Symptoms related to intracranial pressure or new\nneurological deficits were denied. Fortunately, while on anticonvulsant\ntherapy with Lacosamide, Mr. Miller experienced no epileptic seizures.\nHis skin condition is normal. However, Mr. Miller did mention some\ncognitive challenges that minimally impact his daily activities,\nalongside feelings of fatigue and grade I CTCAE symptoms. The cMRI scan\nfrom 06/02/2021 revealed a notable reduction in the barrier disturbance\nof the right-sided basal ganglia. This was accompanied by small, mildly\nhyperperfused residual findings near the third ventricle. Moreover, the\npinpoint contrast enhancement in the left parietal lobe appeared\nunchanged, suggesting it is a scarring reaction. In collaboration with\nthe neurooncology team, Mr. Miller has discussed starting chemotherapy.\nThe next imaging assessment is scheduled for mid-September. We have also\nscheduled another radio-oncologic follow-up with Mr. Miller for\nSeptember 28th, per his preference, via telephone. For patient safety,\nMr. Miller is prohibited from operating private or commercial vehicles\nfor 3 months post-intracerebral radiotherapy. This duration may extend\nif there are existing or progressing brain conditions. Following\nradiotherapy, we are mandated by the Radiation Protection Act to\nfacilitate regular checks. Hence, we encourage enrollment in the\naftercare calendar, prompt reporting of any significant findings, and\nattendance of scheduled follow-ups. Alongside these, regular oncological\ncheck-ups by specialist practitioners are mandatory. Mr. Miller has been\nduly informed of all these requirements.\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_3\n**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n### text_5\n**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n\n\n\nHere is the query:\nWhat physical examination finding was noted in Mr. Davies during his 2009 hospital stay?\n\nChoose the correct answer from the following options:\nA. Diminished breath sounds on the left base\nB. Cervical lymphadenopathy\nC. Hepatosplenomegaly\nD. Signs of meningeal irritation\nE. Exacerbation of headaches with bending forward\n\n\nYour response:\n", "role": "user" }, { "content": "Diminished breath sounds on the left base", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho was admitted to our inpatient care from 04/09/2009 to 04/23/2009.\n\n**Diagnoses:**\n\n- Bronchopneumonia\n\n- Classic Galactosemia\n\n**Medical History:** The patient has a known diagnosis of galactosemia\n(dietetically managed). For the past week, he has been experiencing\ndaily fevers up to 39°C, especially in the evenings and at night. He has\nbeen heavily congested with yellowish-tinged sputum. The patient also\nhad difficulty sleeping through the night due to coughing fits, along\nwith excessive nighttime sweating, as reported by the father. He has had\na decreased appetite, resulting in a weight loss of 5 kg. He has\nexperienced frequent nausea but no vomiting, and there has been no\ndiarrhea. He has also complained of occasional headaches and neck pain.\nHe visited the family doctor, where he was prescribed a mucolytic\nmedication.\n\n**Physical Examination:** Good general condition, with a lean build.\nSkin color rosy. Mucous membranes moist. No pathological skin\nmanifestations. Pupils isochoric and react to light. Oropharynx\nunremarkable. Tympanic membranes bilaterally reflective. No cervical\nlymphadenopathy. Heart: Regular and rhythmic. Lungs: Clear breath sounds\nbilaterally, diminished breath sounds on the left base. Abdomen: Soft,\nnon-tender, no masses, no hepatosplenomegaly, active peristalsis, no\nsigns of meningeal irritation, no exacerbation of headaches with bending\nforward. Weight: 67 kg.\n\n**Chest X-ray (posteroanterior view) dated 04/09/2009:**\n\n**Findings:** In the lower left lung, there is a patchy area of reduced\ntransparency with partial obscuration of the heart contour. Mildly\nincreased markings caudal to the right hilum: Left-sided\nbronchopneumonia with accompanying effusion on the left. The mediastinum\nis not widened. Heart size is within normal limits. Equal ventilation of\nboth lungs. No pneumothorax detected.\n\nPlease note that this translation is for informational purposes and\nshould not replace professional medical advice or interpretation.\n\n**Treatment and Progression:** The patient was admitted due to\nbronchopneumonia. He received intravenous therapy with Cefuroxime and\nadditional inhalation therapy with Sodium Chloride 0.9%. Oxygen\nsupplementation was never required. His fever subsided rapidly, and his\ncondition improved significantly, allowing for his discharge today in a\nsatisfactory state for outpatient follow-up care. We recommend\ncontinuing the Cefuroxime therapy until 09/10/2009. Laboratory results\nshowed an elevated creatinine level, and we request an outpatient\nfollow-up for further evaluation.\n\n**Current Recommendations:**\n\n- Follow-up appointment in the metabolic clinic on 09/20/09.\n\n- Outpatient creatinine level check.\n\n**Medication upon Discharge:**\n\n- Cefuroxime axetil 2 x 500 mg daily orally.\n\n**Neuropsychological findings**\n\n**Self-assessment**: Mr. Davies reported not noticing any significant\ndeterioration in his memory. His ability to concentrate remained\nessentially unchanged. Additionally, he stated that previous occasional\nword-finding difficulties had improved. Currently, after completing\ntwelve years of education, he works part-time as a nursing assistant. He\nstill resides with his parents.\n\n[Behavioral Observation]{.underline}: During the neuropsychological\nassessment, Mr. Davies was cooperative, communicative, and friendly. He\nunderstood instructions well and executed them appropriately.\n\n[Neuropsychological Assessment Performed Procedures:]{.underline} Test\nbattery for attention assessment, subtests Alertness and Divided\nAttention;\n\nWechsler Memory Scale -- Revised Version, subtests Forward and Backward\nDigit Span; Verbal Learning and Memory Test by Rey, Rey-Osterrieth\nComplex Figure Test Form B; Multiple-Choice Vocabulary Intelligence Test\n(MWT-A, by Lehrl).\n\nAttention In testing simple visual reactions, Mr. Davies exhibited\nborderline reaction times with poor stability (245 ms, reaction time\nmedian for tonic alertness; 52 ms, standard deviation for tonic\nalertness). However, when provided with a warning stimulus, he\ndemonstrated normative performance with appropriate stability (212 ms,\nreaction time median for phasic alertness; 45 ms, standard deviation for\nphasic alertness). In the Divided Attention subtest, the subject must\nsimultaneously attend to both a visual and an auditory stimulus and\nrespond to a defined critical stimulus constellation. Mr. Davies\nresponded moderately to the visual stimuli (825 ms) and as expected to\nthe auditory stimuli (575 ms). However, the qualitative performance was\ninadequate, with 2 omissions and 13 incorrect responses.\n\n[Memory Short-term/Working Memory:]{.underline} The retention of verbal\ninformation in short-term memory (Forward Digit Span) was average (raw\nscore 6). Mental manipulation of these briefly held contents (Backward\nDigit Span) fell below expectations (raw score 3). Verbal Learning and\nMemory: In the VLMT, 15 unrelated words are learned over 5 learning\ntrials. Mr. Davies demonstrated consistent learning (words in trials 1\nto 5: 7-9-12-15-15) with an adequate span (raw score 7). The overall\nlearning performance matched age-related expectations (raw score 58).\nAfter interference (remembering 7 words from an interference list), he\nrecalled all 15 words, and after a 30-minute retention interval, he\ncould also recall all 15 items. Two intrusions occurred during the\nlearning trials. Recognition performance was maximal.\n\n[Figural Memory Performance]{.underline}: Immediate reproduction of a\ncomplex geometric figure following error-free copying was average (raw\nscore 22.5,). After an approximately 30-minute retention interval,\nperformance remained within the normal range (raw score 21.5).\n\n[Orientation and Knowledge:]{.underline} Orientation was intact in all\naspects. The patient could correctly answer questions regarding\nsituation and person, time, and place. He could name well-known public\nfigures and correctly place important historical events in time. Level\nof [Intelligence and Problem Solving:]{.underline}In the MWT-A, four\nfictitious words and one correctly spelled word are presented in a row,\nand the task is to identify the correct word. Since this assesses\ncrystalline intelligence, which typically remains intact even after\nbrain damage, this parameter is used to estimate the premorbid\nintellectual level. Mr. Davies achieved an average result here (raw\nscore 22). In logical-analytical thinking (LPS, subtest 3), which can be\nused as an estimate for current fluid intelligence, his performance also\nmatched age-related expectations (raw score 19). In the Color-Word\nInterference Test, a highly automated response tendency must be\nsuppressed in favor of a new behavior. This demand was completed within\nan appropriate time frame (143 seconds).\n\n[Evaluation of Cognitive Status:]{.underline} The neuropsychological\nassessment revealed a patient oriented in all aspects, with an education\nlevel estimated as average and corresponding ability for\nlogical-analytical thinking. Information processing speed was slightly\nreduced under monotonous conditions but could be improved with external\nstimulation. During dual-task demands, numerous incorrect responses were\nobserved. Short-term retention of information and its mental\nmanipulation (working memory aspect) were below average. Learning new\nverbal content was quite possible, and the long-term retention\nperformance for newly learned material exceeded age-related\nexpectations. Figural content was retained within the norm. Increased\nvulnerability to interference was present. In summary, within an average\nlevel of intelligence, the patient exhibited limited attention and\nworking memory capacity but otherwise demonstrated age-appropriate\nperformance. The degree of impairment was mild.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/25/1979,\nwho presented at our outpatient clinic on 08/27/2016.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with the detection of a homozygous mutation\nconfirms the diagnosis. The exact mutation is available in the\npatient\\'s file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was\ndelivered by secondary cesarean section due to prolonged labor. Birth\nweight was 4030 g, Apgar scores were 9-9-10. Postnatally, there was an\namnion infection syndrome, followed by hyperbilirubinemia and\nhepatopathy, leading to the diagnosis of classical galactosemia in the\nnewborn screening on the 7th day of life. Normalization of liver\nfunction parameters was achieved after initiating a lactose-free and\ngalactose-restricted diet. Since diagnosis, the patient has been under\nthe care of the Metabolic Clinic. In the course of development, there\nwere delays in fine and gross motor skills and, notably, in speech\ndevelopment. In childhood, there were recurrent upper respiratory\ninfections and gastroenteritis, with the surgical insertion of ear\ntubes. In 2006, an age-appropriate alpha EEG was recorded. In 2009, the\nHAWIK IV intelligence test showed a total IQ of 76 with normal language\ncomprehension (IQ 42), reduced perception-based logical thinking (IQ\n84), and working memory (IQ 77), as well as significantly reduced\nprocessing speed (IQ 68). Despite adherence to the dietary regimen,\nmetabolic control has remained stable. Osteopenia was detected in the\nlumbar spine and both femurs. Abdominal sonography showed normal\nfindings. Neuropsychological testing revealed restricted attention and\nworking memory capacities despite average intelligence. The extent of\nimpairments was considered mild. Ophthalmologically, apart from mild\nmyopic astigmatism, there were no abnormalities, and glasses or contact\nlenses were recommended. He has completed his intermediate examination\nand intends to pursue training as a nurse.\n\n**Therapy and Progression:** Mr. Davies has classical galactosemia with\ncomplete loss of galactose-1-phosphate uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, developmental delays typical of\nclassical galactosemia have occurred, including speech development\ndisorder. The patient\\'s general condition is good. He adheres to a\nlactose-free and galactose-restricted diet, with disease-specific\nlaboratory parameters (galactose-1-phosphate and galactitol) within\ntarget ranges. Additionally, there are no signs of liver dysfunction. A\nbone density measurement revealed osteopenia in both femurs, with a\nslight deterioration compared to the previous examination. To prevent\nthe development of overt osteoporosis, the importance of regular intake\nof vitamin D (20.000 I.U. once a week) and sufficient calcium intake,\ne.g., through calcium-rich mineral water, was discussed with the\npatient. Supplementation was initiated for low folate levels, and the\nresult will be monitored during follow-up. The annual check-ups have\nbeen discussed with the patient.\n\n **Medication** **Dosage** **Frequency**\n ---------------------------- ------------------------------------------------ -------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium-rich mineral water Aim for a total of 1,500 mg calcium intake/day As needed\n Folic Acid 15 mg 1-0-0\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- -------------- ---------------------\n Neutrophils 76.2% 42.0-77.0%\n Lymphocytes 22.2% 20.0-44.0%\n Monocytes 9.8% 2.0-9.5%\n Basophils 1.42% 0.0-1.8%\n Eosinophils 5.4% 0.5-5.5%\n Immature Granulocytes 0.2% 0.0-1.0%\n Sodium 136 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Calcium 9.32 mg/dL 8.8-10.2 mg/dL\n Chloride 104 mEq/L 98-107 mEq/L\n Creatinine 1.22 mg/dL 0.70-1.20 mg/dL\n BUN 45 mg/dL 17-48 mg/dL\n Uric Acid 5.3 mg/dL 3.6-8.2 mg/dL\n CRP 0.6 mg/L \\< 5.0 mg/L\n PSA 2.21 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 37 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 244 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 12.7 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5% 37.0-49.0%\n Red Blood Cells 4.2 M/µL 4.0-5.6 M/µL\n White Blood Cells 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.6% 11.5-15.0%\n Neutrophils Absolute 3.53 K/µL 1.50-7.70 K/µL\n Immature Granulocytes Absolute 0.010 K/µL \\< 0.050 K/µL\n Lymphocytes Absolute 0.44 K/µL 1.10-4.50 K/µL\n Monocytes Absolute 0.58 K/µL 0.10-0.90 K/µL\n Eosinophils Absolute 0.30 K/µL 0.02-0.50 K/µL\n Basophils Absolute 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94% 0.50-2.00%\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.5 pg\n Prothrombin Time 112% \\> 78%\n INR 0.95 \\< 1.25\n Activated Partial Thromboplastin Time 30.2 sec. 25.0-38.0 sec.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting to you about our patient, Mr. George Davies, born on\n07/25/1979, who was under our outpatient care on 05/01/2017.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** The molecular genetic analysis of the\nuridyltransferase gene with evidence of a homozygous mutation confirms\nthe diagnosis. The exact mutation is on file.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. After an uneventful pregnancy, he was born\nvia secondary cesarean section due to prolonged labor. Birth weight was\n4030 g, Apgar scores were 9-9-10. Postnatally, there was amnion\ninfection syndrome, followed by hyperbilirubinemia and hepatopathy.\nClassic galactosemia was detected in the newborn screening on the 7th\nday of life. Normalization of liver function parameters occurred after\nthe initiation of a lactose-free and galactose-poor diet. Since the\ndiagnosis, the patient has been under the care of the Metabolic Clinic.\nSubsequently, he experienced developmental delays in fine and gross\nmotor skills, particularly in speech development. In childhood, he had\nrecurrent upper respiratory tract infections and gastroenteritis, and\near tubes were surgically inserted.\n\nIn 2006, there was an age-appropriate alpha EEG, and in 2009, in the\nHAWIK IV intelligence test, he had an overall IQ of 76 with normal\nlanguage comprehension (IQ 42), reduced perception-based logical\nthinking (IQ 84), reduced working memory (IQ 77), and significantly\nreduced processing speed (IQ 68). He maintained stable metabolic control\nwith the diet. In 02/15, osteopenia was detected in the lumbar spine,\nleft femur, and right femur during diagnostics. Abdominal sonography\nshowed normal findings. Neuropsychological testing at an average\nintelligence level revealed restricted attention and working memory\ncapacities but otherwise age-appropriate performance. The degree of\nimpairment was mild. On the ophthalmological side, apart from myopic\nastigmatism in both eyes, there were regular ophthalmological findings.\nThe patient was recommended glasses or contact lenses. He has completed\nhis intermediate examination and aims to complete an apprenticeship as a\nnurse.\n\nDespite good metabolic control and excellent compliance, he experienced\ntypical developmental delays associated with classical galactosemia,\nincluding speech development disorders. His general condition is good.\nThe patient adheres to a lactose-free and galactose-poor diet, and\ncurrently, the disease-specific laboratory parameters of\ngalactose-1-phosphate and galactitol are within target ranges. There are\nno signs of liver dysfunction. The remaining laboratory parameters were\nunremarkable. To prevent overt osteoporosis, we discussed with the\npatient the importance of regularly taking vitamin D (20,000 I.U. once a\nweek) and ensuring an adequate calcium intake, for example, through\ncalcium-rich mineral water. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------- -------------- ---------------------\n Taurine EDTA 104.7 µmol/L 54.0-210.0 µmol/L\n Aspartic Acid 4.3 µmol/L 1.0-25.0 µmol/L\n Glutamic Acid 33.1 µmol/L 10.0-131.0 µmol/L\n Hydroxyproline 14.2 µmol/L \\<35.0 µmol/L\n Threonine 154.5 µmol/L 60.0-255.0 µmol/L\n Asparagine 52.3 µmol/L 35.0-74.0 µmol/L\n Glutamine 577.3 µmol/L 205.0-756.0 µmol/L\n Proline 244.6 µmol/L \\<329.0 µmol/L\n Glycine 239.1 µmol/L 151.0-490.0 µmol/L\n Alanine 347.1 µmol/L 177.0-583.0 µmol/L\n Citrulline 49.4 µmol/L 12.0-55.0 µmol/L\n Alpha-Aminobutyric Acid 19.5 µmol/L 5.0-41.0 µmol/L\n Cystine 16.8 µmol/L 5.0-82.0 µmol/L\n Cystathionine 0.1 µmol/L \\<3.0 µmol/L\n Methionine 24.0 µmol/L 13.0-42.0 µmol/L\n Tyrosine 68.5 µmol/L 34.0-112.0 µmol/L\n Phenylalanine 57.8 µmol/L 35.0-85.0 µmol/L\n Tryptophan 42.9 µmol/L 10.0-140.0 µmol/L\n Histidine 81.4 µmol/L 72.0-142.0 µmol/L\n 3-Methylhistidine 3.9 µmol/L \\<8.0 µmol/L\n 1-Methylhistidine 14.2 µmol/L \\<39.0 µmol/L\n Ornithine 69.7 µmol/L 48.0-195.0 µmol/L\n Lysine 183.5 µmol/L 110.0-282.0 µmol/L\n Arginine 87.2 µmol/L 15.0-128.0 µmol/L\n Alanine/Lysine Ratio 1.9 \\<3.0\n Valine 210.4 µmol/L 119.0-336.0 µmol/L\n Allo-Isoleucine 1.9 µmol/L \\<5.0 µmol/L\n Isoleucine 63.1 µmol/L 30.0-108.0 µmol/L\n Leucine 117.9 µmol/L 72.0-201.0 µmol/L\n Serine 147.4 µmol/L 68.0-181.0 µmol/L\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 143 mEq/L 136-145 mEq/L\n Potassium 3.6 mEq/L 3.4-4.5 mEq/L\n Calcium 2.40 mEq/L 2.15-2.50 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Inorganic Phosphate 0.94 mEq/L 0.87-1.45 mEq/L\n Magnesium 0.84 mEq/L 0.66-1.07 mEq/L\n Glucose in Fluoride 89 mg/dL 60-110 mg/dL\n Creatinine (Jaffé) 1.07 mg/dL 0.70-1.20 mg/dL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe would like to report on our shared patient, Mr. George Davies, born\non 07/25/1979\n\nHe presented at our Center for Rare Metabolic Diseases on 07/05/2018.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In February 2015, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Current Recommendations:** Mr. Davies has classic galactosemia with\ncomplete loss of Galactose-1-Phosphate Uridyltransferase activity,\nconfirmed both enzymatically and molecularly. Despite good metabolic\ncontrol and excellent compliance, he has experienced developmental\ndelays, particularly in language development, characteristic of classic\ngalactosemia. His overall condition is currently good. He adheres to a\nlactose-free and low-galactose diet, resulting in his disease-specific\nlaboratory parameters (Galactose-1-Phosphate and Galactitol) being\nwithin the target range. Additionally, there are no signs of liver\ndysfunction or ocular changes. However, there is a minimal deficiency in\nfolate and vitamin D. We recommend supplementation with a lactose-free\nfolate preparation. We also plan to monitor thyroid parameters due to\nlatent hypothyroidism. His 2018 bone density measurement revealed\nosteopenia in both femurs, which has slightly worsened compared to the\nprevious assessment. To prevent the development of manifest\nosteoporosis, we discussed the importance of regular vitamin D\nsupplementation (20.000 IU once a week) and adequate calcium intake,\nsuch as through calcium-rich mineral water or mature cheese.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to report on our patient, Mr. George Davies, born on\n07/25/1979. He presented at our Center for Rare Metabolic Diseases on\n06/14/2019.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History**: The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Summary**: Mr. Davies has classic galactosemia with a loss of\nGalactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Currently, the patient reports\noccasional back tension, but his overall condition is good. He follows a\nlactose-free and low-galactose diet, which has kept disease-specific\nlaboratory parameters, especially free Galactose, within therapeutic\ntarget ranges. The rest of the laboratory diagnostics were pleasingly\nunremarkable. Osteodensitometry in 2018 revealed osteopenia in both\nfemurs. The findings have slightly worsened compared to previous bone\ndensity measurements in the femur area. A repeat bone density\nmeasurement is scheduled for 2020. To prevent manifest osteoporosis, we\ndiscussed the importance of regular vitamin D supplementation (20.000 IU\nonce a week) and adequate calcium intake, such as through calcium-rich\nmineral water or mature cheese. The annual check-ups have been discussed\nwith the patient.\n\n**Current lab results:**\n\n **Parameter** **Reference Range** **Result**\n ---------------------------------------------- --------------------- --------------\n Neutrophils 42.0-77.0 % 72.2 %\n Lymphocytes 20.0-44.0 % 20.2 %\n Monocytes 2.0-9.5 % 9.8 %\n Basophils 0.0-1.8 % 1.2 %\n Eosinophils 0.5-5.5 % 6.0 %\n Immature Granulocytes 0.0-1.0 % 0.2 %\n Sodium 136-145 mEq/L 137 mEq/L\n Potassium 3.5-4.5 mEq/L 4.2 mEq/L\n Calcium 8.8-10.2 mg/dL 9.24 mg/dL\n Chloride 98-107 mEq/L 100 mEq/L\n Creatinine 0.70-1.20 mg/dL 1.10 mg/dL\n BUN (Blood Urea Nitrogen) 17-48 mg/dL 45 mg/dL\n Uric Acid 3.6-8.2 mg/dL 5.2 mg/dL\n CRP \\< 5.0 mg/L 0.8 mg/L\n PSA \\< 4.40 ng/mL 2.31 ng/mL\n ALT \\< 41 U/L 12 U/L\n AST \\< 50 U/L 38 U/L\n Alkaline Phosphatase 40-130 U/L 115 U/L\n Gamma-GT 8-61 U/L 20 U/L\n LDH 135-250 U/L 335 U/L\n Testosterone 1.32-8.92 ng/mL \\<0.03 ng/mL\n TSH 0.27-4.20 mIU/L 1.42 mIU/L\n Hemoglobin 12.5-17.2 g/dL 10.1 g/dL\n Hematocrit 37.0-49.0 % 28.5 %\n Red Blood Cells 4.0-5.6 M/uL 3.3 M/uL\n White Blood Cells 3.90-10.50 K/uL 4.98 K/uL\n Platelets 150-370 K/uL 281 K/uL\n MCV 80.0-101.0 fL 85.6 fL\n MCH 27.0-34.0 pg 30.3 pg\n MCHC 31.5-36.0 g/dL 35.4 g/dL\n MPV 7.0-12.0 fL 9.2 fL\n RDW 11.5-15.0 % 13.4 %\n Neutrophils Absolute 1.50-7.70 K/uL 3.59 K/uL\n Immature Granulocytes Absolute \\< 0.050 K/uL 0.010 K/uL\n Lymphocytes Absolute 1.10-4.50 K/uL 0.43 K/uL\n Monocytes Absolute 0.10-0.90 K/uL 0.58 K/uL\n Eosinophils Absolute 0.02-0.50 K/uL 0.30 K/uL\n Basophils Absolute 0.00-0.20 K/uL 0.07 K/uL\n Reticulocytes 25.0-105.0 K/uL 31.3 K/uL\n Reticulocyte 0.50-2.00 % 0.94 %\n Ret-Hb 28.5-34.5 pg 33.9 pg\n PT \\> 78 % 112 %\n INR \\< 1.25 0.95\n aPTT (Activated Partial Thromboplastin Time) 25.0-38.0 sec. 30.2 sec.\n\n**Current Medication:**\n\n **Medication (Brand Name)** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe would like to provide a summary of the clinical course of our\npatient, Mr. George Davies, born on 07/25/1979. He presented at our\nCenter for Rare Metabolic Diseases on 01/26/2020.\n\n**Diagnoses:**\n\n- Galactosemia\n\n- Osteopenia\n\n - Last bone density measurement\n\n - Lumbar spine T-score: -0.8\n\n - Left proximal femur T-score: -1.4\n\n - Right proximal femur T-score: -1.5\n\n<!-- -->\n\n- Vitamin D deficiency\n\n- Status post appendectomy\n\n- Status post elbow fracture left arm\n\n**Molecular Genetic Diagnosis:** Molecular genetic analysis of the\nuridyltransferase gene confirmed a homozygous mutation, confirming the\ndiagnosis. The exact mutation is documented in the patient\\'s records.\n\n**Medical History:** The patient is the first child of\nnon-consanguineous parents. He was born via secondary cesarean section\nafter a prolonged labor, with a birth weight of 4030 grams and Apgar\nscores of 9-9-10. Postnatally, he had amnion infection syndrome,\nfollowed by hyperbilirubinemia and hepatopathy. Classic galactosemia was\ndiagnosed through newborn screening on the 7th day of life.\nNormalization of liver function parameters occurred after the initiation\nof a lactose-free and low-galactose diet. Since diagnosis, the patient\nhas been monitored at the Metabolic Clinic. In the course of his\ndevelopment, he experienced delays in fine and gross motor skills,\nespecially in language development. In childhood, he had recurrent upper\nrespiratory infections and gastroenteritis, requiring the insertion of\near tubes. In 2006, he had an age-appropriate alpha EEG, and in 2009, he\nscored an overall IQ of 76 in the HAWIK IV intelligence test. This\nincluded normal language comprehension (IQ 42), reduced perception-based\nlogical thinking (IQ 84), reduced working memory (IQ 77), and\nsignificantly reduced processing speed (IQ 68). Despite adhering to the\ndiet, his metabolic parameters remained stable. In January 2013, a\ndiagnosis of osteopenia was made for his lumbar spine and both femurs.\nAbdominal sonography was normal. Neuropsychological testing revealed\nslightly limited attention and working memory capacity, with otherwise\nage-appropriate performance. Ophthalmological examination showed no\nabnormalities except for mild myopic astigmatism, for which glasses or\ncontact lenses were recommended.\n\n**Physical Examination on 02/12/2020:** Blood Pressure: 120/87 mmHg\nHeart Rate: 68/min Height: 175 cm Weight: 84.6 kg\n\n**Current Presentation**: Mr. Davies has classic galactosemia with a\nloss of Galactose-1-Phosphate Uridyltransferase activity, confirmed both\nenzymatically and molecularly. Despite good metabolic control and\nexcellent compliance, he has experienced developmental delays,\nparticularly in language development. Clinically, the patient reports a\nstable overall condition, although he can become overwhelmed in\nstressful situations. He follows a lactose-free and low-galactose diet,\nwhich has kept disease-specific laboratory parameters, especially\nGalactose-1 Phosphate and Galactitol, within therapeutic target ranges.\nLaboratory chemistry shows no signs of liver dysfunction. A mild vitamin\nD deficiency was noted. Abdominal sonography revealed a minimally\nenlarged liver without signs of hepatic steatosis, otherwise\nunremarkable. The current bone density measurement showed osteopenia in\nboth femurs, with slight improvement compared to the previous\nmeasurement in 2018. To prevent manifest osteoporosis, we discussed the\nimportance of regular vitamin D supplementation (20,000 IU once a week)\nand adequate calcium intake, such as through calcium-rich mineral water\nor mature cheese.\n\n**Eye Examination:**\n\n- 03/09/2015: Known, unchanged myopia in both eyes. Otherwise, a\n regular ophthalmological examination with no evidence of cataracts.\n\n- 03/20/2017: During today\\'s examination, the known and essentially\n unchanged myopic astigmatism was observed, with an otherwise regular\n ophthalmological examination.\n\n- 2018: Not performed.\n\n- 2020: Unremarkable ophthalmological examination with known myopia in\n both eyes.\n\n**Upper Abdominal Ultrasound:**\n\n- 01/20/2015: Unremarkable sonographic findings of the abdomen.\n\n- 04/16/2017: Unremarkable sonographic findings of the upper abdomen,\n particularly no hepatomegaly, hepatic steatosis, space-occupying\n lesions, or kidney stones.\n\n- 04/16/2018: Unremarkable sonographic findings of the abdomen,\n especially no relevant hepatosplenomegaly and no hepatic steatosis.\n\n- 01/12/2018: Unremarkable sonographic findings of the abdomen, mild\n hepatomegaly without signs of hepatic steatosis.\n\n**Bone Density Measurement on 05/02/2016:**\n\n**Results:** Previous examination data from 2013 are available.\n\n- Lumbar Spine Bone Density: 1.148 g/cm2 (94% of age-appropriate\n reference) with a T-score of -0.8\n\n- Left Proximal Femur Bone Density: 0.911 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.4\n\n- Right Proximal Femur Bone Density: 0.890 g/cm2 (81% of\n age-appropriate reference) with a T-score of -1.5\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white women: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white women for T-score determination).\n\n[Changes compared to the previous examination:]{.underline}\n\n- Lumbar Spine (LWS): +6.0%\n\n- Left Proximal Femur: -2.5%\n\n- Right Proximal Femur: -1.7% Assessment: Bone density in both\n proximal femurs is below the age-appropriate norm, indicating\n osteopenia according to T-score analysis. Bone density in the lumbar\n spine is within the normal range according to T-score analysis.\n Compared to the previous examination, bone density has increased in\n the lumbar spine and decreased in the proximal femurs.\n\n**Bone Density Measurement on 12/01/2020: **\n\n[Clinical Background and Indication:]{.underline} Galactosemia. Known\nosteopenia, requesting bone density measurement.\n\n[Results: ]{.underline}\n\n- Lumbar Spine (L1-L4) Bone Density: 1.190 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.3\n\n- Lumbar Spine (L2-L4) Bone Density: 1.216 g/cm2 (97% of\n age-appropriate reference) with a T-score of -0.2\n\n- Left Proximal Femur Bone Density: 0.915 g/cm2 (83% of\n age-appropriate reference) with a T-score of -1.3\n\n- Right Proximal Femur Bone Density: 0.907 g/cm2 (82% of\n age-appropriate reference) with a T-score of -1.4\n\nDefinition by the World Health Organization for Osteoporosis and\nOsteopenia in white men: Normal: T-score at or above -1.0 SD;\nOsteopenia: T-score between -1.0 and -2.5 SD; Osteoporosis: T-score at\nor below -2.5 SD (WHO definitions apply only when using a reference\ndatabase of healthy young white men for T-score determination).\n\nChanges compared to the previous examination:\n\n- Lumbar Spine: +6.2%\n\n- Left Proximal Femur: +0.4%\n\n- Right Proximal Femur: +1.9%\n\nTrabecular Bone Score (TBS) T-score for Lumbar Spine (L1-L4): 1.454\n(0.0)\n\n[Assessment:]{.underline}\n\n- Bone density in the proximal femora remains below the\n age-appropriate norm, consistent with osteopenia according to\n T-score analysis.\n\n- Lumbar spine bone density remains within the normal range.\n\n- Compared to the previous examination on 04.07.2018, there is an\n increase in bone density in the lumbar\n\n**Outpatient Sonography Report Assessment:**\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Abdominal Sonography 12/02/2020:**\n\n[Clinical Background and Indication]{.underline}: Galactosemia. Liver\nsize? Steatosis? Liver function? Kidney stones?\n\nResults: Several previous examinations are available, most recently the\nabdominal sonography from 01/12/2020.\n\nMinimal liver enlargement with homogeneous parenchyma and no steatosis.\nNo suspicious focal lesions indicative of malignancy. Hepatic veins are\npatent. Portal vein with antegrade flow. Gallbladder and bile ducts\ncontinue to show sludge-like concrements with no signs of inflammation.\nNo intrahepatic or extrahepatic cholestasis, and the common bile duct\n(DHC) is not dilated. Spleen measures 12 cm in pole-to-pole distance,\nappears homogeneous. The pancreas is not adequately assessable due to\nintestinal gas interference. Both kidneys are of normal size with no\nevidence of concrements or suspicious solid masses. No evidence of\nurinary obstruction. Retroperitoneum is difficult to assess due to\nintestinal gas interference and constitutional factors. The urinary\nbladder is properly configured and adequately filled. No ascites is\nobserved.\n\n[Assessment:]{.underline} The liver remains minimally enlarged without\nhepatic steatosis. Gallbladder stones persist with concrements showing\nno signs of irritation or cholestasis.\n\n**Current Medication:**\n\n **Medication ** **Dosage** **Frequency**\n ------------------------------------- ------------------------------------------------ ---------------------------\n Vitamin D3 (Drisdol) 20.000 IU 1 tablet per week\n Calcium supplements (e.g. Caltrate) Aim for a total of 1,500 mg calcium intake/day \n Folic acid 15 mg Once daily in the morning\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n\n\n\n\nHere is the query:\nWhich of the following is NOT a part of Mr. Rudolph's medical history?\n\nChoose the correct answer from the following options:\nA. Atrial fibrillation with ablation\nB. pTCA stenting for acute myocardial infarction/CHD\nC. Laparoscopic cholecystectomy\nD. Left psoas abscess\nE. Prostatectomy\n\n\nYour response:\n", "role": "user" }, { "content": "Prostatectomy", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n\n\n### text_5\n**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n\n\n\n\nHere is the query:\nWhat did the MRI Liver on 11/20/2020 reveal about Mr. Wells' hepatic lesions\n\nChoose the correct answer from the following options:\nA. New lesions were observed\nB. Lesions were stable in size and characteristics\nC. Lesions showed signs of necrosis\nD. Lesions had significantly increased in size\nE. Lesions had disappeared\n\n\nYour response:\n", "role": "user" }, { "content": "Lesions were stable in size and characteristics", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n\n\n\n\nHere is the query:\nRegarding Mr. Chapman, what was the finding in the CT Head on 04/21/2017?\n\nChoose the correct answer from the following options:\nA. Ischemic stroke\nB. Brain tumor\nC. Malresorptive hydrocephalus\nD. Cerebral abscess\nE. Normal study\n\n\nYour response:\n", "role": "user" }, { "content": "Malresorptive hydrocephalus", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n\n\n\n\nHere is the query:\nWhat was the creatinine level upon Mr. Chapman's discharge from the outpatient clinic in 2018?\n\nChoose the correct answer from the following options:\nA. 0.70 mg/dL\nB. 1.20 mg/dL\nC. 0.42 mg/dL\nD. 0.44 mg/dL\nE. 0.90 mg/dL\n\n\nYour response:\n", "role": "user" }, { "content": "0.44 mg/dL", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our shared patient, Mr. John Chapman, born on\n11/16/1994, who received emergency treatment at our clinic on\n04/03/2017.\n\n**Diagnoses**:\n\n- Severe open traumatic brain injury with fractures of the cranial\n vault, mastoid, and skull base\n\n- Dissection of the distal internal carotid artery on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into the basal cisterns\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture 2005\n\n- Status post appendectomy 2006\n\n- Status post distal radius fracture 2008\n\n- Status post elbow fracture 20010\n\n**Procedure**: External ventricular drain (EVD) placement.\n\n**Medical History:** Admission through the emergency department as a\npolytrauma alert. The patient was involved in a motocross accident,\nwhere he jumped, fell, and landed face-first. He was intubated at the\nscene, and either during or before intubation, aspiration occurred. No\nissues with airway, breathing, or circulation (A, B, or C problems) were\nnoted. A CT scan performed in the emergency department revealed an open\ntraumatic brain injury with fractures of the cranial vault, mastoid, and\nskull base, as well as dissection of both carotid arteries. Upon\nadmission, we encountered an intubated and sedated patient with a\nRichmond Agitation-Sedation Scale (RASS) score of -4. He was\nhemodynamically stable at all times.\n\n**Current Recommendations:**\n\n- Regular checks of vigilance, laboratory values and microbiological\n findings.\n\n- Careful balancing\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report on Mr. John Chapman, born on 11/16/1994, who was admitted to\nour Intensive Care Unit from 04/03/2017 to 05/01/2017.\n\n**Diagnoses:**\n\n- Open severe traumatic brain injury with fractures of the skull\n vault, mastoid, and skull base\n\n- Dissection of the distal ACI on both sides\n\n- Subarachnoid hemorrhage involving both hemispheres and extending\n into basal cisterns\n\n- Infarct areas in the border zone between MCA-ACA on the right\n frontal and left parietal sides\n\n- Malresorptive hydrocephalus\n\n<!-- -->\n\n- Rhabdomyolysis\n\n- Aspiration pneumonia\n\n**Other Diagnoses: **\n\n- Status post rib fracture in 2005\n\n- Status post appendectomy in 2006\n\n- Status post distal radius fracture in 2008\n\n- Status post elbow fracture in 20010\n\n**Surgical Procedures:**\n\n- 04/03/2017: Placement of external ventricular drain\n\n- 04/08/2017: Placement of an intracranial pressure monitoring\n catheter\n\n- 04/13/2017: Surgical tracheostomy\n\n- 05/01/2017: Left ventriculoperitoneal shunt placement\n\n**Medical History:** The patient was admitted through the emergency\ndepartment as a polytrauma alert. The patient had fallen while riding a\nmotocross bike, landing face-first after jumping. He was intubated at\nthe scene. Aspiration occurred either during or before intubation. No\nproblems with breathing or circulation were noted. The CT performed in\nthe emergency department showed an open traumatic brain injury with\nfractures of the skull vault, mastoid, and skull base, as well as\ndissection of the carotid arteries on both sides and bilateral\nsubarachnoid hemorrhage.\n\nUpon admission, the patient was sedated and intubated, with a Richmond\nAgitation-Sedation Scale (RASS) score of -4, and was hemodynamically\nstable under controlled ventilation.\n\n**Therapy and Progression:**\n\n[Neurology]{.underline}: Following the patient\\'s admission, an external\nventricular drain was placed. Reduction of sedation had to be\ndiscontinued due to increased intracranial pressure. A right pupil size\ngreater than the left showed no intracranial correlate. With\npersistently elevated intracranial pressure, intensive intracranial\npressure therapy was initiated using deeper sedation, administration of\nhyperosmolar sodium, and cerebrospinal fluid drainage, which normalized\nintracranial pressure. Intermittently, there were recurrent intracranial\npressure peaks, which could be treated conservatively. Transcranial\nDoppler examinations showed normal flow velocities. Microbiological\nsamples from cerebrospinal fluid were obtained when the patient had\nelevated temperatures, but no bacterial growth was observed. Due to the\ninability to adequately monitor intracranial pressure via the external\nventricular drain, an intracranial pressure monitoring catheter was\nplaced to facilitate adequate intracranial pressure monitoring. In the\nperfusion computed tomography, progressive edema with increasingly\nobstructed external ventricular spaces and previously known infarcts in\nthe border zone area were observed. To ensure appropriate intracranial\npressure monitoring, a Tuohy drain was inserted due to cerebrospinal\nfluid buildup on 04/21/2017. After the initiation of antibiotic therapy\nfor suspected ventriculitis, the intracranial pressure monitoring\ncatheter was removed on 04/20/2017. Subsequently, a liquorrhea\ndeveloped, leading to the placement of a Tuohy drain. After successful\nantibiotic treatment of ventriculitis, a ventriculoperitoneal shunt was\nplaced on 05/01/2017 without complications, and the Tuohy drain was\nremoved. Radiological control confirmed the correct positioning. The\npatient gradually became more alert. Both pupils were isochoric and\nreacted to light. All extremities showed movement, although the patient\nonly intermittently responded to commands. On 05/01/2017, a VP shunt was\nplaced on the left side without complications. Currently, the patient is\nsedated with continuous clonidine at 60µg/h.\n\n**Hemodynamics**: To maintain cerebral perfusion pressure in the\npresence of increased intracranial pressure, circulatory support with\nvasopressors was necessary. Echocardiography revealed preserved cardiac\nfunction without wall motion abnormalities or right heart strain,\ndespite the increasing need for noradrenaline support. As the patient\nhad bilateral carotid dissection, a therapy with Aspirin 100mg was\ninitiated. On 04/16/2017, clinical examination revealed right\\>left leg\ncircumference difference and redness of the right leg. Utrasound\nrevealed a long-segment deep vein thrombosis in the right leg, extending\nfrom the pelvis (proximal end of the thrombus not clearly delineated) to\nthe lower leg. Therefore, Heparin was increased to a therapeutic dose.\nHeparin therapy was paused on postoperative day 1, and prophylactic\nanticoagulation started, followed by therapeutic anticoagulation on\npostoperative day 2. The patient was switched to subcutaneous Lovenox.\n\n**Pulmonary**: Due to the history of aspiration in the prehospital\nsetting, a bronchoscopy was performed, revealing a moderately obstructed\nbronchial system with several clots. As prolonged sedation was\nnecessary, a surgical tracheostomy was performed without complications\non 04/13/2017. Subsequently, we initiated weaning from mechanical\nventilation. The current weaning strategy includes 12 hours of\nsynchronized intermittent mandatory ventilation (SIMV) during the night,\nwith nighttime pressure support ventilation (DuoPAP: Ti high 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Abdomen**: FAST examinations did not reveal any signs of\nintra-abdominal trauma. Enteral feeding was initiated via a gastric\ntube, along with supportive parenteral nutrition. With forced bowel\nmovement measures, the patient had regular bowel movements. On\n04/17/2017, a complication-free PEG (percutaneous endoscopic\ngastrostomy) placement was performed due to the potential long-term need\nfor enteral nutrition. The PEG tube is currently being fed with tube\nfeed nutrition, with no bowel movement for the past four days.\nAdditionally, supportive parenteral nutrition is being provided.\n\n**Kidney**: Initially, the patient had polyuria without confirming\ndiabetes insipidus, and subsequently, adequate diuresis developed.\nRetention parameters were within the normal range. As crush parameters\nincreased, a therapy involving forced diuresis was initiated, resulting\nin a significant reduction of crush parameters.\n\n**Infection Course:** Upon admission, with elevated infection parameters\nand intermittently febrile temperatures, empirical antibiotic therapy\nwas initiated for suspected pneumonia using Piperacillin/Tazobactam.\nStaphylococcus capitis was identified in blood cultures, and\nStaphylococcus aureus was found in bronchial lavage. Both microbes were\nsensitive to the current antibiotic therapy, so treatment with\nPiperacillin/Tazobactam continued. Additionally, Enterobacter cloacae\nwas identified in tracheobronchial secretions during the course, also\nsensitive to the ongoing antibiotic therapy. On 05/17, the patient\nexperienced another fever episode with elevated infection parameters and\nright lower lobe infiltrates in the chest X-ray. After obtaining\nmicrobiological samples, antibiotic therapy was switched to Meropenem\nfor suspected pneumonia. Microbiological findings from cerebrospinal\nfluid indicated gram-negative rods. Therefore, antibiotic therapy was\nadjusted to Ciprofloxacin in accordance with susceptibility testing due\nto suspected ventriculitis, and the Meropenem dose was increased. This\nled to a reduction in infection parameters. Finally, microbiological\nexamination of cerebrospinal fluid, blood cultures, and urine revealed\nno pathological findings. Infection parameters decreased. We recommend\ncontinuing antibiotic therapy until 05/02/2017.\n\n**Anti-Infective Course: **\n\n- Piperacillin/Tazobactam 04/03/2017-04/16/2017: Staph. Capitis in\n Blood Culture Staph. Aureus in Bronchial Lavage\n\n- Meropenem 04/16/2017-present (increased dose since 04/18) CSF:\n gram-negative rods in Blood Culture: Pseudomonas aeruginosa\n Acinetobacter radioresistens\n\n- Ciprofloxacin 04/18/2017-present CSF: gram-negative rods in Blood\n Culture: Pseudomonas aeruginosa, Acinetobacter radioresistens\n\n**Weaning Settings:** Weaning Stage 6: 12-hour synchronized intermittent\nmandatory ventilation (SIMV) with DuoPAP during the night (Thigh 1.3s,\nrespiratory rate 11/min, Phigh 11 mbar, PEEP 5 mbar, Psupport 5 mbar,\ntrigger 4l, ramp 50 ms, expiratory trigger sensitivity 25%).\n\n**Status at transfer:** Currently, Mr. Chapman is monosedated with\nClonidine. He spontaneously opens both eyes and spontaneously moves all\nfour extremities. Pupils are bilaterally moderately dilated, round and\nsensitive to light. There is bulbar divergence. Circulation is stable\nwithout catecholamine therapy. He is in the process of weaning,\ncurrently spontaneous breathing with intermittent CPAP. Renal function\nis sufficient, enteral nutrition via PEG with supportive parenteral\nnutrition is successful.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------ ---------------- ---------------\n Bisoprolol (Zebeta) 2.5 mg 1-0-0\n Ciprofloxacin (Cipro) 400 mg 1-1-1\n Meropenem (Merrem) 4 g Every 4 hours\n Morphine Hydrochloride (MS Contin) 10 mg 1-1-1-1-1-1\n Polyethylene Glycol 3350 (MiraLAX) 13.1 g 1-1-1\n Acetaminophen (Tylenol) 1000 mg 1-1-1-1\n Aspirin 100 mg 1-0-0\n Enoxaparin (Lovenox) 30 mg (0.3 mL) 0-0-1\n Enoxaparin (Lovenox) 70 mg (0.7 mL) 1-0-1\n\n**Lab results:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.42 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.6 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n**Addition: Radiological Findings**\n\n[Clinical Information and Justification:]{.underline} Suspected deep\nvein thrombosis (DVT) on the right leg.\n\n[Special Notes:]{.underline} Examination at the bedside in the intensive\ncare unit, no digital image archiving available.\n\n[Findings]{.underline}: Confirmation of a long-segment deep venous\nthrombosis in the right leg, starting in the pelvis (proximal end not\nclearly delineated) and extending to the lower leg.\n\nVisible Inferior Vena Cava without evidence of thrombosis.\n\nThe findings were communicated to the treating physician.\n\n**Full-Body Trauma CT on 04/03/2017:**\n\n[Clinical Information and Justification:]{.underline} Motocross\naccident. Polytrauma alert. Consequences of trauma? Informed consent:\nEmergency indication. Recommended monitoring of kidney and thyroid\nlaboratory parameters.\n\n**Findings**: CCT: Dissection of the distal internal carotid artery on\nboth sides (left 2-fold).\n\nSigns of generalized elevated intracranial pressure.\n\nOpen skull-brain trauma with intracranial air inclusions and skull base\nfracture at the level of the roof of the ethmoidal/sphenoidal sinuses\nand clivus (in a close relationship to the bilateral internal carotid\narteries) and the temporal\n\n**CT Head on 04/16/2017:**\n\n[Clinical Information and Justification:]{.underline} History of skull\nfracture, removal of EVD (External Ventricular Drain). Inquiry about the\ncourse.\n\n[Findings]{.underline}: Regression of ventricular system width (distance\nof SVVH currently 41 mm, previously 46 mm) with residual liquor caps,\nindicative of regressed hydrocephalus. Interhemispheric fissure in the\nmidline. No herniation.\n\nComplete regression of subdural hematoma on the left, tentorial region.\n\nKnown defect areas on the right frontal lobe where previous catheters\nwere inserted.\n\nProgression of a newly hypodense demarcated cortical infarct on the\nleft, postcentral.\n\nKnown bilateral skull base fractures involving the petrous bone, with\nsecretion retention in the mastoid air cells bilaterally. Minimal\nsecretion also in the sphenoid sinuses.\n\nPostoperative bone fragments dislocated intracranially after right\nfrontal trepanation.\n\n**Chest X-ray on 04/24/2017.**\n\n[Clinical Information and Justification:]{.underline} Mechanically\nventilated patient. Suspected pneumonia. Question about infiltrates.\n\n[Findings]{.underline}: Several previous images for comparison, last one\nfrom 08/20/2021.\n\nPersistence of infiltrates in the right lower lobe. No evidence of new\ninfiltrates. Removal of the tracheal tube and central venous catheter\nwith a newly inserted tracheal cannula. No evidence of pleural effusion\nor pneumothorax.\n\n**CT Head on 04/25/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe traumatic\nbrain injury with brain edema, one External Ventricular Drain removed,\none parenchymal catheter removed; Follow-up.\n\n[Findings]{.underline}: Previous images available, CT last performed on\n04/09/17, and MRI on 04/16/17.\n\nMassive cerebrospinal fluid (CSF) stasis supra- and infratentorially\nwith CSF pressure caps at the ventricular and cisternal levels with\ncompletely depleted external CSF spaces, differential diagnosis:\nmalresorptive hydrocephalus. The EVD and parenchymal catheter have been\ncompletely removed.\n\nNo evidence of fresh intracranial hemorrhage. Residual subdural hematoma\non the left, tentorial. Slight regression of the cerebellar tonsils.\n\nIncreasing hypodensity of the known defect zone on the right frontal\nregion, differential diagnosis: CSF diapedesis. Otherwise, the status is\nthe same as for the other defects.\n\nSecretion in the sphenoid sinus and mastoid cells bilaterally, known\nbilateral skull base fractures.\n\n**Bedside Chest X-ray on 04/262017:**\n\n[Clinical Information and Justification]{.underline}: Respiratory\ninsufficiency. Inquiry about cardiorespiratory status.\n\n[Findings]{.underline}: Previous image from 08/17/2021.\n\nLeft Central Venous Catheter and gastric tube in unchanged position.\n\nPersistent consolidation in the right para-hilar region, differential\ndiagnosis: contusion or partial atelectasis. No evidence of new\npulmonary infiltrates. No pleural effusion. No pneumothorax. No\npulmonary congestion.\n\n**Brain MRI on 04/26/2017:**\n\n[Clinical Information and Justification:]{.underline} Severe skull-brain\ntrauma with skull calvarium, mastoid, and skull base fractures.\nAssessment of infarct areas/edema for rehabilitation planning.\n\n[Findings:]{.underline} Several previous examinations available.\n\nPersistent small sulcal hemorrhages in both hemispheres (left \\> right)\nand parenchymal hemorrhage on the left frontal with minimal perifocal\nedema.\n\nNarrow subdural hematoma on the left occipital extending tentorially (up\nto 2 mm).\n\nNo current signs of hypoxic brain damage. No evidence of fresh ischemia.\n\nSlightly regressed ventricular size. No herniation. Unchanged placement\nof catheters on the right frontal side. Mastoid air cells blocked\nbilaterally due to known bilateral skull base fractures, mucosal\nswelling in the sphenoid and ethmoid sinuses. Polypous mucosal swelling\nin the left maxillary sinus. Other involved paranasal sinuses and\nmastoids are clear.\n\n**Bedside Chest X-ray on 04/27/2017:**\n\n[Clinical Information and Justification:]{.underline} Tracheal cannula\nplacement. Inquiry about the position.\n\n[Findings]{.underline}: Images from 04/03/2017 for comparison.\n\nTracheal cannula with tip projecting onto the trachea. No pneumothorax.\n\nRegressing infiltrate in the right lower lung field. No leaking pleural\neffusions.\n\nLeft ubclavian central venous catheter with tip projecting onto the\nsuperior vena cava. Gastric tube in situ.\n\n**CT Head on 04/28/2017:**\n\n[Clinical Information and Justification:]{.underline} Open head injury,\nbilateral subarachnoid hemorrhage (SAH), EVD placement. Inquiry about\nherniation.\n\n[Findings]{.underline}: Comparison with the last prior examination from\nthe previous day.\n\nGeneralized signs of cerebral edema remain constant, slightly\nprogressing with a somewhat increasing blurred cortical border,\nparticularly high frontal.\n\nEssentially constant transtentorial herniation of the midbrain and low\nposition of the cerebellar tonsils. Marked reduction of inner CSF spaces\nand depleted external CSF spaces, unchanged position of the ventricular\ndrainage catheter with the tip in the left lateral ventricle.\n\nConstant small parenchymal hemorrhage on the left frontal and constant\nSDH at the tentorial edge on both sides. No evidence of new intracranial\nspace-occupying hemorrhage.\n\nSlightly less distinct demarcation of the demarcated infarcts/defect\nzones, e.g., on the right frontal region, differential diagnosis:\nfogging.\n\n**CT Head Angiography with Perfusion on 04/28/2017:**\n\n[Clinical Information and Justification]{.underline}: Post-traumatic\nhead injury, rising intracranial pressure, bilateral internal carotid\nartery dissection. Inquiry about intracranial bleeding, edema course,\nherniation, brain perfusion.\n\n[Emergency indication:]{.underline} Vital indication. Recommended\nmonitoring of kidney and thyroid laboratory parameters. Consultation\nwith the attending physician from and the neuroradiology service was\nconducted.\n\n[Technique]{.underline}: Native moderately of the neurocranium. CT\nangiography of brain-supplying cervical intracranial vessels during\narterial contrast agent phase and perfusion imaging of the neurocranium\nafter intravenous injection of a total of 140 ml of Xenetix-350. DLP\nHead 502.4 mGy*cm. DLP Body 597.4 mGy*cm.\n\n[Findings]{.underline}: Previous images from 08/11/2021 and the last CTA\nof the head/neck from 04/03/2017 for comparison.\n\n[Brain]{.underline}: Constant bihemispheric and cerebellar brain edema\nwith a slit-like appearance of the internal and completely compressed\nexternal ventricular spaces. Constant compression of the midbrain with\ntranstentorial herniation and a constant tonsillar descent.\n\nIncreasing demarcation of infarct areas in the border zone of MCA-ACA on\nthe right frontal, possibly also on the left frontal. Predominantly\npreserved cortex-gray matter contrast, sometimes discontinuous on both\nfrontal sides, differential diagnosis: artifact-related, differential\ndiagnosis: disseminated infarct demarcations/contusions.\n\nUnchanged placement of the ventricular drainage from the right frontal\nwith the catheter tip in the left lateral ventricle anterior horn.\n\nConstant subdural hematoma tentorial and posterior falx. Increasingly\nvague delineation of the small frontal parenchymal hemorrhage. No new\nspace-occupying intracranial bleeding.\n\nNo evidence of secondary dislocation of the skull base fracture with\nconstant fluid collections in the paranasal sinuses and mastoid air\ncells. Hematoma possible, cerebrospinal fluid leakage possible.\n\n[CT Angiography Head/Neck]{.underline}: Constant presentation of\nbilateral internal carotid artery dissection.\n\nNo evidence of higher-grade vessel stenosis or occlusion of the\nbrain-supplying intracranial arteries.\n\nModerately dilated venous collateral circuits in the cranial soft\ntissues on both sides, right \\> left. Moderately dilated ophthalmic\nveins on both sides, right \\> left.\n\nNo evidence of sinus or cerebral venous thrombosis. Slight perfusion\ndeficits in the area of the described infarct areas and contusions.\n\nNo evidence of perfusion mismatches in the perfusion imaging.\n\nUnchanged presentation of the other documented skeletal segments.\n\nAdditional Note: Discussion of findings with the responsible medical\ncolleagues on-site and by telephone, as well as with the neuroradiology\nservice by telephone, was conducted.\n\n**CT Head on 04/30/2017:**\n\n[Clinical Information and Justification]{.underline}: Open head injury\nfollowing a motorcycle accident.. Inquiry about rebleeding, edema, EVD\ndisplacement.\n\n[Findings and Assessment:]{.underline} CT last performed on 04/05/2017\nfor comparison.\n\nConstant narrow subdural hematoma on both sides, tentorial and posterior\nparasagittal. Constant small parenchymal hemorrhage on the left frontal.\nNo new intracranial bleeding.\n\nProgressively demarcated infarcts on the right frontal and left\nparietal.\n\nSlightly progressive compression of the narrow ventricles as an\nindication of progressive edema. Completely depleted external CSF spaces\nwith the ventricular drain catheter in the left lateral ventricle.\nIncreasing compression of the midbrain due to transtentorial herniation,\nprogressive tonsillar descent of 6 mm.\n\nFracture of the skull base and the petrous part of the temporal bone on\nboth sides without significant displacement. Hematoma in the mastoid and\nsphenoid sinuses and the maxillary sinus.\n\n**CT Head on 05/01/2017:**\n\n[Clinical Information and Justification:]{.underline} Open skull-brain\ntrauma. Inquiry about CSF stasis, bleeding, edema.\n\n[Findings]{.underline}: CT last performed on 04/05/17 for comparison.\n\nCompletely regressed subarachnoid hemorrhages on both sides. Minimal SDH\ncomponents on the tentorial edges bilaterally (left more than right,\nwith a 3 mm margin width). No new intracranial bleeding. Continuously\nnarrow inner ventricular system and narrow basal cisterns. The fourth\nventricle is unfolded. Narrow external CSF spaces and consistently\nswollen gyration with global cerebral edema.\n\nBetter demarcated circumscribed hypodensity in the centrum semiovale on\nthe right (Series 3, Image 176) and left (Series 3, Image 203);\nDifferential diagnosis: fresh infarcts due to distal ACI dissections.\nConsider repeat vascular imaging. No midline shift. No herniation.\n\nRegressing intracranial air inclusions. Fracture of the skull base and\nthe petrous part of the temporal bone on both sides without significant\ndisplacement. Hematoma in the maxillary, sphenoidal, and ethmoidal\nsinuses.\n\n**Consultation Reports:**\n\n**1) Consultation with Ophthalmology on 04/03/2017**\n\n[Patient Information:]{.underline}\n\n- Motorbike accident, heavily contaminated eyes.\n\n- Request for assessment.\n\n**Diagnosis:** Motorbike accident\n\n**Findings:** Patient intubated, unresponsive. In cranial CT, the\neyeball appears intact, no retrobulbar hematoma. Intraocular pressure:\nRight/left within the normal range. Eyelid margins of both eyes crusty\nwith sand, inferiorly in the lower lid sac, and on the upper lid with\nsand. Lower lid somewhat chemotic. Slight temporal hyperemia in the left\neyelid angle. Both eyes have erosions, small, multiple, superficial.\nLower conjunctival sac clean. Round pupils, anisocoria right larger than\nleft. Left iris hyperemia, no iris defects in the direct light. Lens\nunremarkable. Reduced view of the optic nerve head due to miosis,\nsomewhat pale, rather sharp-edged, central neuroretinal rim present,\ncentral vessels normal. Left eye, due to narrow pupil, limited view,\noptic nerve head not visible, central vessels normal, no retinal\nhemorrhages.\n\n**Assessment:** Eyelid and conjunctival foreign bodies removed. Mild\nerosions in the lower conjunctival sac. Right optic nerve head somewhat\npale, rather sharp-edged.\n\n**Current Recommendations:**\n\n- Antibiotic eye drops three times a day for both eyes.\n\n- Ensure complete eyelid closure.\n\n**2) Consultation with Craniomaxillofacial (CMF) Surgery on 04/05/2017**\n\n**Patient Information:**\n\n- Motorbike accident with severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Patient with maxillary fracture.\n\n**Findings:** According to the responsible attending physician,\n\\\"minimal handling in case of decompensating intracranial pressure\\\" is\nindicated. Therefore, currently, a cautious approach is suggested\nregarding surgical intervention for the radiologically hardly displaced\nmaxillary fracture. Re-consultation is possible if there are changes in\nthe clinical outcome.\n\n**Assessment:** Awaiting developments.\n\n**3) Consultation with Neurology on 04/06/2017**\n\n**Patient Information:**\n\n- Brain edema following a severe open traumatic brain injury with\n fractures of the cranial vault, mastoid, and skull base\n\n<!-- -->\n\n- Request for assessment.\n\n- Traumatic subarachnoid hemorrhage, intracranial artery dissection,\n and various other injuries.\n\n**Findings:** Patient comatose, intubated, sedated. Isocoric pupils. No\nlight reaction in either eye. No reaction to pain stimuli for\nvestibulo-ocular reflex and oculomotor responses. Babinski reflex\nnegative.\n\n**Assessment:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. No response to pain stimuli or light\nreactions in the eyes.\n\n**Procedure/Therapy Suggestion:** Monitoring of patient condition.\n\n**4) Consultation with ENT on 04/16/2017**\n\n**Patient Information:** Tracheostomy tube change.\n\n**Findings:** Tracheostomy tube change performed. Stoma unremarkable.\nTrachea clear up to the bifurcation. Sutures in place.\n\n**Assessment:** Re-consultation on 08/27/2021 for suture removal.\n\n**5) Consultation with Neurology on 04/22/2017**\n\n**Patient Information:** Adduction deficit., Request for assessment.\n\n**Findings:** Long-term ventilation due to a history of intracerebral\nbleeding and skull base fracture. Adduction deficit in the right eye and\nhorizontal nystagmus.\n\n**Assessment:** Suspected mesencephalic lesion due to horizontal\nnystagmus, but no diagnostic or therapeutic action required.\n\n**6) Consultation with ENT on 04/23/2017**\n\n**Patient Information:** Suture removal. Request for assessment.\n\n**Findings:** Tracheostomy site unremarkable. Sutures trimmed, and skin\nsutures removed.\n\n**Assessment:** Procedure completed successfully.\n\nPlease note that some information is clinical and may not include\nspecific dates or recommendations for further treatment.\n\n**Antibiogram:**\n\n **Antibiotic** **Organism 1 (Pseudomonas aeruginosa)** **Organism 2 (Acinetobacter radioresistens)**\n ------------------------- ----------------------------------------- -----------------------------------------------\n Aztreonam I (4.0) \\-\n Cefepime I (2.0) \\-\n Cefotaxime \\- \\-\n Amikacin S (\\<=2.0) S (4.0)\n Ampicillin \\- \\-\n Piperacillin I (\\<=4.0) \\-\n Piperacillin/Tazobactam I (8.0) \\-\n Imipenem I (2.0) S (\\<=0.25)\n Meropenem S (\\<=0.25) S (\\<=0.25)\n Ceftriaxone \\- \\-\n Ceftazidime I (4.0) \\-\n Gentamicin . (\\<=1.0) S (\\<=1.0)\n Tobramycin S (\\<=1.0) S (\\<=1.0)\n Cotrimoxazole \\- S (\\<=20.0)\n Ciprofloxacin I (\\<=0.25) I (0.5)\n Moxifloxacin \\- \\-\n Fosfomycin \\- \\-\n Tigecyclin \\- \\-\n\n\\\"S\\\" means Susceptible\n\n\\\"I\\\" means Intermediate\n\n\\\".\\\" indicates not specified\n\n\\\"-\\\" means Resistant\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. John Chapman, born on\n11/16/1994, who presented himself to our Outpatient Clinic from\n08/08/2018.\n\n**Diagnoses**:\n\n- Right abducens Nerve Palsy and Facial Nerve Palsy\n\n- Lagophthalmos with corneal opacities due to eyelid closure deficit\n\n- Left Abducens Nerve Palsy with slight compensatory head leftward\n rotation and preferred leftward gaze\n\n- Bilateral disc swelling\n\n- Suspected left cavernous internal carotid artery aneurysm following\n traumatic ICA dissection\n\n- History of shunt explantation due to dysfunction and right-sided\n re-implantation (Codman, current pressure setting 12 cm H2O)\n\n- History of left VP shunt placement (programmable\n ventriculoperitoneal shunt, initial pressure setting 5/25 cm H2O,\n adjusted to 3 cm H2O before discharge)\n\n- Malresorptive hydrocephalus\n\n- History of severe open head injury in a motocross accident with\n multiple skull fractures and distal dissection\n\n**Procedure**: We conducted the following preoperative assessment:\n\n- Visual acuity: Distant vision: Right eye: 0.5, Left eye: 0.8p\n\n- Eye position: Fusion/Normal with significant esotropia in the right\n eye; no fusion reflex observed\n\n- Ocular deviation: After CT, at distance, esodeviation simulating\n alternating 100 prism diopters (overcorrection); at near,\n esodeviation simulating alternating 90 prism diopters\n\n- Head posture: Fusion/Normal with leftward head turn of 5-10 degrees\n\n- Correspondence: Bagolini test shows suppression at both distance and\n near fixation\n\n- Motility: Right eye abduction limited to 25 degrees from the\n midline, abduction in up and down gaze limited to 30 degrees from\n midline; left eye abduction limited to 30 degrees\n\n- Binocular functions: Bagolini test shows suppression in the right\n eye at both distance and near fixation; Lang I negative\n\n**Current Presentation:** Mr. Chapman presented himself today in our\nneurovascular clinic, providing an MRI of the head.\n\n**Medical History:** The patient is known to have a pseudoaneurysm of\nthe cavernous left internal carotid artery following traumatic carotid\ndissection in 04/2017, along with ipsilateral abducens nerve palsy.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Therapy and Progression:** The pseudoaneurysm has shown slight\nenlargement in the recent follow-up imaging and remains partially\nthrombosed. The findings were discussed on during a neurovascular board\nmeeting, where a recommendation for endovascular treatment was made,\nwhich the patient has not yet pursued. Since Mr. Chapman has not been\nable to decide on treatment thus far, it is advisable to further\nevaluate this still asymptomatic condition through a diagnostic\nangiography. This examination would also help in better planning any\npotential intervention. Mr. Chapman agreed to this course of action, and\nwe will provide him with a timely appointment for the angiography.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------- ------------- ---------------------\n Creatinine (Jaffé) 0.44 mg/dL 0.70-1.20 mg/dL\n Urea 31 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\< 1.20 mg/dL\n Hemoglobin 7.8 g/dL 13.5-17.0 g/dL\n Hematocrit 28% 39.5-50.5%\n Red Blood Cells 3.5 M/uL 4.3-5.8 M/uL\n White Blood Cells 10.35 K/uL 3.90-10.50 K/uL\n Platelets 379 K/uL 150-370 K/uL\n MCV 77.2 fL 80.0-99.0 fL\n MCH 24.1 pg 27.0-33.5 pg\n MCHC 32.5 g/dL 31.5-36.0 g/dL\n MPV 11.3 fL 7.0-12.0 fL\n RDW-CV 17.7% 11.5-15.0%\n Quick 54% 78-123%\n INR 1.36 0.90-1.25\n aPTT 32.8 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. John Chapman, born on 11/16/1994,\nwho was under our inpatient care from 05/25/2019 to 05/26/2019.\n\n**Diagnoses: **\n\n- Pseudoaneurysm of the cavernous left internal carotid artery\n following traumatic carotid dissection\n\n- Abducens nerve palsy.\n\n- History of severe open head trauma with fractures of the cranial\n vault, mastoid, and skull base. Distal ICA dissection bilaterally.\n Bilateral hemispheric subarachnoid hemorrhage extending into the\n basal cisterns.mInfarct areas in the MCA-ACA border zones, right\n frontal, and left parietal. Malresorptive hydrocephalus.\n\n<!-- -->\n\n- Rhabdomyolysis.\n\n- History of aspiration pneumonia.\n\n- Suspected Propofol infusion syndrome.\n\n**Current Presentation:** For cerebral digital subtraction angiography\nof the intracranial vessels. The patient presented with stable\ncardiopulmonary conditions.\n\n**Medical History**: The patient was admitted for the evaluation of a\npseudoaneurysm of the supra-aortic vessels. Further medical history can\nbe assumed to be known.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds. Heart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation are unremarkable.\n\n**Supra-aortic angiography on 05/25/2019:**\n\n[Clinical context, question, justifying indication:]{.underline}\nPseudoaneurysm of the left ICA. Written consent was obtained for the\nprocedure. Anesthesia, Medications: Procedure performed under local\nanesthesia. Medications: 500 IU Heparin in 500 mL NaCl for flushing.\n[Methodology]{.underline}: Puncture of the right common femoral artery\nunder local anesthesia. 4F sheath, 4F vertebral catheter. Serial\nangiographies after selective catheterization of the internal carotid\narteries. Uncomplicated manual intra-arterial contrast medium injection\nwith a total of 50 mL of Iomeron 300. Post-interventional closure of the\npuncture site by manual compression. Subsequent application of a\ncircular pressure bandage.\n\n[Technique]{.underline}: Biplanar imaging technique, area dose product\n1330 cGy x cm², fluoroscopy time 3:43 minutes.\n\n[Findings]{.underline}: The perfused portion of the partially thrombosed\ncavernous aneurysm of the left internal carotid artery measures 4 x 2\nmm. No evidence of other vascular pathologies in the anterior\ncirculation.\n\n[Recommendation]{.underline}: In case of post-procedural bleeding,\nimmediate manual compression of the puncture site and notification of\nthe on-call neuroradiologist are advised.\n\n- Pressure bandage to be kept until 2:30 PM. Bed rest until 6:30 PM.\n\n- Follow-up in our Neurovascular Clinic\n\n**Addition: Doppler ultrasound of the right groin on 05/26/2019:**\n\n[Clinical context, question, justifying indication:]{.underline} Free\nfluid? Hematoma?\n\n[Findings]{.underline}: A CT scan from 04/05/2017 is available for\ncomparison. No evidence of a significant hematoma or an aneurysm in the\nright groin puncture site. No evidence of an arteriovenous fistula.\nNormal flow profiles of the femoral artery and vein. No evidence of\nthrombosis.\n\n**Treatment and Progression:** Pre-admission occurred on 05/24/2019 due\nto a medically justified increase in risk for DSA of intracranial\nvessels. After appropriate preparation, the angiography was performed on\n05/25/2019. The puncture site was managed with a pressure bandage. In\nthe color Doppler sonographic control the following day, neither a\npuncture aneurysm nor an arteriovenous fistula was detected. On\n05/25/2019, we discharged the patient in good subjective condition for\nyour outpatient follow-up care.\n\n**Current Recommendations:** Outpatient follow-up\n\n**Lab results:**\n\n **Parameter** **Reference Range** **Result**\n ----------------------- --------------------- -------------\n Sodium 136-145 mEq/L 141 mEq/L\n Potassium 3.5-4.5 mEq/L 4.9 mEq/L\n Chloride 98-107 mEq/L 100 mEq/L\n Osmolality 280-300 mOsm/kg 290 mOsm/kg\n Glucose in Fluoride 60-110 mg/dL 76 mg/dL\n Creatinine (Jaffé) 0.70-1.20 mg/dL 0.98 mg/dL\n CRP \\< 5.0 mg/L 4.5 mg/L\n Triglycerides \\< 150 mg/dL 119 mg/dL\n Creatine Kinase \\< 190 U/L 142 U/L\n Free Triiodothyronine 2.00-4.40 ng/L 3.25 ng/L\n Free Thyroxine 9.30-17.00 ng/L 14.12 ng/L\n TSH Basal 0.27-4.20 mU/L 1.65 mU/L\n Hemoglobin 13.5-17.0 g/dL 14.3 g/dL\n Hematocrit 39.5-50.5% 43.4%\n Erythrocytes 4.3-5.8 M/uL 5.6 M/uL\n Leukocytes 3.90-10.50 K/uL 10.25 K/uL\n Platelets 150-370 K/uL 198 K/uL\n MCV 80.0-99.0 fL 83.2 fL\n MCH 27.0-33.5 pg 28.1 pg\n MCHC 31.5-36.0 g/dL 33.4 g/dL\n MPV 7.0-12.0 fL 11.6 fL\n RDW-CV 11.5-15.0% 13.5%\n Quick \\> 78% 90%\n INR \\< 1.25 1.07\n aPTT 25.0-38.0 sec 36.1 sec\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. Brian Carter, born on\n04/24/1956, who was under our inpatient care from 09/28/2021 to\n09/30/2021.\n\n**Diagnosis**: ARDS in the context of a COVID-19 infection\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Mr. Carter presented to our facility on foot\non 09/28/2021 with a five-day history of slowly progressive dyspnea, dry\ncough, and non-apoplectic, holocentral headache. His initial room air\nsaturation was 78%, which improved to 86% with 10 liters of oxygen.\nArterial blood gas analysis revealed an oxygenation disorder with a paO2\nof 50 mmHg, prompting the initiation of NIV therapy, under which Mr.\nCarter remained hemodynamically stable. CT imaging showed bilateral\ninterstitial pneumonia with COVID-typical infiltrates. Both a rapid test\nin the initial care unit and one from his primary care physician were\nnegative for COVID-19. Therefore, we admitted Mr. Carter to our\nintensive care unit for further evaluation.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Alert and cooperative\n\n[Cardiovascular/Abdominal Examination]{.underline}: Severely impaired\noxygenation improved with NIV; Sinus rhythm at 80 beats per minute\n\n[Abdomen]{.underline}: Surgical abdomen\n\n[Renal System:]{.underline} Urination initially scant, then polyuria\nOthers.\n\n**Therapy and Progression:** Upon admission, Mr. Carter was alert,\ncooperative, and hemodynamically stable despite significant oxygenation\nimpairment. Temporary improvement was achieved with differentiated NIV\nmask ventilation. On 09/30, there was a further deterioration in\noxygenation with an increase in respiratory rate and escalation of\nventilator settings, leading to the decision to intubate. A tolerable\nventilation situation was achieved with an oxygenation index of 125. Due\nto radiological suspicion of atypical pneumonia, we initiated empirical\nanti-infective therapy with Piperacillin/Tazobactam, Clarithromycin, and\nCotrimoxazole. Microbiological test results were pending at the time of\ntransfer. We also initiated mucolytic therapy with Ambroxol. The\npre-existing immunosuppressive therapy with Prednisolone was\ndiscontinued and switched to Dexamethasone 10 mg. At the time of\ntransfer, Mr. Carter was hemodynamically stable with low catecholamine\ndoses (0.07 µg/kg/min). A central venous catheter was placed, and\nenteral or parenteral nutrition had not yet been initiated. Diuresis was\nsufficient after a single dose of 20 mg furosemide, with retention\nparameters within the normal range. Prophylactic anticoagulation with\nheparin 500 U/h was initiated.\n\n**Status at Transfer**:\n\n[Neurology]{.underline}: RASS -5 under Propofol and Sufentanil sedation\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline (NA)\n0.07; Hemoglobin 12.8 g/dL\n\n[Lungs]{.underline}: Adequate decarboxylation with borderline\noxygenation: paO2 87.6 under FiO2 0.7; PEEP 16; PEAK 27\n\n[Abdomen]{.underline}: Soft abdomen, no nutrition initiated\n\n[Renal System]{.underline}: Normal urine output without stimulation.\nRetention values within normal range. Clear urine.\n\n[Access]{.underline}: CVC placed on 09/30, left radial artery catheter\nplaced on 09/30.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under our inpatient care from 09/30/2021 to 10/13/2021.\n\n**Diagnosis:** ARDS due to COVID-19 pneumonia with superinfection by\nAspergillus fumigatus\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The patient was admitted from the emergency\ndepartment, presenting with dyspnea and confirmed SARS-CoV-2 infection.\nAfter initial management in the intensive care unit, a non-invasive\nventilation (NIV) trial was attempted, followed by successful\nintubation. The patient was then transferred to the Intensive Care Unit.\n\n**Therapy and Progression:** Upon admission, the patient was sedated,\nintubated, and controlled on mechanical ventilation with mild\ncatecholamine support. Due to oxygenation impairment despite\nlung-protective ventilation and inhaled supportive NO therapy,\nconservative ARDS therapy was initiated, including positioning therapy\n(a total of 9 prone positions). After stabilization of gas exchange with\npositioning therapy, sedation and ventilation weaning were performed.\nGas exchange and oxygenation are currently stable under BIPAP\nventilation (PiP 25 mbar, PEEP 13 mbar, breathing rate 18/min). The\npatient, under reduced analgosedation with Sufentanil and Clonidine,\nexhibits a sufficient awakening response, is adequately responsive, and\nfollows commands with reduced muscle strength.\n\nThe home medication of Methotrexate and Prednisolone for uveitis was\ndiscontinued upon admission. The patient received Dexamethasone for 10\ndays initially and, starting from 11/10, prednisolone with prophylactic\nCotrimoxazole therapy.\n\nUpon detection of Aspergillus in tracheobronchial secretions, antifungal\ntherapy with Voriconazole and Caspofungin (until target Voriconazole\nlevels were achieved) was initiated. The initially started antimicrobial\ntherapy with Piperacillin + Tazobactam was escalated to Meropenem on\n10/05/2021 due to worsening infection parameters and progression of\ninfiltrates on X-ray. Infection parameters have been fluctuating, and\nfever is not currently observed. Diuresis is qualitatively and\nquantitatively within normal limits, and retention parameters are within\nthe normal range.\n\nAnticoagulation was administered in therapeutic doses using\nlow-molecular-weight heparin.\n\nEnteral nutrition is provided through a nasogastric tube, and the\npatient has regular bowel movements.\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Analgosedated, GCS 10, pupils equal and\nreactive, limb movement prompt, follows commands with reduced strength\n\n[Lungs]{.underline}: Intubated with BIPAP 25/13, FiO2 0.4\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline 0.05\n\n[Abdomen]{.underline}: Obese, no tenderness, abdomen soft, oral intake\nvia a nasogastric tube, regular bowel movements\n\n[Diuresis]{.underline}: Normal urine output, retention parameters within\nnormal limits\n\nSkin/Wounds: Some pressure sores from positioning (see nursing handover\nsheet)\n\n[Mobilization]{.underline}: Not conducted\n\n**Imaging:**\n\n**Bedside Chest X-ray from 10/11/2021:**\n\n[Clinical information, question, justifying indication:]{.underline}\nCOVID pneumonia, insertion of a central venous catheter (CVC)\n\n**Assessment**: Comparison with 10/05/21: Endotracheal tube identical,\ngastric tube seen extending well into the abdomen, left CVC currently\npositioned in the brachiocephalic vein region, right CVC via internal\njugular vein with tip in superior vena cava. No pneumothorax, no\neffusions, increasing consolidation of infiltrates in the right lower\nlobe and retrocardially on the left without significant cavitation as\nfar as can be assessed. Left heart without significant central\ncongestion.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under intensive care treatment from 09/28/2021 to 10/12/2021 and\nin our intensive care unit from 10/13/2021 to 10/21/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The initial hospital admission of the patient was\nthrough our emergency department due to severe respiratory insufficiency\nin the context of COVID-19 pneumonia.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Skin/Mucous Membranes]{.underline}: Warm, Skin Perfusion: Good\nperfusion, Edema: Lower legs\n\n[Head]{.underline}: Mobility: Active and passive free movement, Tongue:\nMoist\n\n[Thorax]{.underline}: Auscultation: Clear bilaterally\n\n[Abdomen]{.underline}: Soft, no guarding, Bowel Sounds: Sparse\nperistalsis, Tenderness: None\n\n[Neurology]{.underline}: Pupil Shape: Round, Pupil Size: Moderate, Light\nReaction: Both sides +++\n\nAlertness: Awake\n\n**ECG on admission:** Tachycardic sinus rhythm with 107/min, Left type,\nP-wave normally configured, normal PQ interval, no pathological Q as in\nPardee-Q, narrow QRS, regular R progression, R/S transition in V3/4, no\nS persistence, no ST segment changes, no discordant T-negatives.\n\n**Therapy and Progression:** Despite intensified oxygen therapy with\nnasal high-flow and mask CPAP, adequate oxygenation could not be\nachieved, and the patient was intubated on 09/29/21. Leading oxygenation\nimpairment led to lung-protective ventilation with inhaled supportive NO\ntherapy and conservative ARDS therapy, including positioning therapy (a\ntotal of 9 prone positions, 16 hours each, from 09/29/21 to 10/8/21).\n\nDue to elevated procalcitonin, the patient received empirical antibiotic\ntreatment with Piperacillin/Tazobactam starting from 10/2/21, which was\nescalated to Meropenem on 10/5/21 and continued until 10/14/21.\n\nAfter the detection of Aspergillus in tracheobronchial secretions and\nBAL, the patient received Voriconazole since 10/7/2021 (treatment\nduration formally 4-6 weeks). Most recently, the level was\nsubtherapeutic, so the dose was adjusted to 2 x 400 mg daily.\n\nThe immunosuppressive therapy with Methotrexate and Prednisolone for\nrheumatoid arthritis was switched to Dexamethasone (09/29 to 10/8) and,\nsince 10/09, Prednisolone monotherapy. After controlling the fungal\ninfection, a rheumatology re-consultation was planned. Furthermore,\nsubtherapeutic anticoagulation with Fraxiparine was initiated for the\nprevention of thrombotic complications in the context of COVID-19.\n\nUnder this treatment regimen, gas exchange continuously improved, and on\n10/12/21, the patient was transferred with low catecholamine\nrequirements for ventilation and sedation weaning. Mr. Carter was\nextubated on 12/13/21 and now maintains good oxygenation with less than\n3L oxygen via nasal cannula. Delirium symptoms after extubation\ncompletely regressed within a few days.\n\nSevere dysphagia was observed after invasive ventilation, leading to a\nspeech therapy consultation. Oral feeding is currently not possible, so\nMr. Carter is receiving parenteral nutrition. As a result, there was a\nparavasate in the upper right extremity with painful erythema. Adequate\npain control was achieved with local cooling and Piritramide as needed.\nDue to continued dietary restrictions, a central venous catheter was\nplaced on 10/20/2021 for parenteral nutrition.\n\nWe request continued speech therapy treatment.\n\nOn 10/21/21, Staphylococcus aureus was detected in blood culture, so we\ninitiated the administration of Flucloxacillin. The MRSA rapid test was\nnegative.\n\nWe are transferring Mr. Carter on 10/21/21 in stable condition, awake,\nand appropriately responsive for further treatment. We appreciate the\ntransfer of our patient and are available for any further questions.\n\n**Current Recommendations:**\n\n- Continuation of antifungal therapy for a total of at least 4-6 weeks\n\n- Voriconazole level measurement\n\n- Speech therapy consultation\n\n- Rheumatology re-consultation\n\n- Follow-up blood cultures upon detection of Staph. aureus\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Mr. Brian Carter, born on 04/24/1956, who was under\nour inpatient care from 10/21/2021 to 11/08/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Transfer for continuation of antimicrobial\ntherapy for MSSA bacteremia. Transesophageal echocardiogram planned for\ntomorrow. Cleared for full diet by speech therapy today. Patient\nmobilized to standing position for the first time today. Overall,\nmobility is significantly limited, but the patient can mobilize to the\nedge of the bed independently. No pain, no fever, mild cough without\nsputum. No shortness of breath. Mood is significantly depressed, but\nthis is a known issue. Before COVID-19, he was heavily affected by\nrheumatoid arthritis.\n\n**Medical History:** The patient was transferred to our COVID ward after\na positive SARS-CoV-2 RNA PCR test in the naso-oropharyngeal swab and\nrespiratory failure. On physical examination, he had a reduced general\ncondition. Respiratory rate was 24/min, and oxygen saturation was 97% on\n4 L/min of O2 via nasal cannula. Oxygen supply of 4 L via nasal cannula\ncould not be reduced during the course. A chest X-ray performed on 11/21\nshowed increasingly loosened infiltrates in the left basal region and a\nminimal effusion at the base.\n\nA SARS-CoV-2 RNA PCR test from 11/10/2020 was negative, so Mr. Carter\nwas no longer in isolation.\n\nDue to the detection of Aspergillus fumigatus in bronchoalveolar lavage,\nintravenous Voriconazole therapy initiated on 10/07/2021 was continued\nand was planned to be adjusted according to drug level monitoring.\nAdditionally, Staph. aureus was identified in a blood culture, and\nStaph. epidermidis. Antibiotic therapy with Cefazolin was started on\n10/22 and was to be continued for a total of 14 days after the first\nnegative blood culture. The central venous catheter, likely the source\nof infection, was removed on 10/22, and microbiological examination of\nthe catheter tip indicated suspicion of Staphylococci. To rule out\nendocarditis, a transesophageal echocardiogram was scheduled for 10/24.\nMr. Carter has already been informed about this intervention, and\nFraxiparine was to be paused on the evening of 10/24 and the morning of\n10/27, with the patient kept fasting.\n\nThere is also a known history of rheumatoid arthritis, which was treated\non an outpatient basis with Methotrexate and Prednisolone. Due to the\ncurrent infection, Methotrexate was paused, and after consultation with\nthe rheumatologists, it was decided to continue with prednisolone 5mg.\nAfter complete pulmonary recovery, a rheumatology re-consultation was\nplanned, and the resumption of methotrexate was considered.\n\nUpon admission, the patient had significant dysphagia, which improved\nduring the course. A flexible endoscopic swallowing examination\nperformed on 10/24/2021 by speech therapists and phoniatrics revealed a\nnormal swallow reflex. Mr. Carter can now resume a regular diet.\n\n**Physical Examination:** Weight: 83 kg, Height: 182 cm. Temperature:\n36.5°C, Heart rate: 80/min, Respiratory rate: 25/min, Blood pressure:\n130/80 mmHg, Oxygen saturation: 98% with 2 L/min O2\n\n[Skin/mucous membranes:]{.underline} No edema, no skin abnormalities.\nCentral venous catheter exit site on the neck is unremarkable.\n\n[Head/neck:]{.underline} Own teeth, intact mucous membranes\n\n[Heart]{.underline}: Rhythmic, tachycardic up to 100/min, clear heart\nsounds, no murmurs\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no adventitious\nsounds\n\n[Abdomen]{.underline}: Soft, active bowel sounds, no tenderness, no\nresistance\n\n[Lymph nodes:]{.underline} Cervical, axillary nodes not palpable\n\n[Vessels]{.underline}: Foot pulses palpable\n\n[Musculoskeletal:]{.underline} Muscle strength reduced due to CIP/CIM.\nCan mobilize to the bedside independently\n\n[Basic neurological examination:]{.underline} Alert, oriented, friendly\n\n[Psychological state]{.underline}: Depressed mood\n\n**Therapy and Progression:** The emergency presentation of Mr. Carter\nwas on 09/28/2021 due to severe dyspnea and respiratory insufficiency.\nAfter direct transfer to Intensive Care Unit, despite intensified oxygen\ntherapy with nasal high flow and mask CPAP, adequate oxygenation could\nnot be achieved, leading to intubation on 10/29/21.\n\nLung-protective ventilation was initiated due to leading oxygenation\nimpairment, with inhalational supportive NO therapy and conservative\nARDS therapy, including positional changes (a total of 9 sessions of 16\nhours each from 09/29/21 to 10/08/21). Due to elevated PCT levels, the\npatient received empiric antibiotic therapy with\nPiperacillin/Tazobactam, escalated to Meropenem. Voriconazole was\ninitiated on 10/07/2021 after the detection of Aspergillus in\ntracheobronchial secretions and BAL (intended treatment duration 4-6\nweeks).\n\nSubtherapeutic anticoagulation with Fraxiparine was administered for the\nprevention of thrombotic complications in the context of COVID-19. Under\nthis treatment regimen, gas exchange steadily improved, and on 10/12/21,\nthe patient was transferred with low catecholamine requirements for\nweaning from mechanical ventilation and sedation. There, he was\nextubated on 10/13/21.\n\nAfter extubation, severe dysphagia was observed, and speech therapy was\nconsulted. Oral diet is currently not possible, so Mr. Carter is on\nparenteral nutrition. This led to a paravasate in the right upper\nextremity with painful erythema. Adequate pain control was achieved with\nlocal cooling and subcutaneous Piritramide, as needed.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- ------------ ---------------------\n Absolute Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.3 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.61 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\>90 \\>90\n BUN 23 mg/dL 17-48 mg/dL\n Total Bilirubin 0.18 mg/dL \\< 1.20 mg/dL\n C-Reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 6.1 ng/L \\< 14 ng/L\n ALT 50 U/L \\< 41 U/L\n AST 40 U/L \\< 50 U/L\n Alkaline Phosphatase 111 U/L 40-130 U/L\n Gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cells 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.56 K/µL 3.90-10.50 K/µL\n Platelets 280 K/µL 150-370 K/µL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Prothrombin Time 89% 78-123%\n INR 1.09 0.90-1.25\n Activated Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n**Imaging:**\n\n**Chest X-ray bedside on 09/29/2021:** CT scan of the chest from\n9/28/2021 is available for comparison. Tracheal tube tip supracarinal.\nCentral venous catheter (CVC) via right internal jugular vein, tip in\nthe confluence of veins. Gastric tube tip infradiaphragmatic. Patchy\nconfluent bilateral lung infiltrates, mainly perihilar, left and right\nupper and lower fields. No significant changes compared to the previous\nday. Small bilateral pleural effusions. No pneumothorax in the lying\nposition. Left-sided heart prominence with mild stasis/capillary leak.\n\n**Chest X-ray bedside on 10/3/2021:**\n\n[Findings]{.underline}: Compared to 09/29/2021. Tracheal tube with tip\napproximately 4 cm above the carina. Gastric tube slightly retracted,\ntip located just below the diaphragm. Central venous catheter via the\nright internal jugular vein, currently with the tip in the superior vena\ncava. Regression and loosening of infiltrates (mainly in the lower\nfields on both sides). No significant effusion or pneumothorax. No\nsubstantial volume overload.\n\n**Chest X-ray bedside on 10/6/2021:**\n\n[Findings]{.underline}: Compared to the previous examination on\n11/4/2020. New central venous catheter (CVC) from the left internal\njugular vein with tip in the confluence. No pneumothorax in the lying\nposition, no large pleural effusions. Progressive infiltrates in the\nright lower field, perihilar regions on both sides. No significant\ncentral stasis. Heart not enlarged, mediastinum slim.\n\n**Chest X-ray bedside on 10/11/2021:**\n\n[Findings]{.underline}: Compared to 10/5/2021. Tracheal tube and gastric\ntube as before. Left CVC with the tip currently in the region of the\nbrachiocephalic vein, right CVC via the internal jugular vein with the\ntip in the superior vena cava. No pneumothorax, no effusions, increasing\nconsolidation of infiltrates in the right lower field and retrocardial\nleft with no significant cavitation. Left-biased heart without\nsignificant central congestion.\n\n**Chest X-ray bedside on 10/16/2021:**\n\n[Findings]{.underline}: Compared to previous examinations on 10/11/2021.\nHeart borderline enlarged. Mediastinum, as far as can be assessed from\nslightly rotated images, appears central and slim. Increasing\nconsolidation in the right lower lobe and left lower lobe, which is well\ncompatible with pneumonic infiltrates. At most, a small pleural effusion\non the left. No pneumothorax in the lying position. No signs of\nsignificant congestion. Right jugular catheter projecting into the\nsuperior vena cava. Tracheal tube and left jugular catheter have been\nremoved since the last examination.\n\n**Chest X-ray bedside on 10/20/2021:**\n\n[Findings]{.underline}: Compared to the examination on 10/16/2021. In\nthe course of known COVID pneumonia, there is an increasingly loosened\nappearance of infiltrates in the left basal region. A small effusion\ncontinues to drain basally. Otherwise, no significant changes in the\nshort-term follow-up. Right jugular catheter projecting into the\nsuperior vena cava, as before.\n\n**EKG on 10/27/2021:** Normal sinus rhythm, 86/min. Indeterminate axis.\nPQ interval: 108ms QRS duration: 108ms. QTc interval: 484ms. Peripheral\nlow voltage. Delayed R progression up to and including V3. RS transition\nin V4. No significant ST-T wave changes.\n\n**Ultrasound Abdomen on 11/01/2021:**\n\n[Reason for referral:]{.underline} History of COVID, Aspergillosis\n\n[Liver]{.underline}: Vertical diameter in the midclavicular line on the\nright is 120 mm.\n\n[Biliary tract]{.underline}: Well visualized. No abnormalities in the\nintrahepatic and extrahepatic bile ducts. Maximum width of the common\nbile duct is 3 mm.\n\n[Gallbladder]{.underline}: Well visualized. Normal findings.\n\n[Pancreas]{.underline}: Maximum diameters - Head: 17 mm, Body: 12 mm,\nTail: 15 mm. Well visualized. Normal findings.\n\n[Spleen]{.underline}: Normal size, normal homogeneous internal echo\npattern, no focal changes, hilum is free. Organ size: 120 mm x 38 mm.\n\n[Right kidney:]{.underline} Partially assessable, as far as\nrecognizable, parenchymal edge is age-appropriate, smooth organ contour,\nno urinary obstruction, no stones. Size: 120 mm x 45 mm, parenchymal\nthickness 21 mm.\n\n[Left kidney:]{.underline} Partially assessable, as far as recognizable,\nparenchymal edge is age-appropriate, smooth organ contour, no urinary\nobstruction, no stones. Size: 115 mm x 61 mm, parenchymal thickness 19\nmm.\n\n[Bladder:]{.underline} Well visualized, orthotopically located, normal\nwall proportions, no pathological echo structures in the lumen, normal\norgan size.\n\n[Abdominal vessels:]{.underline} Normal findings.\n\n[Abdominal lymph nodes:]{.underline} No evidence of enlarged lymph nodes\nin the subphrenic region.\n\n[Peritoneum]{.underline}: No free fluid.\n\n[Color duplex sonography of the portal vein:]{.underline} Orthograde\nflow, no evidence of thrombosis.\n\n[Assessment]{.underline}: In the right lower lobe cranial-lateral\n(segment VII), there is an entirely echo-free cystic structure with a\nslightly lobulated contour. There is no \\\"double wall,\\\" and there are\nno features suggestive of Echinococcus. This is most likely a congenital\ncyst. The overall structure, architecture, and texture of the liver are\nnormal, with no other focal abnormalities. In the rest of the abdomen,\nthere are no other pathological findings.\n\n**Cardiology Consultation on 10/29/2021:**\n\n**Medical History:** The patient reports thoracic complaints following\nthe intensive care unit stay post-COVID. These pains have been noticed\nwith mild exertion and are described as retrosternal with radiation to\nthe left chest. This last occurred on Sunday afternoon, lasting for\napproximately 1 hour and then spontaneously resolving at rest. This pain\ncannot be induced by a change in position, coughing, or deep\ninspiration. Dyspnea is continuously present, and the patient still\nrequires oxygen. Dyspnea worsens when lying down.\n\n**Cardiovascular risk factors**: Mildly elevated blood pressure\n(hypertension) since May of this year, managed with half a tablet\naccording to self-measurements (averaging 120/80 mmHg, rarely in the\n130s). Lipid profile checked by the general practitioner earlier this\nyear, presumably with good results. No known diabetes. Former smoker\nuntil 2007, but it is difficult to estimate the pack-years, as smoking\noccurred on occasions and during stressful times, less than 15\npack-years. No family history of cardiovascular diseases.\nUveitis/scleritis/episcleritis managed with 10mg MTX per week and 5 mg p\n\nPrednisolone orally daily, well-controlled without recurrence.\n\n**Physical Examination**: Lungs with moist rales bilaterally. Cardiac\nexamination with faint heart sounds. Regular heart rate of 80/min. No\npericardial rub. Pale-gray skin color. Respiratory rate of 15/min while\nsitting. Radial pulses palpable bilaterally. Groin pulses not examined.\nAllen\\'s test operable on the right, borderline on the left.\n\n**ECG**: tachycardic sinus rhythm with a heart rate of 109/min, left\naxis deviation, regular R-wave progression in chest leads, mild\nS-persistence in V6, no significant ST-T wave changes.\n\n**Transthoracic and transesophageal echocardiography on 11/27/2020**:\n\n[Kinetics]{.underline}: Hypokinesia of the lateral and anterior walls,\notherwise normokinetic and synergistic. Systolic function (right\nventricle): TAPSE 18 mm (\\> 16 mm), RV-S\\' 17.6 cm/s (\\> 10 cm/s).\n\n[Valves]{.underline}: Mitral valve - Delicate leaflets, good opening\nmotion, no significant insufficiency. Lambl\\'s excrescences on the\natrial side. Small fluttering structure at the subvalvular apparatus,\ncompatible with chordae tendineae. Aortic valve - Tricuspid, delicate\nvalve. Functionally intact (AV Vmax 1.0 m/s). Tricuspid valve -\nMorphologically normal. Mild insufficiency. TR Vmax 1.9 m/s, sPAP 15\nmmHg + CVP. Pulmonic valve - Morphologically and functionally normal.\n\n[Other Findings:]{.underline} No pericardial effusion. Small Persistent\nForamen Ovale. Left atrial appendage free of intracavitary thrombi at\n60°/90°/150°. Thoracic aorta with smooth-walled plaques, no dissections\nor thrombi.\n\n[Assessment]{.underline}: No structures suggestive of endocarditis. No\nrelevant valvular abnormalities. Incidentally, there is a moderately\nreduced LVEF with wall motion abnormalities in the RIVA (right\nventricular anterior) region. We request a cardiology consultation and\nfurther diagnostics.\n\n**Phoniatric Consultation on 10/24/2021:**\n\n[Medical History:]{.underline} Patient with a history of COVID\npneumonia, twice tested negative. Currently, the patient has Aspergillus\nand pneumonia. Previously, the patient was in the ICU and intubated for\ntwo weeks due to COVID. Following speech therapy for dysphagia, a\nflexible endoscopic evaluation of swallowing (FEES) is requested.\n\n[Findings]{.underline}: FEES reveals a normal configuration of the\nlarynx with good mobility of the tongue and lips. Normal gross mobility\nof the vocal cords during phonation and respiration transitions. Full\nglottic closure appears complete. Flexible transnasal swallow evaluation\n(FEES) with blue dye: Sufficient oral bolus control for liquids, purees,\nand solids. No drooling or leakage. Swallow reflex present. Voluntary\ninitiation of the swallow act is possible. Side-by-side swallowing of\ntest substances over the valleculae without evidence of\npre-/intra-/post-deglutitive penetration or aspiration for all test\nconsistencies. Rosenbeck\\'s Penetration-Aspiration Scale score: 1\n(Minimal retention in the valleculae with puree, which can be completely\ncleared by swallowing). Normal sensitivity, strong cough reflex. No\nnasal regurgitation.\n\n[Assessment]{.underline}: Normal swallowing function.\n\n[Current Recommendations:]{.underline} Able to consume regular diet and\nthin liquids, as well as medications with water.\n\n**Therapy and Progression:** The patient was admitted for further\ntreatment. Upon admission, the patient was in a reduced general\ncondition with significant mobility limitations.\n\nStaphylococcus aureus was detected in a blood culture, leading to a\ntransesophageal echocardiogram (TEE) on 11/26/2020. No vegetations were\nfound, but a moderate hypokinesia of the left ventricle in the RIVA area\nwas observed. Cardiac enzymes were within normal limits. This was\ninterpreted as post-COVID myocarditis, differential diagnosis myocardial\ninjury in severe ARDS, coronary artery disease, or mixed picture.\n\nIn consultation with the cardiology colleagues, a cautious heart failure\nmedication regimen with beta-blockers and ACE inhibitors was initiated.\nWe recommend an elective coronary angiography in the future. Currently,\nthe patient was symptom-free with low cardiac markers and a normal ECG,\nso acute diagnostic procedures were not indicated.\n\nThe antibiotic therapy with Cefazolin was continued until 11/05/2021\n(last sterile blood cultures from 10/24/2021). Staphylococcus\nepidermidis detected in the blood culture on 10/20/21 and at the tip of\nthe central venous catheter on 10/22/21 were considered\ncatheter-associated. The catheter was immediately removed. The patient\ndid not develop a fever during the hospital stay. Inflammatory markers\nimproved over time.\n\nAn abdominal ultrasound was performed due to an unclear liver lesion,\nwhich was found to be a congenital cyst. Echinococcus serology was\nnegative.\n\nIn consultation with the psychiatric colleagues, Quetiapine medication\nwas cautiously resumed for known depression, but it had to be\ndiscontinued later due to significant QTc prolongation. Long-term oxygen\ntherapy of 2 liters was indicated.\n\nOur ophthalmology colleagues recommended the resumption of MTX therapy\ngiven the patient\\'s stable vision. We request this therapy be initiated\nand an outpatient follow-up appointment in ophthalmology arranged after\nthe patient completes rehabilitation.\n\nWith physiotherapy, the patient achieved mobilization up to walking.\nSwallowing and articulation difficulties also significantly improved.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency** **Route**\n ---------------------------------- --------------- ------------------------------ ------------\n Metoprolol Succinate (Toprol XL) 23.8 mg 1-0-1-0 Oral\n Dicloxacillin Sodium (Dynapen) 2176 mg 1-1-1-0 Oral\n Voriconazole (Vfend) 200 mg 2-0-2-0 Oral\n Acetaminophen (Tylenol) 500 mg As needed Oral\n Ipratropium Bromide (Atrovent) 0.26 mg/2 ml 6-0-0-0 Inhalation\n Albuterol Sulfate (ProAir) 1.5 mg/2.5 ml 6-0-0-0 Inhalation\n Amitriptyline (Elavil) 28.3 mg 0-0-1-0 Oral\n Citalopram (Celexa) 50 mg 1-0-0-0 Oral\n Melatonin 2 mg 0-0-2-0 Oral\n Montelukast (Singulair) 10 mg 1-0-0-0 Oral\n Pantoprazole (Protonix) 45 mg 0-0-1-0 Oral\n Eplerenone (Inspra) 25 mg 1-0-0-0 Oral\n Ramipril (Altace) 2.5 mg 0-0-1-0 Oral\n Folic Acid 5 mg 0-0-1-0 48h after MTX intake Oral\n Methotrexate (Trexall) 15 mg 1-0-0-0 Once a Week Oral\n\n\n\n### text_4\n**Dear colleague, **\n\nWe thank you for referring your patient, Mr. Brian Carter, born on\n04/24/1956 to our outpatient care on 02/03/2022.\n\n**Diagnoses**: Suspected Post-Intensive-Care Syndrome with:\n\n- Dysphagia\n\n- ICU-acquired weakness\n\n- Depressive mood, anxiety\n\n**Other Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n<!-- -->\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** Mr. Carter was treated in the intensive care unit\nfor a total of 24 days in September and October 2021 due to COVID-19.\nFollowing intensive care treatment, he underwent neurological\nrehabilitation from 11/08/2021 to 01/18/2022, with the following\nrehabilitation results: \\\"Mr. I. benefited well from the therapies.\nParticularly, physiotherapy helped regain confidence in walking. During\ntreatment, breathing difficulties improved, and oxygen supplementation\nwas no longer necessary.\\\" An antidepressant therapy with Mirtazapine\nwas initiated for sleep disorders and mood swings, resulting in a\nreduction in sleep disturbances.\n\n**Assessment**: Since the illness, Mr. Carter reports general fatigue,\nquick fatigue, and weakness, especially in the lower extremities. He is\ncurrently not undergoing physiotherapy or any other treatments.\nRegarding psychopharmacological therapy, the patient has been seeing a\npsychiatrist once a month based on anamnesis. After a short exertion, he\nexperiences dyspnea and regularly needs to take breaks. Room air\nsaturation was at 94%. Physical examination revealed significant\nexpiratory wheezing and prolonged expiration bilaterally. Furthermore,\nthe patient reports cognitive impairments with marked forgetfulness and\ndifficulty concentrating. This is evident in the reduced results of the\nMiniCog (2/3 words, normal clock, 4 points) and animal naming tests\n(correct single naming of 10 animals, 3 points). Additionally, the\npatient reports an exacerbation of symptoms of depression known since\n2011, including sadness, fatigue, sleep disturbances, and anxiety. These\nworsened during the ICU stay. The current medication includes Citalopram\n40 mg and Mirtazapine 7.5 mg, which have somewhat improved previously\nworsened sleep disturbances. Psychotherapy is not currently taking place\nbut is strongly recommended.\n\nDysphagia diagnosed during the intensive care unit stay has slightly\nimproved, allowing Mr. Carter to consume regular food again. However, he\nstill experiences dysphagia and coughing during each meal. An\nappointment at the swallowing clinic has been scheduled by us (see\nbelow).\n\n**Current Recommendations:**\n\nAs swallowing difficulties persist, an appointment has been scheduled at\nour local swallowing clinic. We also recommend a pulmonary evaluation.\nContact has already been made, and the colleagues from Pulmonology will\nget in touch with Mr. Carter. Furthermore, due to a previously existing\ndepressive mood with currently exacerbated symptoms, we recommend\nconnecting the patient with an outpatient psychotherapist. Some\ntherapists have already been suggested by the patient\\'s general\npractitioner, and we strongly recommend further contact. A prescription\nfor physiotherapy has been issued for pronounced muscle weakness and\nsuspected ICU-acquired weakness. Further physiotherapeutic engagement\nwith the general practitioner\\'s assistance is urgently required.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------- ------------- ---------------------\n Neutrophils 49.0 % 42.0-77.0 %\n Lymphocytes 31.9 % 20.0-44.0 %\n Monocytes 7.2 % 2.0-9.5 %\n Basophils 0.7 % 0.0-1.8 %\n Eosinophils 10.8 % 0.5-5.5 %\n Immature Granulocytes 0.4 % 0.0-1.0 %\n Sodium 139 mEq/L 136-145 mEq/L\n Potassium 3.5 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.99 mg/dL 0.70-1.20 mg/dL\n BUN 25 mg/dL 17-48 mg/dL\n Total Bilirubin 0.45 mg/dL \\< 1.20 mg/dL\n CRP 3.9 mg/dL \\< 5.0 mg/dL\n ALT 21 U/L \\< 41 U/L\n AST 20 U/L \\< 50 U/L\n Alkaline Phosphatase 65 U/L 40-130 U/L\n Gamma-GT 38 U/L 8-61 U/L\n LDH 160 U/L 135-250 U/L\n Lipase 20 U/L 13-60 U/L\n Procalcitonin 0.03 µg/L \\< 0.50 µg/L\n Hemoglobin 13.2 g/dL 13.5-17.0 g/dL\n Hematocrit 44.2 % 39.5-50.5 %\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 7.62 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n\n\n\n\nHere is the query:\nHow long was Mr. Carter's prone positioning therapy, which was included in the conservative ARDS therapy?\n\nChoose the correct answer from the following options:\nA. A total of 7 prone positions overnight\nB. A total of 9 prone positions, 16 hours each\nC. A total of 9 prone positions overnight\nD. A total of 12 prone positions, 24 hours each\nE. Not specified\n\n\nYour response:\n", "role": "user" }, { "content": "A total of 9 prone positions, 16 hours each", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. Brian Carter, born on\n04/24/1956, who was under our inpatient care from 09/28/2021 to\n09/30/2021.\n\n**Diagnosis**: ARDS in the context of a COVID-19 infection\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Mr. Carter presented to our facility on foot\non 09/28/2021 with a five-day history of slowly progressive dyspnea, dry\ncough, and non-apoplectic, holocentral headache. His initial room air\nsaturation was 78%, which improved to 86% with 10 liters of oxygen.\nArterial blood gas analysis revealed an oxygenation disorder with a paO2\nof 50 mmHg, prompting the initiation of NIV therapy, under which Mr.\nCarter remained hemodynamically stable. CT imaging showed bilateral\ninterstitial pneumonia with COVID-typical infiltrates. Both a rapid test\nin the initial care unit and one from his primary care physician were\nnegative for COVID-19. Therefore, we admitted Mr. Carter to our\nintensive care unit for further evaluation.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Alert and cooperative\n\n[Cardiovascular/Abdominal Examination]{.underline}: Severely impaired\noxygenation improved with NIV; Sinus rhythm at 80 beats per minute\n\n[Abdomen]{.underline}: Surgical abdomen\n\n[Renal System:]{.underline} Urination initially scant, then polyuria\nOthers.\n\n**Therapy and Progression:** Upon admission, Mr. Carter was alert,\ncooperative, and hemodynamically stable despite significant oxygenation\nimpairment. Temporary improvement was achieved with differentiated NIV\nmask ventilation. On 09/30, there was a further deterioration in\noxygenation with an increase in respiratory rate and escalation of\nventilator settings, leading to the decision to intubate. A tolerable\nventilation situation was achieved with an oxygenation index of 125. Due\nto radiological suspicion of atypical pneumonia, we initiated empirical\nanti-infective therapy with Piperacillin/Tazobactam, Clarithromycin, and\nCotrimoxazole. Microbiological test results were pending at the time of\ntransfer. We also initiated mucolytic therapy with Ambroxol. The\npre-existing immunosuppressive therapy with Prednisolone was\ndiscontinued and switched to Dexamethasone 10 mg. At the time of\ntransfer, Mr. Carter was hemodynamically stable with low catecholamine\ndoses (0.07 µg/kg/min). A central venous catheter was placed, and\nenteral or parenteral nutrition had not yet been initiated. Diuresis was\nsufficient after a single dose of 20 mg furosemide, with retention\nparameters within the normal range. Prophylactic anticoagulation with\nheparin 500 U/h was initiated.\n\n**Status at Transfer**:\n\n[Neurology]{.underline}: RASS -5 under Propofol and Sufentanil sedation\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline (NA)\n0.07; Hemoglobin 12.8 g/dL\n\n[Lungs]{.underline}: Adequate decarboxylation with borderline\noxygenation: paO2 87.6 under FiO2 0.7; PEEP 16; PEAK 27\n\n[Abdomen]{.underline}: Soft abdomen, no nutrition initiated\n\n[Renal System]{.underline}: Normal urine output without stimulation.\nRetention values within normal range. Clear urine.\n\n[Access]{.underline}: CVC placed on 09/30, left radial artery catheter\nplaced on 09/30.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under our inpatient care from 09/30/2021 to 10/13/2021.\n\n**Diagnosis:** ARDS due to COVID-19 pneumonia with superinfection by\nAspergillus fumigatus\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The patient was admitted from the emergency\ndepartment, presenting with dyspnea and confirmed SARS-CoV-2 infection.\nAfter initial management in the intensive care unit, a non-invasive\nventilation (NIV) trial was attempted, followed by successful\nintubation. The patient was then transferred to the Intensive Care Unit.\n\n**Therapy and Progression:** Upon admission, the patient was sedated,\nintubated, and controlled on mechanical ventilation with mild\ncatecholamine support. Due to oxygenation impairment despite\nlung-protective ventilation and inhaled supportive NO therapy,\nconservative ARDS therapy was initiated, including positioning therapy\n(a total of 9 prone positions). After stabilization of gas exchange with\npositioning therapy, sedation and ventilation weaning were performed.\nGas exchange and oxygenation are currently stable under BIPAP\nventilation (PiP 25 mbar, PEEP 13 mbar, breathing rate 18/min). The\npatient, under reduced analgosedation with Sufentanil and Clonidine,\nexhibits a sufficient awakening response, is adequately responsive, and\nfollows commands with reduced muscle strength.\n\nThe home medication of Methotrexate and Prednisolone for uveitis was\ndiscontinued upon admission. The patient received Dexamethasone for 10\ndays initially and, starting from 11/10, prednisolone with prophylactic\nCotrimoxazole therapy.\n\nUpon detection of Aspergillus in tracheobronchial secretions, antifungal\ntherapy with Voriconazole and Caspofungin (until target Voriconazole\nlevels were achieved) was initiated. The initially started antimicrobial\ntherapy with Piperacillin + Tazobactam was escalated to Meropenem on\n10/05/2021 due to worsening infection parameters and progression of\ninfiltrates on X-ray. Infection parameters have been fluctuating, and\nfever is not currently observed. Diuresis is qualitatively and\nquantitatively within normal limits, and retention parameters are within\nthe normal range.\n\nAnticoagulation was administered in therapeutic doses using\nlow-molecular-weight heparin.\n\nEnteral nutrition is provided through a nasogastric tube, and the\npatient has regular bowel movements.\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Analgosedated, GCS 10, pupils equal and\nreactive, limb movement prompt, follows commands with reduced strength\n\n[Lungs]{.underline}: Intubated with BIPAP 25/13, FiO2 0.4\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline 0.05\n\n[Abdomen]{.underline}: Obese, no tenderness, abdomen soft, oral intake\nvia a nasogastric tube, regular bowel movements\n\n[Diuresis]{.underline}: Normal urine output, retention parameters within\nnormal limits\n\nSkin/Wounds: Some pressure sores from positioning (see nursing handover\nsheet)\n\n[Mobilization]{.underline}: Not conducted\n\n**Imaging:**\n\n**Bedside Chest X-ray from 10/11/2021:**\n\n[Clinical information, question, justifying indication:]{.underline}\nCOVID pneumonia, insertion of a central venous catheter (CVC)\n\n**Assessment**: Comparison with 10/05/21: Endotracheal tube identical,\ngastric tube seen extending well into the abdomen, left CVC currently\npositioned in the brachiocephalic vein region, right CVC via internal\njugular vein with tip in superior vena cava. No pneumothorax, no\neffusions, increasing consolidation of infiltrates in the right lower\nlobe and retrocardially on the left without significant cavitation as\nfar as can be assessed. Left heart without significant central\ncongestion.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under intensive care treatment from 09/28/2021 to 10/12/2021 and\nin our intensive care unit from 10/13/2021 to 10/21/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The initial hospital admission of the patient was\nthrough our emergency department due to severe respiratory insufficiency\nin the context of COVID-19 pneumonia.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Skin/Mucous Membranes]{.underline}: Warm, Skin Perfusion: Good\nperfusion, Edema: Lower legs\n\n[Head]{.underline}: Mobility: Active and passive free movement, Tongue:\nMoist\n\n[Thorax]{.underline}: Auscultation: Clear bilaterally\n\n[Abdomen]{.underline}: Soft, no guarding, Bowel Sounds: Sparse\nperistalsis, Tenderness: None\n\n[Neurology]{.underline}: Pupil Shape: Round, Pupil Size: Moderate, Light\nReaction: Both sides +++\n\nAlertness: Awake\n\n**ECG on admission:** Tachycardic sinus rhythm with 107/min, Left type,\nP-wave normally configured, normal PQ interval, no pathological Q as in\nPardee-Q, narrow QRS, regular R progression, R/S transition in V3/4, no\nS persistence, no ST segment changes, no discordant T-negatives.\n\n**Therapy and Progression:** Despite intensified oxygen therapy with\nnasal high-flow and mask CPAP, adequate oxygenation could not be\nachieved, and the patient was intubated on 09/29/21. Leading oxygenation\nimpairment led to lung-protective ventilation with inhaled supportive NO\ntherapy and conservative ARDS therapy, including positioning therapy (a\ntotal of 9 prone positions, 16 hours each, from 09/29/21 to 10/8/21).\n\nDue to elevated procalcitonin, the patient received empirical antibiotic\ntreatment with Piperacillin/Tazobactam starting from 10/2/21, which was\nescalated to Meropenem on 10/5/21 and continued until 10/14/21.\n\nAfter the detection of Aspergillus in tracheobronchial secretions and\nBAL, the patient received Voriconazole since 10/7/2021 (treatment\nduration formally 4-6 weeks). Most recently, the level was\nsubtherapeutic, so the dose was adjusted to 2 x 400 mg daily.\n\nThe immunosuppressive therapy with Methotrexate and Prednisolone for\nrheumatoid arthritis was switched to Dexamethasone (09/29 to 10/8) and,\nsince 10/09, Prednisolone monotherapy. After controlling the fungal\ninfection, a rheumatology re-consultation was planned. Furthermore,\nsubtherapeutic anticoagulation with Fraxiparine was initiated for the\nprevention of thrombotic complications in the context of COVID-19.\n\nUnder this treatment regimen, gas exchange continuously improved, and on\n10/12/21, the patient was transferred with low catecholamine\nrequirements for ventilation and sedation weaning. Mr. Carter was\nextubated on 12/13/21 and now maintains good oxygenation with less than\n3L oxygen via nasal cannula. Delirium symptoms after extubation\ncompletely regressed within a few days.\n\nSevere dysphagia was observed after invasive ventilation, leading to a\nspeech therapy consultation. Oral feeding is currently not possible, so\nMr. Carter is receiving parenteral nutrition. As a result, there was a\nparavasate in the upper right extremity with painful erythema. Adequate\npain control was achieved with local cooling and Piritramide as needed.\nDue to continued dietary restrictions, a central venous catheter was\nplaced on 10/20/2021 for parenteral nutrition.\n\nWe request continued speech therapy treatment.\n\nOn 10/21/21, Staphylococcus aureus was detected in blood culture, so we\ninitiated the administration of Flucloxacillin. The MRSA rapid test was\nnegative.\n\nWe are transferring Mr. Carter on 10/21/21 in stable condition, awake,\nand appropriately responsive for further treatment. We appreciate the\ntransfer of our patient and are available for any further questions.\n\n**Current Recommendations:**\n\n- Continuation of antifungal therapy for a total of at least 4-6 weeks\n\n- Voriconazole level measurement\n\n- Speech therapy consultation\n\n- Rheumatology re-consultation\n\n- Follow-up blood cultures upon detection of Staph. aureus\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Brian Carter, born on 04/24/1956, who was under\nour inpatient care from 10/21/2021 to 11/08/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Transfer for continuation of antimicrobial\ntherapy for MSSA bacteremia. Transesophageal echocardiogram planned for\ntomorrow. Cleared for full diet by speech therapy today. Patient\nmobilized to standing position for the first time today. Overall,\nmobility is significantly limited, but the patient can mobilize to the\nedge of the bed independently. No pain, no fever, mild cough without\nsputum. No shortness of breath. Mood is significantly depressed, but\nthis is a known issue. Before COVID-19, he was heavily affected by\nrheumatoid arthritis.\n\n**Medical History:** The patient was transferred to our COVID ward after\na positive SARS-CoV-2 RNA PCR test in the naso-oropharyngeal swab and\nrespiratory failure. On physical examination, he had a reduced general\ncondition. Respiratory rate was 24/min, and oxygen saturation was 97% on\n4 L/min of O2 via nasal cannula. Oxygen supply of 4 L via nasal cannula\ncould not be reduced during the course. A chest X-ray performed on 11/21\nshowed increasingly loosened infiltrates in the left basal region and a\nminimal effusion at the base.\n\nA SARS-CoV-2 RNA PCR test from 11/10/2020 was negative, so Mr. Carter\nwas no longer in isolation.\n\nDue to the detection of Aspergillus fumigatus in bronchoalveolar lavage,\nintravenous Voriconazole therapy initiated on 10/07/2021 was continued\nand was planned to be adjusted according to drug level monitoring.\nAdditionally, Staph. aureus was identified in a blood culture, and\nStaph. epidermidis. Antibiotic therapy with Cefazolin was started on\n10/22 and was to be continued for a total of 14 days after the first\nnegative blood culture. The central venous catheter, likely the source\nof infection, was removed on 10/22, and microbiological examination of\nthe catheter tip indicated suspicion of Staphylococci. To rule out\nendocarditis, a transesophageal echocardiogram was scheduled for 10/24.\nMr. Carter has already been informed about this intervention, and\nFraxiparine was to be paused on the evening of 10/24 and the morning of\n10/27, with the patient kept fasting.\n\nThere is also a known history of rheumatoid arthritis, which was treated\non an outpatient basis with Methotrexate and Prednisolone. Due to the\ncurrent infection, Methotrexate was paused, and after consultation with\nthe rheumatologists, it was decided to continue with prednisolone 5mg.\nAfter complete pulmonary recovery, a rheumatology re-consultation was\nplanned, and the resumption of methotrexate was considered.\n\nUpon admission, the patient had significant dysphagia, which improved\nduring the course. A flexible endoscopic swallowing examination\nperformed on 10/24/2021 by speech therapists and phoniatrics revealed a\nnormal swallow reflex. Mr. Carter can now resume a regular diet.\n\n**Physical Examination:** Weight: 83 kg, Height: 182 cm. Temperature:\n36.5°C, Heart rate: 80/min, Respiratory rate: 25/min, Blood pressure:\n130/80 mmHg, Oxygen saturation: 98% with 2 L/min O2\n\n[Skin/mucous membranes:]{.underline} No edema, no skin abnormalities.\nCentral venous catheter exit site on the neck is unremarkable.\n\n[Head/neck:]{.underline} Own teeth, intact mucous membranes\n\n[Heart]{.underline}: Rhythmic, tachycardic up to 100/min, clear heart\nsounds, no murmurs\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no adventitious\nsounds\n\n[Abdomen]{.underline}: Soft, active bowel sounds, no tenderness, no\nresistance\n\n[Lymph nodes:]{.underline} Cervical, axillary nodes not palpable\n\n[Vessels]{.underline}: Foot pulses palpable\n\n[Musculoskeletal:]{.underline} Muscle strength reduced due to CIP/CIM.\nCan mobilize to the bedside independently\n\n[Basic neurological examination:]{.underline} Alert, oriented, friendly\n\n[Psychological state]{.underline}: Depressed mood\n\n**Therapy and Progression:** The emergency presentation of Mr. Carter\nwas on 09/28/2021 due to severe dyspnea and respiratory insufficiency.\nAfter direct transfer to Intensive Care Unit, despite intensified oxygen\ntherapy with nasal high flow and mask CPAP, adequate oxygenation could\nnot be achieved, leading to intubation on 10/29/21.\n\nLung-protective ventilation was initiated due to leading oxygenation\nimpairment, with inhalational supportive NO therapy and conservative\nARDS therapy, including positional changes (a total of 9 sessions of 16\nhours each from 09/29/21 to 10/08/21). Due to elevated PCT levels, the\npatient received empiric antibiotic therapy with\nPiperacillin/Tazobactam, escalated to Meropenem. Voriconazole was\ninitiated on 10/07/2021 after the detection of Aspergillus in\ntracheobronchial secretions and BAL (intended treatment duration 4-6\nweeks).\n\nSubtherapeutic anticoagulation with Fraxiparine was administered for the\nprevention of thrombotic complications in the context of COVID-19. Under\nthis treatment regimen, gas exchange steadily improved, and on 10/12/21,\nthe patient was transferred with low catecholamine requirements for\nweaning from mechanical ventilation and sedation. There, he was\nextubated on 10/13/21.\n\nAfter extubation, severe dysphagia was observed, and speech therapy was\nconsulted. Oral diet is currently not possible, so Mr. Carter is on\nparenteral nutrition. This led to a paravasate in the right upper\nextremity with painful erythema. Adequate pain control was achieved with\nlocal cooling and subcutaneous Piritramide, as needed.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- ------------ ---------------------\n Absolute Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.3 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.61 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\>90 \\>90\n BUN 23 mg/dL 17-48 mg/dL\n Total Bilirubin 0.18 mg/dL \\< 1.20 mg/dL\n C-Reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 6.1 ng/L \\< 14 ng/L\n ALT 50 U/L \\< 41 U/L\n AST 40 U/L \\< 50 U/L\n Alkaline Phosphatase 111 U/L 40-130 U/L\n Gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cells 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.56 K/µL 3.90-10.50 K/µL\n Platelets 280 K/µL 150-370 K/µL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Prothrombin Time 89% 78-123%\n INR 1.09 0.90-1.25\n Activated Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n**Imaging:**\n\n**Chest X-ray bedside on 09/29/2021:** CT scan of the chest from\n9/28/2021 is available for comparison. Tracheal tube tip supracarinal.\nCentral venous catheter (CVC) via right internal jugular vein, tip in\nthe confluence of veins. Gastric tube tip infradiaphragmatic. Patchy\nconfluent bilateral lung infiltrates, mainly perihilar, left and right\nupper and lower fields. No significant changes compared to the previous\nday. Small bilateral pleural effusions. No pneumothorax in the lying\nposition. Left-sided heart prominence with mild stasis/capillary leak.\n\n**Chest X-ray bedside on 10/3/2021:**\n\n[Findings]{.underline}: Compared to 09/29/2021. Tracheal tube with tip\napproximately 4 cm above the carina. Gastric tube slightly retracted,\ntip located just below the diaphragm. Central venous catheter via the\nright internal jugular vein, currently with the tip in the superior vena\ncava. Regression and loosening of infiltrates (mainly in the lower\nfields on both sides). No significant effusion or pneumothorax. No\nsubstantial volume overload.\n\n**Chest X-ray bedside on 10/6/2021:**\n\n[Findings]{.underline}: Compared to the previous examination on\n11/4/2020. New central venous catheter (CVC) from the left internal\njugular vein with tip in the confluence. No pneumothorax in the lying\nposition, no large pleural effusions. Progressive infiltrates in the\nright lower field, perihilar regions on both sides. No significant\ncentral stasis. Heart not enlarged, mediastinum slim.\n\n**Chest X-ray bedside on 10/11/2021:**\n\n[Findings]{.underline}: Compared to 10/5/2021. Tracheal tube and gastric\ntube as before. Left CVC with the tip currently in the region of the\nbrachiocephalic vein, right CVC via the internal jugular vein with the\ntip in the superior vena cava. No pneumothorax, no effusions, increasing\nconsolidation of infiltrates in the right lower field and retrocardial\nleft with no significant cavitation. Left-biased heart without\nsignificant central congestion.\n\n**Chest X-ray bedside on 10/16/2021:**\n\n[Findings]{.underline}: Compared to previous examinations on 10/11/2021.\nHeart borderline enlarged. Mediastinum, as far as can be assessed from\nslightly rotated images, appears central and slim. Increasing\nconsolidation in the right lower lobe and left lower lobe, which is well\ncompatible with pneumonic infiltrates. At most, a small pleural effusion\non the left. No pneumothorax in the lying position. No signs of\nsignificant congestion. Right jugular catheter projecting into the\nsuperior vena cava. Tracheal tube and left jugular catheter have been\nremoved since the last examination.\n\n**Chest X-ray bedside on 10/20/2021:**\n\n[Findings]{.underline}: Compared to the examination on 10/16/2021. In\nthe course of known COVID pneumonia, there is an increasingly loosened\nappearance of infiltrates in the left basal region. A small effusion\ncontinues to drain basally. Otherwise, no significant changes in the\nshort-term follow-up. Right jugular catheter projecting into the\nsuperior vena cava, as before.\n\n**EKG on 10/27/2021:** Normal sinus rhythm, 86/min. Indeterminate axis.\nPQ interval: 108ms QRS duration: 108ms. QTc interval: 484ms. Peripheral\nlow voltage. Delayed R progression up to and including V3. RS transition\nin V4. No significant ST-T wave changes.\n\n**Ultrasound Abdomen on 11/01/2021:**\n\n[Reason for referral:]{.underline} History of COVID, Aspergillosis\n\n[Liver]{.underline}: Vertical diameter in the midclavicular line on the\nright is 120 mm.\n\n[Biliary tract]{.underline}: Well visualized. No abnormalities in the\nintrahepatic and extrahepatic bile ducts. Maximum width of the common\nbile duct is 3 mm.\n\n[Gallbladder]{.underline}: Well visualized. Normal findings.\n\n[Pancreas]{.underline}: Maximum diameters - Head: 17 mm, Body: 12 mm,\nTail: 15 mm. Well visualized. Normal findings.\n\n[Spleen]{.underline}: Normal size, normal homogeneous internal echo\npattern, no focal changes, hilum is free. Organ size: 120 mm x 38 mm.\n\n[Right kidney:]{.underline} Partially assessable, as far as\nrecognizable, parenchymal edge is age-appropriate, smooth organ contour,\nno urinary obstruction, no stones. Size: 120 mm x 45 mm, parenchymal\nthickness 21 mm.\n\n[Left kidney:]{.underline} Partially assessable, as far as recognizable,\nparenchymal edge is age-appropriate, smooth organ contour, no urinary\nobstruction, no stones. Size: 115 mm x 61 mm, parenchymal thickness 19\nmm.\n\n[Bladder:]{.underline} Well visualized, orthotopically located, normal\nwall proportions, no pathological echo structures in the lumen, normal\norgan size.\n\n[Abdominal vessels:]{.underline} Normal findings.\n\n[Abdominal lymph nodes:]{.underline} No evidence of enlarged lymph nodes\nin the subphrenic region.\n\n[Peritoneum]{.underline}: No free fluid.\n\n[Color duplex sonography of the portal vein:]{.underline} Orthograde\nflow, no evidence of thrombosis.\n\n[Assessment]{.underline}: In the right lower lobe cranial-lateral\n(segment VII), there is an entirely echo-free cystic structure with a\nslightly lobulated contour. There is no \\\"double wall,\\\" and there are\nno features suggestive of Echinococcus. This is most likely a congenital\ncyst. The overall structure, architecture, and texture of the liver are\nnormal, with no other focal abnormalities. In the rest of the abdomen,\nthere are no other pathological findings.\n\n**Cardiology Consultation on 10/29/2021:**\n\n**Medical History:** The patient reports thoracic complaints following\nthe intensive care unit stay post-COVID. These pains have been noticed\nwith mild exertion and are described as retrosternal with radiation to\nthe left chest. This last occurred on Sunday afternoon, lasting for\napproximately 1 hour and then spontaneously resolving at rest. This pain\ncannot be induced by a change in position, coughing, or deep\ninspiration. Dyspnea is continuously present, and the patient still\nrequires oxygen. Dyspnea worsens when lying down.\n\n**Cardiovascular risk factors**: Mildly elevated blood pressure\n(hypertension) since May of this year, managed with half a tablet\naccording to self-measurements (averaging 120/80 mmHg, rarely in the\n130s). Lipid profile checked by the general practitioner earlier this\nyear, presumably with good results. No known diabetes. Former smoker\nuntil 2007, but it is difficult to estimate the pack-years, as smoking\noccurred on occasions and during stressful times, less than 15\npack-years. No family history of cardiovascular diseases.\nUveitis/scleritis/episcleritis managed with 10mg MTX per week and 5 mg p\n\nPrednisolone orally daily, well-controlled without recurrence.\n\n**Physical Examination**: Lungs with moist rales bilaterally. Cardiac\nexamination with faint heart sounds. Regular heart rate of 80/min. No\npericardial rub. Pale-gray skin color. Respiratory rate of 15/min while\nsitting. Radial pulses palpable bilaterally. Groin pulses not examined.\nAllen\\'s test operable on the right, borderline on the left.\n\n**ECG**: tachycardic sinus rhythm with a heart rate of 109/min, left\naxis deviation, regular R-wave progression in chest leads, mild\nS-persistence in V6, no significant ST-T wave changes.\n\n**Transthoracic and transesophageal echocardiography on 11/27/2020**:\n\n[Kinetics]{.underline}: Hypokinesia of the lateral and anterior walls,\notherwise normokinetic and synergistic. Systolic function (right\nventricle): TAPSE 18 mm (\\> 16 mm), RV-S\\' 17.6 cm/s (\\> 10 cm/s).\n\n[Valves]{.underline}: Mitral valve - Delicate leaflets, good opening\nmotion, no significant insufficiency. Lambl\\'s excrescences on the\natrial side. Small fluttering structure at the subvalvular apparatus,\ncompatible with chordae tendineae. Aortic valve - Tricuspid, delicate\nvalve. Functionally intact (AV Vmax 1.0 m/s). Tricuspid valve -\nMorphologically normal. Mild insufficiency. TR Vmax 1.9 m/s, sPAP 15\nmmHg + CVP. Pulmonic valve - Morphologically and functionally normal.\n\n[Other Findings:]{.underline} No pericardial effusion. Small Persistent\nForamen Ovale. Left atrial appendage free of intracavitary thrombi at\n60°/90°/150°. Thoracic aorta with smooth-walled plaques, no dissections\nor thrombi.\n\n[Assessment]{.underline}: No structures suggestive of endocarditis. No\nrelevant valvular abnormalities. Incidentally, there is a moderately\nreduced LVEF with wall motion abnormalities in the RIVA (right\nventricular anterior) region. We request a cardiology consultation and\nfurther diagnostics.\n\n**Phoniatric Consultation on 10/24/2021:**\n\n[Medical History:]{.underline} Patient with a history of COVID\npneumonia, twice tested negative. Currently, the patient has Aspergillus\nand pneumonia. Previously, the patient was in the ICU and intubated for\ntwo weeks due to COVID. Following speech therapy for dysphagia, a\nflexible endoscopic evaluation of swallowing (FEES) is requested.\n\n[Findings]{.underline}: FEES reveals a normal configuration of the\nlarynx with good mobility of the tongue and lips. Normal gross mobility\nof the vocal cords during phonation and respiration transitions. Full\nglottic closure appears complete. Flexible transnasal swallow evaluation\n(FEES) with blue dye: Sufficient oral bolus control for liquids, purees,\nand solids. No drooling or leakage. Swallow reflex present. Voluntary\ninitiation of the swallow act is possible. Side-by-side swallowing of\ntest substances over the valleculae without evidence of\npre-/intra-/post-deglutitive penetration or aspiration for all test\nconsistencies. Rosenbeck\\'s Penetration-Aspiration Scale score: 1\n(Minimal retention in the valleculae with puree, which can be completely\ncleared by swallowing). Normal sensitivity, strong cough reflex. No\nnasal regurgitation.\n\n[Assessment]{.underline}: Normal swallowing function.\n\n[Current Recommendations:]{.underline} Able to consume regular diet and\nthin liquids, as well as medications with water.\n\n**Therapy and Progression:** The patient was admitted for further\ntreatment. Upon admission, the patient was in a reduced general\ncondition with significant mobility limitations.\n\nStaphylococcus aureus was detected in a blood culture, leading to a\ntransesophageal echocardiogram (TEE) on 11/26/2020. No vegetations were\nfound, but a moderate hypokinesia of the left ventricle in the RIVA area\nwas observed. Cardiac enzymes were within normal limits. This was\ninterpreted as post-COVID myocarditis, differential diagnosis myocardial\ninjury in severe ARDS, coronary artery disease, or mixed picture.\n\nIn consultation with the cardiology colleagues, a cautious heart failure\nmedication regimen with beta-blockers and ACE inhibitors was initiated.\nWe recommend an elective coronary angiography in the future. Currently,\nthe patient was symptom-free with low cardiac markers and a normal ECG,\nso acute diagnostic procedures were not indicated.\n\nThe antibiotic therapy with Cefazolin was continued until 11/05/2021\n(last sterile blood cultures from 10/24/2021). Staphylococcus\nepidermidis detected in the blood culture on 10/20/21 and at the tip of\nthe central venous catheter on 10/22/21 were considered\ncatheter-associated. The catheter was immediately removed. The patient\ndid not develop a fever during the hospital stay. Inflammatory markers\nimproved over time.\n\nAn abdominal ultrasound was performed due to an unclear liver lesion,\nwhich was found to be a congenital cyst. Echinococcus serology was\nnegative.\n\nIn consultation with the psychiatric colleagues, Quetiapine medication\nwas cautiously resumed for known depression, but it had to be\ndiscontinued later due to significant QTc prolongation. Long-term oxygen\ntherapy of 2 liters was indicated.\n\nOur ophthalmology colleagues recommended the resumption of MTX therapy\ngiven the patient\\'s stable vision. We request this therapy be initiated\nand an outpatient follow-up appointment in ophthalmology arranged after\nthe patient completes rehabilitation.\n\nWith physiotherapy, the patient achieved mobilization up to walking.\nSwallowing and articulation difficulties also significantly improved.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency** **Route**\n ---------------------------------- --------------- ------------------------------ ------------\n Metoprolol Succinate (Toprol XL) 23.8 mg 1-0-1-0 Oral\n Dicloxacillin Sodium (Dynapen) 2176 mg 1-1-1-0 Oral\n Voriconazole (Vfend) 200 mg 2-0-2-0 Oral\n Acetaminophen (Tylenol) 500 mg As needed Oral\n Ipratropium Bromide (Atrovent) 0.26 mg/2 ml 6-0-0-0 Inhalation\n Albuterol Sulfate (ProAir) 1.5 mg/2.5 ml 6-0-0-0 Inhalation\n Amitriptyline (Elavil) 28.3 mg 0-0-1-0 Oral\n Citalopram (Celexa) 50 mg 1-0-0-0 Oral\n Melatonin 2 mg 0-0-2-0 Oral\n Montelukast (Singulair) 10 mg 1-0-0-0 Oral\n Pantoprazole (Protonix) 45 mg 0-0-1-0 Oral\n Eplerenone (Inspra) 25 mg 1-0-0-0 Oral\n Ramipril (Altace) 2.5 mg 0-0-1-0 Oral\n Folic Acid 5 mg 0-0-1-0 48h after MTX intake Oral\n Methotrexate (Trexall) 15 mg 1-0-0-0 Once a Week Oral\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient, Mr. Brian Carter, born on\n04/24/1956 to our outpatient care on 02/03/2022.\n\n**Diagnoses**: Suspected Post-Intensive-Care Syndrome with:\n\n- Dysphagia\n\n- ICU-acquired weakness\n\n- Depressive mood, anxiety\n\n**Other Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n<!-- -->\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** Mr. Carter was treated in the intensive care unit\nfor a total of 24 days in September and October 2021 due to COVID-19.\nFollowing intensive care treatment, he underwent neurological\nrehabilitation from 11/08/2021 to 01/18/2022, with the following\nrehabilitation results: \\\"Mr. I. benefited well from the therapies.\nParticularly, physiotherapy helped regain confidence in walking. During\ntreatment, breathing difficulties improved, and oxygen supplementation\nwas no longer necessary.\\\" An antidepressant therapy with Mirtazapine\nwas initiated for sleep disorders and mood swings, resulting in a\nreduction in sleep disturbances.\n\n**Assessment**: Since the illness, Mr. Carter reports general fatigue,\nquick fatigue, and weakness, especially in the lower extremities. He is\ncurrently not undergoing physiotherapy or any other treatments.\nRegarding psychopharmacological therapy, the patient has been seeing a\npsychiatrist once a month based on anamnesis. After a short exertion, he\nexperiences dyspnea and regularly needs to take breaks. Room air\nsaturation was at 94%. Physical examination revealed significant\nexpiratory wheezing and prolonged expiration bilaterally. Furthermore,\nthe patient reports cognitive impairments with marked forgetfulness and\ndifficulty concentrating. This is evident in the reduced results of the\nMiniCog (2/3 words, normal clock, 4 points) and animal naming tests\n(correct single naming of 10 animals, 3 points). Additionally, the\npatient reports an exacerbation of symptoms of depression known since\n2011, including sadness, fatigue, sleep disturbances, and anxiety. These\nworsened during the ICU stay. The current medication includes Citalopram\n40 mg and Mirtazapine 7.5 mg, which have somewhat improved previously\nworsened sleep disturbances. Psychotherapy is not currently taking place\nbut is strongly recommended.\n\nDysphagia diagnosed during the intensive care unit stay has slightly\nimproved, allowing Mr. Carter to consume regular food again. However, he\nstill experiences dysphagia and coughing during each meal. An\nappointment at the swallowing clinic has been scheduled by us (see\nbelow).\n\n**Current Recommendations:**\n\nAs swallowing difficulties persist, an appointment has been scheduled at\nour local swallowing clinic. We also recommend a pulmonary evaluation.\nContact has already been made, and the colleagues from Pulmonology will\nget in touch with Mr. Carter. Furthermore, due to a previously existing\ndepressive mood with currently exacerbated symptoms, we recommend\nconnecting the patient with an outpatient psychotherapist. Some\ntherapists have already been suggested by the patient\\'s general\npractitioner, and we strongly recommend further contact. A prescription\nfor physiotherapy has been issued for pronounced muscle weakness and\nsuspected ICU-acquired weakness. Further physiotherapeutic engagement\nwith the general practitioner\\'s assistance is urgently required.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------- ------------- ---------------------\n Neutrophils 49.0 % 42.0-77.0 %\n Lymphocytes 31.9 % 20.0-44.0 %\n Monocytes 7.2 % 2.0-9.5 %\n Basophils 0.7 % 0.0-1.8 %\n Eosinophils 10.8 % 0.5-5.5 %\n Immature Granulocytes 0.4 % 0.0-1.0 %\n Sodium 139 mEq/L 136-145 mEq/L\n Potassium 3.5 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.99 mg/dL 0.70-1.20 mg/dL\n BUN 25 mg/dL 17-48 mg/dL\n Total Bilirubin 0.45 mg/dL \\< 1.20 mg/dL\n CRP 3.9 mg/dL \\< 5.0 mg/dL\n ALT 21 U/L \\< 41 U/L\n AST 20 U/L \\< 50 U/L\n Alkaline Phosphatase 65 U/L 40-130 U/L\n Gamma-GT 38 U/L 8-61 U/L\n LDH 160 U/L 135-250 U/L\n Lipase 20 U/L 13-60 U/L\n Procalcitonin 0.03 µg/L \\< 0.50 µg/L\n Hemoglobin 13.2 g/dL 13.5-17.0 g/dL\n Hematocrit 44.2 % 39.5-50.5 %\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 7.62 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n\n\n\n\nHere is the query:\nAs per the current recommendations, when should Mr. Hurley's next bone marrow puncture be scheduled post-transplantation?\n\nChoose the correct answer from the following options:\nA. Day +30 and +90\nB. Day +60 and +180\nC. Day +60, +120, and +360\nD. Day +100 and +200\nE. Day +180 and +365\n\n\nYour response:\n", "role": "user" }, { "content": "Day +60, +120, and +360", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n\n\n### text_5\n**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n\n\n\n\nHere is the query:\nWhich of the following sequences correctly represents the chronological order of the first set of diagnostic procedures following Mr. Wells' admission on 07/26/2019?\n\nChoose the correct answer from the following options:\nA. Ultrasound-guided liver puncture, MRI Liver, CT Thorax/Abdomen/Pelvis\nB. MRI Liver, Ultrasound-guided liver puncture, Gastroscopy\nC. Ultrasound-guided liver puncture, Gastroscopy, MRI Liver\nD. MRI Liver, CT Thorax/Abdomen/Pelvis, Ultrasound-guided liver puncture\nE. Gastroscopy, Ultrasound-guided liver puncture, MRI Liver\n\n\nYour response:\n", "role": "user" }, { "content": "Ultrasound-guided liver puncture, MRI Liver, CT Thorax/Abdomen/Pelvis", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n\n\n### text_3\n**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n\n\n### text_7\n**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n\n\n### text_8\n**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n\n\n### text_9\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n\n\n### text_10\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n\n\n### text_11\n**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n\n\n### text_12\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n\n\n\n\nHere is the query:\nWhat change in the lung nodules was observed in the CT scan dated 04/02/2023 as compared to the prior scan in Mrs. Anderson?\n\nChoose the correct answer from the following options:\nA. Lung nodules were significantly reduced in size.\nB. Lung nodules remained unchanged in size and number.\nC. Known metastatic lung nodules increased in size.\nD. No known metastatic lung nodules were identified.\nE. The lung nodules were slightly reduced, with a few new ones appearing.\n\n\nYour response:\n", "role": "user" }, { "content": "Known metastatic lung nodules increased in size.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n", "title": "text_9" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n", "title": "text_10" }, { "content": "**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n", "title": "text_11" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n", "title": "text_12" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. Brian Carter, born on\n04/24/1956, who was under our inpatient care from 09/28/2021 to\n09/30/2021.\n\n**Diagnosis**: ARDS in the context of a COVID-19 infection\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Mr. Carter presented to our facility on foot\non 09/28/2021 with a five-day history of slowly progressive dyspnea, dry\ncough, and non-apoplectic, holocentral headache. His initial room air\nsaturation was 78%, which improved to 86% with 10 liters of oxygen.\nArterial blood gas analysis revealed an oxygenation disorder with a paO2\nof 50 mmHg, prompting the initiation of NIV therapy, under which Mr.\nCarter remained hemodynamically stable. CT imaging showed bilateral\ninterstitial pneumonia with COVID-typical infiltrates. Both a rapid test\nin the initial care unit and one from his primary care physician were\nnegative for COVID-19. Therefore, we admitted Mr. Carter to our\nintensive care unit for further evaluation.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Alert and cooperative\n\n[Cardiovascular/Abdominal Examination]{.underline}: Severely impaired\noxygenation improved with NIV; Sinus rhythm at 80 beats per minute\n\n[Abdomen]{.underline}: Surgical abdomen\n\n[Renal System:]{.underline} Urination initially scant, then polyuria\nOthers.\n\n**Therapy and Progression:** Upon admission, Mr. Carter was alert,\ncooperative, and hemodynamically stable despite significant oxygenation\nimpairment. Temporary improvement was achieved with differentiated NIV\nmask ventilation. On 09/30, there was a further deterioration in\noxygenation with an increase in respiratory rate and escalation of\nventilator settings, leading to the decision to intubate. A tolerable\nventilation situation was achieved with an oxygenation index of 125. Due\nto radiological suspicion of atypical pneumonia, we initiated empirical\nanti-infective therapy with Piperacillin/Tazobactam, Clarithromycin, and\nCotrimoxazole. Microbiological test results were pending at the time of\ntransfer. We also initiated mucolytic therapy with Ambroxol. The\npre-existing immunosuppressive therapy with Prednisolone was\ndiscontinued and switched to Dexamethasone 10 mg. At the time of\ntransfer, Mr. Carter was hemodynamically stable with low catecholamine\ndoses (0.07 µg/kg/min). A central venous catheter was placed, and\nenteral or parenteral nutrition had not yet been initiated. Diuresis was\nsufficient after a single dose of 20 mg furosemide, with retention\nparameters within the normal range. Prophylactic anticoagulation with\nheparin 500 U/h was initiated.\n\n**Status at Transfer**:\n\n[Neurology]{.underline}: RASS -5 under Propofol and Sufentanil sedation\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline (NA)\n0.07; Hemoglobin 12.8 g/dL\n\n[Lungs]{.underline}: Adequate decarboxylation with borderline\noxygenation: paO2 87.6 under FiO2 0.7; PEEP 16; PEAK 27\n\n[Abdomen]{.underline}: Soft abdomen, no nutrition initiated\n\n[Renal System]{.underline}: Normal urine output without stimulation.\nRetention values within normal range. Clear urine.\n\n[Access]{.underline}: CVC placed on 09/30, left radial artery catheter\nplaced on 09/30.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under our inpatient care from 09/30/2021 to 10/13/2021.\n\n**Diagnosis:** ARDS due to COVID-19 pneumonia with superinfection by\nAspergillus fumigatus\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The patient was admitted from the emergency\ndepartment, presenting with dyspnea and confirmed SARS-CoV-2 infection.\nAfter initial management in the intensive care unit, a non-invasive\nventilation (NIV) trial was attempted, followed by successful\nintubation. The patient was then transferred to the Intensive Care Unit.\n\n**Therapy and Progression:** Upon admission, the patient was sedated,\nintubated, and controlled on mechanical ventilation with mild\ncatecholamine support. Due to oxygenation impairment despite\nlung-protective ventilation and inhaled supportive NO therapy,\nconservative ARDS therapy was initiated, including positioning therapy\n(a total of 9 prone positions). After stabilization of gas exchange with\npositioning therapy, sedation and ventilation weaning were performed.\nGas exchange and oxygenation are currently stable under BIPAP\nventilation (PiP 25 mbar, PEEP 13 mbar, breathing rate 18/min). The\npatient, under reduced analgosedation with Sufentanil and Clonidine,\nexhibits a sufficient awakening response, is adequately responsive, and\nfollows commands with reduced muscle strength.\n\nThe home medication of Methotrexate and Prednisolone for uveitis was\ndiscontinued upon admission. The patient received Dexamethasone for 10\ndays initially and, starting from 11/10, prednisolone with prophylactic\nCotrimoxazole therapy.\n\nUpon detection of Aspergillus in tracheobronchial secretions, antifungal\ntherapy with Voriconazole and Caspofungin (until target Voriconazole\nlevels were achieved) was initiated. The initially started antimicrobial\ntherapy with Piperacillin + Tazobactam was escalated to Meropenem on\n10/05/2021 due to worsening infection parameters and progression of\ninfiltrates on X-ray. Infection parameters have been fluctuating, and\nfever is not currently observed. Diuresis is qualitatively and\nquantitatively within normal limits, and retention parameters are within\nthe normal range.\n\nAnticoagulation was administered in therapeutic doses using\nlow-molecular-weight heparin.\n\nEnteral nutrition is provided through a nasogastric tube, and the\npatient has regular bowel movements.\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Analgosedated, GCS 10, pupils equal and\nreactive, limb movement prompt, follows commands with reduced strength\n\n[Lungs]{.underline}: Intubated with BIPAP 25/13, FiO2 0.4\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline 0.05\n\n[Abdomen]{.underline}: Obese, no tenderness, abdomen soft, oral intake\nvia a nasogastric tube, regular bowel movements\n\n[Diuresis]{.underline}: Normal urine output, retention parameters within\nnormal limits\n\nSkin/Wounds: Some pressure sores from positioning (see nursing handover\nsheet)\n\n[Mobilization]{.underline}: Not conducted\n\n**Imaging:**\n\n**Bedside Chest X-ray from 10/11/2021:**\n\n[Clinical information, question, justifying indication:]{.underline}\nCOVID pneumonia, insertion of a central venous catheter (CVC)\n\n**Assessment**: Comparison with 10/05/21: Endotracheal tube identical,\ngastric tube seen extending well into the abdomen, left CVC currently\npositioned in the brachiocephalic vein region, right CVC via internal\njugular vein with tip in superior vena cava. No pneumothorax, no\neffusions, increasing consolidation of infiltrates in the right lower\nlobe and retrocardially on the left without significant cavitation as\nfar as can be assessed. Left heart without significant central\ncongestion.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under intensive care treatment from 09/28/2021 to 10/12/2021 and\nin our intensive care unit from 10/13/2021 to 10/21/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The initial hospital admission of the patient was\nthrough our emergency department due to severe respiratory insufficiency\nin the context of COVID-19 pneumonia.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Skin/Mucous Membranes]{.underline}: Warm, Skin Perfusion: Good\nperfusion, Edema: Lower legs\n\n[Head]{.underline}: Mobility: Active and passive free movement, Tongue:\nMoist\n\n[Thorax]{.underline}: Auscultation: Clear bilaterally\n\n[Abdomen]{.underline}: Soft, no guarding, Bowel Sounds: Sparse\nperistalsis, Tenderness: None\n\n[Neurology]{.underline}: Pupil Shape: Round, Pupil Size: Moderate, Light\nReaction: Both sides +++\n\nAlertness: Awake\n\n**ECG on admission:** Tachycardic sinus rhythm with 107/min, Left type,\nP-wave normally configured, normal PQ interval, no pathological Q as in\nPardee-Q, narrow QRS, regular R progression, R/S transition in V3/4, no\nS persistence, no ST segment changes, no discordant T-negatives.\n\n**Therapy and Progression:** Despite intensified oxygen therapy with\nnasal high-flow and mask CPAP, adequate oxygenation could not be\nachieved, and the patient was intubated on 09/29/21. Leading oxygenation\nimpairment led to lung-protective ventilation with inhaled supportive NO\ntherapy and conservative ARDS therapy, including positioning therapy (a\ntotal of 9 prone positions, 16 hours each, from 09/29/21 to 10/8/21).\n\nDue to elevated procalcitonin, the patient received empirical antibiotic\ntreatment with Piperacillin/Tazobactam starting from 10/2/21, which was\nescalated to Meropenem on 10/5/21 and continued until 10/14/21.\n\nAfter the detection of Aspergillus in tracheobronchial secretions and\nBAL, the patient received Voriconazole since 10/7/2021 (treatment\nduration formally 4-6 weeks). Most recently, the level was\nsubtherapeutic, so the dose was adjusted to 2 x 400 mg daily.\n\nThe immunosuppressive therapy with Methotrexate and Prednisolone for\nrheumatoid arthritis was switched to Dexamethasone (09/29 to 10/8) and,\nsince 10/09, Prednisolone monotherapy. After controlling the fungal\ninfection, a rheumatology re-consultation was planned. Furthermore,\nsubtherapeutic anticoagulation with Fraxiparine was initiated for the\nprevention of thrombotic complications in the context of COVID-19.\n\nUnder this treatment regimen, gas exchange continuously improved, and on\n10/12/21, the patient was transferred with low catecholamine\nrequirements for ventilation and sedation weaning. Mr. Carter was\nextubated on 12/13/21 and now maintains good oxygenation with less than\n3L oxygen via nasal cannula. Delirium symptoms after extubation\ncompletely regressed within a few days.\n\nSevere dysphagia was observed after invasive ventilation, leading to a\nspeech therapy consultation. Oral feeding is currently not possible, so\nMr. Carter is receiving parenteral nutrition. As a result, there was a\nparavasate in the upper right extremity with painful erythema. Adequate\npain control was achieved with local cooling and Piritramide as needed.\nDue to continued dietary restrictions, a central venous catheter was\nplaced on 10/20/2021 for parenteral nutrition.\n\nWe request continued speech therapy treatment.\n\nOn 10/21/21, Staphylococcus aureus was detected in blood culture, so we\ninitiated the administration of Flucloxacillin. The MRSA rapid test was\nnegative.\n\nWe are transferring Mr. Carter on 10/21/21 in stable condition, awake,\nand appropriately responsive for further treatment. We appreciate the\ntransfer of our patient and are available for any further questions.\n\n**Current Recommendations:**\n\n- Continuation of antifungal therapy for a total of at least 4-6 weeks\n\n- Voriconazole level measurement\n\n- Speech therapy consultation\n\n- Rheumatology re-consultation\n\n- Follow-up blood cultures upon detection of Staph. aureus\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Mr. Brian Carter, born on 04/24/1956, who was under\nour inpatient care from 10/21/2021 to 11/08/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Transfer for continuation of antimicrobial\ntherapy for MSSA bacteremia. Transesophageal echocardiogram planned for\ntomorrow. Cleared for full diet by speech therapy today. Patient\nmobilized to standing position for the first time today. Overall,\nmobility is significantly limited, but the patient can mobilize to the\nedge of the bed independently. No pain, no fever, mild cough without\nsputum. No shortness of breath. Mood is significantly depressed, but\nthis is a known issue. Before COVID-19, he was heavily affected by\nrheumatoid arthritis.\n\n**Medical History:** The patient was transferred to our COVID ward after\na positive SARS-CoV-2 RNA PCR test in the naso-oropharyngeal swab and\nrespiratory failure. On physical examination, he had a reduced general\ncondition. Respiratory rate was 24/min, and oxygen saturation was 97% on\n4 L/min of O2 via nasal cannula. Oxygen supply of 4 L via nasal cannula\ncould not be reduced during the course. A chest X-ray performed on 11/21\nshowed increasingly loosened infiltrates in the left basal region and a\nminimal effusion at the base.\n\nA SARS-CoV-2 RNA PCR test from 11/10/2020 was negative, so Mr. Carter\nwas no longer in isolation.\n\nDue to the detection of Aspergillus fumigatus in bronchoalveolar lavage,\nintravenous Voriconazole therapy initiated on 10/07/2021 was continued\nand was planned to be adjusted according to drug level monitoring.\nAdditionally, Staph. aureus was identified in a blood culture, and\nStaph. epidermidis. Antibiotic therapy with Cefazolin was started on\n10/22 and was to be continued for a total of 14 days after the first\nnegative blood culture. The central venous catheter, likely the source\nof infection, was removed on 10/22, and microbiological examination of\nthe catheter tip indicated suspicion of Staphylococci. To rule out\nendocarditis, a transesophageal echocardiogram was scheduled for 10/24.\nMr. Carter has already been informed about this intervention, and\nFraxiparine was to be paused on the evening of 10/24 and the morning of\n10/27, with the patient kept fasting.\n\nThere is also a known history of rheumatoid arthritis, which was treated\non an outpatient basis with Methotrexate and Prednisolone. Due to the\ncurrent infection, Methotrexate was paused, and after consultation with\nthe rheumatologists, it was decided to continue with prednisolone 5mg.\nAfter complete pulmonary recovery, a rheumatology re-consultation was\nplanned, and the resumption of methotrexate was considered.\n\nUpon admission, the patient had significant dysphagia, which improved\nduring the course. A flexible endoscopic swallowing examination\nperformed on 10/24/2021 by speech therapists and phoniatrics revealed a\nnormal swallow reflex. Mr. Carter can now resume a regular diet.\n\n**Physical Examination:** Weight: 83 kg, Height: 182 cm. Temperature:\n36.5°C, Heart rate: 80/min, Respiratory rate: 25/min, Blood pressure:\n130/80 mmHg, Oxygen saturation: 98% with 2 L/min O2\n\n[Skin/mucous membranes:]{.underline} No edema, no skin abnormalities.\nCentral venous catheter exit site on the neck is unremarkable.\n\n[Head/neck:]{.underline} Own teeth, intact mucous membranes\n\n[Heart]{.underline}: Rhythmic, tachycardic up to 100/min, clear heart\nsounds, no murmurs\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no adventitious\nsounds\n\n[Abdomen]{.underline}: Soft, active bowel sounds, no tenderness, no\nresistance\n\n[Lymph nodes:]{.underline} Cervical, axillary nodes not palpable\n\n[Vessels]{.underline}: Foot pulses palpable\n\n[Musculoskeletal:]{.underline} Muscle strength reduced due to CIP/CIM.\nCan mobilize to the bedside independently\n\n[Basic neurological examination:]{.underline} Alert, oriented, friendly\n\n[Psychological state]{.underline}: Depressed mood\n\n**Therapy and Progression:** The emergency presentation of Mr. Carter\nwas on 09/28/2021 due to severe dyspnea and respiratory insufficiency.\nAfter direct transfer to Intensive Care Unit, despite intensified oxygen\ntherapy with nasal high flow and mask CPAP, adequate oxygenation could\nnot be achieved, leading to intubation on 10/29/21.\n\nLung-protective ventilation was initiated due to leading oxygenation\nimpairment, with inhalational supportive NO therapy and conservative\nARDS therapy, including positional changes (a total of 9 sessions of 16\nhours each from 09/29/21 to 10/08/21). Due to elevated PCT levels, the\npatient received empiric antibiotic therapy with\nPiperacillin/Tazobactam, escalated to Meropenem. Voriconazole was\ninitiated on 10/07/2021 after the detection of Aspergillus in\ntracheobronchial secretions and BAL (intended treatment duration 4-6\nweeks).\n\nSubtherapeutic anticoagulation with Fraxiparine was administered for the\nprevention of thrombotic complications in the context of COVID-19. Under\nthis treatment regimen, gas exchange steadily improved, and on 10/12/21,\nthe patient was transferred with low catecholamine requirements for\nweaning from mechanical ventilation and sedation. There, he was\nextubated on 10/13/21.\n\nAfter extubation, severe dysphagia was observed, and speech therapy was\nconsulted. Oral diet is currently not possible, so Mr. Carter is on\nparenteral nutrition. This led to a paravasate in the right upper\nextremity with painful erythema. Adequate pain control was achieved with\nlocal cooling and subcutaneous Piritramide, as needed.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- ------------ ---------------------\n Absolute Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.3 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.61 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\>90 \\>90\n BUN 23 mg/dL 17-48 mg/dL\n Total Bilirubin 0.18 mg/dL \\< 1.20 mg/dL\n C-Reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 6.1 ng/L \\< 14 ng/L\n ALT 50 U/L \\< 41 U/L\n AST 40 U/L \\< 50 U/L\n Alkaline Phosphatase 111 U/L 40-130 U/L\n Gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cells 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.56 K/µL 3.90-10.50 K/µL\n Platelets 280 K/µL 150-370 K/µL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Prothrombin Time 89% 78-123%\n INR 1.09 0.90-1.25\n Activated Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n**Imaging:**\n\n**Chest X-ray bedside on 09/29/2021:** CT scan of the chest from\n9/28/2021 is available for comparison. Tracheal tube tip supracarinal.\nCentral venous catheter (CVC) via right internal jugular vein, tip in\nthe confluence of veins. Gastric tube tip infradiaphragmatic. Patchy\nconfluent bilateral lung infiltrates, mainly perihilar, left and right\nupper and lower fields. No significant changes compared to the previous\nday. Small bilateral pleural effusions. No pneumothorax in the lying\nposition. Left-sided heart prominence with mild stasis/capillary leak.\n\n**Chest X-ray bedside on 10/3/2021:**\n\n[Findings]{.underline}: Compared to 09/29/2021. Tracheal tube with tip\napproximately 4 cm above the carina. Gastric tube slightly retracted,\ntip located just below the diaphragm. Central venous catheter via the\nright internal jugular vein, currently with the tip in the superior vena\ncava. Regression and loosening of infiltrates (mainly in the lower\nfields on both sides). No significant effusion or pneumothorax. No\nsubstantial volume overload.\n\n**Chest X-ray bedside on 10/6/2021:**\n\n[Findings]{.underline}: Compared to the previous examination on\n11/4/2020. New central venous catheter (CVC) from the left internal\njugular vein with tip in the confluence. No pneumothorax in the lying\nposition, no large pleural effusions. Progressive infiltrates in the\nright lower field, perihilar regions on both sides. No significant\ncentral stasis. Heart not enlarged, mediastinum slim.\n\n**Chest X-ray bedside on 10/11/2021:**\n\n[Findings]{.underline}: Compared to 10/5/2021. Tracheal tube and gastric\ntube as before. Left CVC with the tip currently in the region of the\nbrachiocephalic vein, right CVC via the internal jugular vein with the\ntip in the superior vena cava. No pneumothorax, no effusions, increasing\nconsolidation of infiltrates in the right lower field and retrocardial\nleft with no significant cavitation. Left-biased heart without\nsignificant central congestion.\n\n**Chest X-ray bedside on 10/16/2021:**\n\n[Findings]{.underline}: Compared to previous examinations on 10/11/2021.\nHeart borderline enlarged. Mediastinum, as far as can be assessed from\nslightly rotated images, appears central and slim. Increasing\nconsolidation in the right lower lobe and left lower lobe, which is well\ncompatible with pneumonic infiltrates. At most, a small pleural effusion\non the left. No pneumothorax in the lying position. No signs of\nsignificant congestion. Right jugular catheter projecting into the\nsuperior vena cava. Tracheal tube and left jugular catheter have been\nremoved since the last examination.\n\n**Chest X-ray bedside on 10/20/2021:**\n\n[Findings]{.underline}: Compared to the examination on 10/16/2021. In\nthe course of known COVID pneumonia, there is an increasingly loosened\nappearance of infiltrates in the left basal region. A small effusion\ncontinues to drain basally. Otherwise, no significant changes in the\nshort-term follow-up. Right jugular catheter projecting into the\nsuperior vena cava, as before.\n\n**EKG on 10/27/2021:** Normal sinus rhythm, 86/min. Indeterminate axis.\nPQ interval: 108ms QRS duration: 108ms. QTc interval: 484ms. Peripheral\nlow voltage. Delayed R progression up to and including V3. RS transition\nin V4. No significant ST-T wave changes.\n\n**Ultrasound Abdomen on 11/01/2021:**\n\n[Reason for referral:]{.underline} History of COVID, Aspergillosis\n\n[Liver]{.underline}: Vertical diameter in the midclavicular line on the\nright is 120 mm.\n\n[Biliary tract]{.underline}: Well visualized. No abnormalities in the\nintrahepatic and extrahepatic bile ducts. Maximum width of the common\nbile duct is 3 mm.\n\n[Gallbladder]{.underline}: Well visualized. Normal findings.\n\n[Pancreas]{.underline}: Maximum diameters - Head: 17 mm, Body: 12 mm,\nTail: 15 mm. Well visualized. Normal findings.\n\n[Spleen]{.underline}: Normal size, normal homogeneous internal echo\npattern, no focal changes, hilum is free. Organ size: 120 mm x 38 mm.\n\n[Right kidney:]{.underline} Partially assessable, as far as\nrecognizable, parenchymal edge is age-appropriate, smooth organ contour,\nno urinary obstruction, no stones. Size: 120 mm x 45 mm, parenchymal\nthickness 21 mm.\n\n[Left kidney:]{.underline} Partially assessable, as far as recognizable,\nparenchymal edge is age-appropriate, smooth organ contour, no urinary\nobstruction, no stones. Size: 115 mm x 61 mm, parenchymal thickness 19\nmm.\n\n[Bladder:]{.underline} Well visualized, orthotopically located, normal\nwall proportions, no pathological echo structures in the lumen, normal\norgan size.\n\n[Abdominal vessels:]{.underline} Normal findings.\n\n[Abdominal lymph nodes:]{.underline} No evidence of enlarged lymph nodes\nin the subphrenic region.\n\n[Peritoneum]{.underline}: No free fluid.\n\n[Color duplex sonography of the portal vein:]{.underline} Orthograde\nflow, no evidence of thrombosis.\n\n[Assessment]{.underline}: In the right lower lobe cranial-lateral\n(segment VII), there is an entirely echo-free cystic structure with a\nslightly lobulated contour. There is no \\\"double wall,\\\" and there are\nno features suggestive of Echinococcus. This is most likely a congenital\ncyst. The overall structure, architecture, and texture of the liver are\nnormal, with no other focal abnormalities. In the rest of the abdomen,\nthere are no other pathological findings.\n\n**Cardiology Consultation on 10/29/2021:**\n\n**Medical History:** The patient reports thoracic complaints following\nthe intensive care unit stay post-COVID. These pains have been noticed\nwith mild exertion and are described as retrosternal with radiation to\nthe left chest. This last occurred on Sunday afternoon, lasting for\napproximately 1 hour and then spontaneously resolving at rest. This pain\ncannot be induced by a change in position, coughing, or deep\ninspiration. Dyspnea is continuously present, and the patient still\nrequires oxygen. Dyspnea worsens when lying down.\n\n**Cardiovascular risk factors**: Mildly elevated blood pressure\n(hypertension) since May of this year, managed with half a tablet\naccording to self-measurements (averaging 120/80 mmHg, rarely in the\n130s). Lipid profile checked by the general practitioner earlier this\nyear, presumably with good results. No known diabetes. Former smoker\nuntil 2007, but it is difficult to estimate the pack-years, as smoking\noccurred on occasions and during stressful times, less than 15\npack-years. No family history of cardiovascular diseases.\nUveitis/scleritis/episcleritis managed with 10mg MTX per week and 5 mg p\n\nPrednisolone orally daily, well-controlled without recurrence.\n\n**Physical Examination**: Lungs with moist rales bilaterally. Cardiac\nexamination with faint heart sounds. Regular heart rate of 80/min. No\npericardial rub. Pale-gray skin color. Respiratory rate of 15/min while\nsitting. Radial pulses palpable bilaterally. Groin pulses not examined.\nAllen\\'s test operable on the right, borderline on the left.\n\n**ECG**: tachycardic sinus rhythm with a heart rate of 109/min, left\naxis deviation, regular R-wave progression in chest leads, mild\nS-persistence in V6, no significant ST-T wave changes.\n\n**Transthoracic and transesophageal echocardiography on 11/27/2020**:\n\n[Kinetics]{.underline}: Hypokinesia of the lateral and anterior walls,\notherwise normokinetic and synergistic. Systolic function (right\nventricle): TAPSE 18 mm (\\> 16 mm), RV-S\\' 17.6 cm/s (\\> 10 cm/s).\n\n[Valves]{.underline}: Mitral valve - Delicate leaflets, good opening\nmotion, no significant insufficiency. Lambl\\'s excrescences on the\natrial side. Small fluttering structure at the subvalvular apparatus,\ncompatible with chordae tendineae. Aortic valve - Tricuspid, delicate\nvalve. Functionally intact (AV Vmax 1.0 m/s). Tricuspid valve -\nMorphologically normal. Mild insufficiency. TR Vmax 1.9 m/s, sPAP 15\nmmHg + CVP. Pulmonic valve - Morphologically and functionally normal.\n\n[Other Findings:]{.underline} No pericardial effusion. Small Persistent\nForamen Ovale. Left atrial appendage free of intracavitary thrombi at\n60°/90°/150°. Thoracic aorta with smooth-walled plaques, no dissections\nor thrombi.\n\n[Assessment]{.underline}: No structures suggestive of endocarditis. No\nrelevant valvular abnormalities. Incidentally, there is a moderately\nreduced LVEF with wall motion abnormalities in the RIVA (right\nventricular anterior) region. We request a cardiology consultation and\nfurther diagnostics.\n\n**Phoniatric Consultation on 10/24/2021:**\n\n[Medical History:]{.underline} Patient with a history of COVID\npneumonia, twice tested negative. Currently, the patient has Aspergillus\nand pneumonia. Previously, the patient was in the ICU and intubated for\ntwo weeks due to COVID. Following speech therapy for dysphagia, a\nflexible endoscopic evaluation of swallowing (FEES) is requested.\n\n[Findings]{.underline}: FEES reveals a normal configuration of the\nlarynx with good mobility of the tongue and lips. Normal gross mobility\nof the vocal cords during phonation and respiration transitions. Full\nglottic closure appears complete. Flexible transnasal swallow evaluation\n(FEES) with blue dye: Sufficient oral bolus control for liquids, purees,\nand solids. No drooling or leakage. Swallow reflex present. Voluntary\ninitiation of the swallow act is possible. Side-by-side swallowing of\ntest substances over the valleculae without evidence of\npre-/intra-/post-deglutitive penetration or aspiration for all test\nconsistencies. Rosenbeck\\'s Penetration-Aspiration Scale score: 1\n(Minimal retention in the valleculae with puree, which can be completely\ncleared by swallowing). Normal sensitivity, strong cough reflex. No\nnasal regurgitation.\n\n[Assessment]{.underline}: Normal swallowing function.\n\n[Current Recommendations:]{.underline} Able to consume regular diet and\nthin liquids, as well as medications with water.\n\n**Therapy and Progression:** The patient was admitted for further\ntreatment. Upon admission, the patient was in a reduced general\ncondition with significant mobility limitations.\n\nStaphylococcus aureus was detected in a blood culture, leading to a\ntransesophageal echocardiogram (TEE) on 11/26/2020. No vegetations were\nfound, but a moderate hypokinesia of the left ventricle in the RIVA area\nwas observed. Cardiac enzymes were within normal limits. This was\ninterpreted as post-COVID myocarditis, differential diagnosis myocardial\ninjury in severe ARDS, coronary artery disease, or mixed picture.\n\nIn consultation with the cardiology colleagues, a cautious heart failure\nmedication regimen with beta-blockers and ACE inhibitors was initiated.\nWe recommend an elective coronary angiography in the future. Currently,\nthe patient was symptom-free with low cardiac markers and a normal ECG,\nso acute diagnostic procedures were not indicated.\n\nThe antibiotic therapy with Cefazolin was continued until 11/05/2021\n(last sterile blood cultures from 10/24/2021). Staphylococcus\nepidermidis detected in the blood culture on 10/20/21 and at the tip of\nthe central venous catheter on 10/22/21 were considered\ncatheter-associated. The catheter was immediately removed. The patient\ndid not develop a fever during the hospital stay. Inflammatory markers\nimproved over time.\n\nAn abdominal ultrasound was performed due to an unclear liver lesion,\nwhich was found to be a congenital cyst. Echinococcus serology was\nnegative.\n\nIn consultation with the psychiatric colleagues, Quetiapine medication\nwas cautiously resumed for known depression, but it had to be\ndiscontinued later due to significant QTc prolongation. Long-term oxygen\ntherapy of 2 liters was indicated.\n\nOur ophthalmology colleagues recommended the resumption of MTX therapy\ngiven the patient\\'s stable vision. We request this therapy be initiated\nand an outpatient follow-up appointment in ophthalmology arranged after\nthe patient completes rehabilitation.\n\nWith physiotherapy, the patient achieved mobilization up to walking.\nSwallowing and articulation difficulties also significantly improved.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency** **Route**\n ---------------------------------- --------------- ------------------------------ ------------\n Metoprolol Succinate (Toprol XL) 23.8 mg 1-0-1-0 Oral\n Dicloxacillin Sodium (Dynapen) 2176 mg 1-1-1-0 Oral\n Voriconazole (Vfend) 200 mg 2-0-2-0 Oral\n Acetaminophen (Tylenol) 500 mg As needed Oral\n Ipratropium Bromide (Atrovent) 0.26 mg/2 ml 6-0-0-0 Inhalation\n Albuterol Sulfate (ProAir) 1.5 mg/2.5 ml 6-0-0-0 Inhalation\n Amitriptyline (Elavil) 28.3 mg 0-0-1-0 Oral\n Citalopram (Celexa) 50 mg 1-0-0-0 Oral\n Melatonin 2 mg 0-0-2-0 Oral\n Montelukast (Singulair) 10 mg 1-0-0-0 Oral\n Pantoprazole (Protonix) 45 mg 0-0-1-0 Oral\n Eplerenone (Inspra) 25 mg 1-0-0-0 Oral\n Ramipril (Altace) 2.5 mg 0-0-1-0 Oral\n Folic Acid 5 mg 0-0-1-0 48h after MTX intake Oral\n Methotrexate (Trexall) 15 mg 1-0-0-0 Once a Week Oral\n\n\n\n### text_4\n**Dear colleague, **\n\nWe thank you for referring your patient, Mr. Brian Carter, born on\n04/24/1956 to our outpatient care on 02/03/2022.\n\n**Diagnoses**: Suspected Post-Intensive-Care Syndrome with:\n\n- Dysphagia\n\n- ICU-acquired weakness\n\n- Depressive mood, anxiety\n\n**Other Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n<!-- -->\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** Mr. Carter was treated in the intensive care unit\nfor a total of 24 days in September and October 2021 due to COVID-19.\nFollowing intensive care treatment, he underwent neurological\nrehabilitation from 11/08/2021 to 01/18/2022, with the following\nrehabilitation results: \\\"Mr. I. benefited well from the therapies.\nParticularly, physiotherapy helped regain confidence in walking. During\ntreatment, breathing difficulties improved, and oxygen supplementation\nwas no longer necessary.\\\" An antidepressant therapy with Mirtazapine\nwas initiated for sleep disorders and mood swings, resulting in a\nreduction in sleep disturbances.\n\n**Assessment**: Since the illness, Mr. Carter reports general fatigue,\nquick fatigue, and weakness, especially in the lower extremities. He is\ncurrently not undergoing physiotherapy or any other treatments.\nRegarding psychopharmacological therapy, the patient has been seeing a\npsychiatrist once a month based on anamnesis. After a short exertion, he\nexperiences dyspnea and regularly needs to take breaks. Room air\nsaturation was at 94%. Physical examination revealed significant\nexpiratory wheezing and prolonged expiration bilaterally. Furthermore,\nthe patient reports cognitive impairments with marked forgetfulness and\ndifficulty concentrating. This is evident in the reduced results of the\nMiniCog (2/3 words, normal clock, 4 points) and animal naming tests\n(correct single naming of 10 animals, 3 points). Additionally, the\npatient reports an exacerbation of symptoms of depression known since\n2011, including sadness, fatigue, sleep disturbances, and anxiety. These\nworsened during the ICU stay. The current medication includes Citalopram\n40 mg and Mirtazapine 7.5 mg, which have somewhat improved previously\nworsened sleep disturbances. Psychotherapy is not currently taking place\nbut is strongly recommended.\n\nDysphagia diagnosed during the intensive care unit stay has slightly\nimproved, allowing Mr. Carter to consume regular food again. However, he\nstill experiences dysphagia and coughing during each meal. An\nappointment at the swallowing clinic has been scheduled by us (see\nbelow).\n\n**Current Recommendations:**\n\nAs swallowing difficulties persist, an appointment has been scheduled at\nour local swallowing clinic. We also recommend a pulmonary evaluation.\nContact has already been made, and the colleagues from Pulmonology will\nget in touch with Mr. Carter. Furthermore, due to a previously existing\ndepressive mood with currently exacerbated symptoms, we recommend\nconnecting the patient with an outpatient psychotherapist. Some\ntherapists have already been suggested by the patient\\'s general\npractitioner, and we strongly recommend further contact. A prescription\nfor physiotherapy has been issued for pronounced muscle weakness and\nsuspected ICU-acquired weakness. Further physiotherapeutic engagement\nwith the general practitioner\\'s assistance is urgently required.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------- ------------- ---------------------\n Neutrophils 49.0 % 42.0-77.0 %\n Lymphocytes 31.9 % 20.0-44.0 %\n Monocytes 7.2 % 2.0-9.5 %\n Basophils 0.7 % 0.0-1.8 %\n Eosinophils 10.8 % 0.5-5.5 %\n Immature Granulocytes 0.4 % 0.0-1.0 %\n Sodium 139 mEq/L 136-145 mEq/L\n Potassium 3.5 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.99 mg/dL 0.70-1.20 mg/dL\n BUN 25 mg/dL 17-48 mg/dL\n Total Bilirubin 0.45 mg/dL \\< 1.20 mg/dL\n CRP 3.9 mg/dL \\< 5.0 mg/dL\n ALT 21 U/L \\< 41 U/L\n AST 20 U/L \\< 50 U/L\n Alkaline Phosphatase 65 U/L 40-130 U/L\n Gamma-GT 38 U/L 8-61 U/L\n LDH 160 U/L 135-250 U/L\n Lipase 20 U/L 13-60 U/L\n Procalcitonin 0.03 µg/L \\< 0.50 µg/L\n Hemoglobin 13.2 g/dL 13.5-17.0 g/dL\n Hematocrit 44.2 % 39.5-50.5 %\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 7.62 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n\n\n\n\nHere is the query:\nWhat change in Mr. Carter's blood profile from November 2021 to February 2022 might suggest an improvement in his hepatic function?\n\nChoose the correct answer from the following options:\nA. Increase in Hemoglobin from 11.6 g/dL to 15.8 g/dL\nB. Decrease in Gamma-GT from 200 U/L to 38 U/L\nC. Increase in Sodium from 138 mEq/L to 139 mEq/L\nD. Decrease in Creatinine from 0.61 mg/dL to 0.99 mg/dL\nE. Increase in White Blood Cells from 9.56 K/µL to 7.62 K/µL\n\n\nYour response:\n", "role": "user" }, { "content": "Decrease in Gamma-GT from 200 U/L to 38 U/L", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. Brian Carter, born on\n04/24/1956, who was under our inpatient care from 09/28/2021 to\n09/30/2021.\n\n**Diagnosis**: ARDS in the context of a COVID-19 infection\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Mr. Carter presented to our facility on foot\non 09/28/2021 with a five-day history of slowly progressive dyspnea, dry\ncough, and non-apoplectic, holocentral headache. His initial room air\nsaturation was 78%, which improved to 86% with 10 liters of oxygen.\nArterial blood gas analysis revealed an oxygenation disorder with a paO2\nof 50 mmHg, prompting the initiation of NIV therapy, under which Mr.\nCarter remained hemodynamically stable. CT imaging showed bilateral\ninterstitial pneumonia with COVID-typical infiltrates. Both a rapid test\nin the initial care unit and one from his primary care physician were\nnegative for COVID-19. Therefore, we admitted Mr. Carter to our\nintensive care unit for further evaluation.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Alert and cooperative\n\n[Cardiovascular/Abdominal Examination]{.underline}: Severely impaired\noxygenation improved with NIV; Sinus rhythm at 80 beats per minute\n\n[Abdomen]{.underline}: Surgical abdomen\n\n[Renal System:]{.underline} Urination initially scant, then polyuria\nOthers.\n\n**Therapy and Progression:** Upon admission, Mr. Carter was alert,\ncooperative, and hemodynamically stable despite significant oxygenation\nimpairment. Temporary improvement was achieved with differentiated NIV\nmask ventilation. On 09/30, there was a further deterioration in\noxygenation with an increase in respiratory rate and escalation of\nventilator settings, leading to the decision to intubate. A tolerable\nventilation situation was achieved with an oxygenation index of 125. Due\nto radiological suspicion of atypical pneumonia, we initiated empirical\nanti-infective therapy with Piperacillin/Tazobactam, Clarithromycin, and\nCotrimoxazole. Microbiological test results were pending at the time of\ntransfer. We also initiated mucolytic therapy with Ambroxol. The\npre-existing immunosuppressive therapy with Prednisolone was\ndiscontinued and switched to Dexamethasone 10 mg. At the time of\ntransfer, Mr. Carter was hemodynamically stable with low catecholamine\ndoses (0.07 µg/kg/min). A central venous catheter was placed, and\nenteral or parenteral nutrition had not yet been initiated. Diuresis was\nsufficient after a single dose of 20 mg furosemide, with retention\nparameters within the normal range. Prophylactic anticoagulation with\nheparin 500 U/h was initiated.\n\n**Status at Transfer**:\n\n[Neurology]{.underline}: RASS -5 under Propofol and Sufentanil sedation\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline (NA)\n0.07; Hemoglobin 12.8 g/dL\n\n[Lungs]{.underline}: Adequate decarboxylation with borderline\noxygenation: paO2 87.6 under FiO2 0.7; PEEP 16; PEAK 27\n\n[Abdomen]{.underline}: Soft abdomen, no nutrition initiated\n\n[Renal System]{.underline}: Normal urine output without stimulation.\nRetention values within normal range. Clear urine.\n\n[Access]{.underline}: CVC placed on 09/30, left radial artery catheter\nplaced on 09/30.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under our inpatient care from 09/30/2021 to 10/13/2021.\n\n**Diagnosis:** ARDS due to COVID-19 pneumonia with superinfection by\nAspergillus fumigatus\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The patient was admitted from the emergency\ndepartment, presenting with dyspnea and confirmed SARS-CoV-2 infection.\nAfter initial management in the intensive care unit, a non-invasive\nventilation (NIV) trial was attempted, followed by successful\nintubation. The patient was then transferred to the Intensive Care Unit.\n\n**Therapy and Progression:** Upon admission, the patient was sedated,\nintubated, and controlled on mechanical ventilation with mild\ncatecholamine support. Due to oxygenation impairment despite\nlung-protective ventilation and inhaled supportive NO therapy,\nconservative ARDS therapy was initiated, including positioning therapy\n(a total of 9 prone positions). After stabilization of gas exchange with\npositioning therapy, sedation and ventilation weaning were performed.\nGas exchange and oxygenation are currently stable under BIPAP\nventilation (PiP 25 mbar, PEEP 13 mbar, breathing rate 18/min). The\npatient, under reduced analgosedation with Sufentanil and Clonidine,\nexhibits a sufficient awakening response, is adequately responsive, and\nfollows commands with reduced muscle strength.\n\nThe home medication of Methotrexate and Prednisolone for uveitis was\ndiscontinued upon admission. The patient received Dexamethasone for 10\ndays initially and, starting from 11/10, prednisolone with prophylactic\nCotrimoxazole therapy.\n\nUpon detection of Aspergillus in tracheobronchial secretions, antifungal\ntherapy with Voriconazole and Caspofungin (until target Voriconazole\nlevels were achieved) was initiated. The initially started antimicrobial\ntherapy with Piperacillin + Tazobactam was escalated to Meropenem on\n10/05/2021 due to worsening infection parameters and progression of\ninfiltrates on X-ray. Infection parameters have been fluctuating, and\nfever is not currently observed. Diuresis is qualitatively and\nquantitatively within normal limits, and retention parameters are within\nthe normal range.\n\nAnticoagulation was administered in therapeutic doses using\nlow-molecular-weight heparin.\n\nEnteral nutrition is provided through a nasogastric tube, and the\npatient has regular bowel movements.\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Analgosedated, GCS 10, pupils equal and\nreactive, limb movement prompt, follows commands with reduced strength\n\n[Lungs]{.underline}: Intubated with BIPAP 25/13, FiO2 0.4\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline 0.05\n\n[Abdomen]{.underline}: Obese, no tenderness, abdomen soft, oral intake\nvia a nasogastric tube, regular bowel movements\n\n[Diuresis]{.underline}: Normal urine output, retention parameters within\nnormal limits\n\nSkin/Wounds: Some pressure sores from positioning (see nursing handover\nsheet)\n\n[Mobilization]{.underline}: Not conducted\n\n**Imaging:**\n\n**Bedside Chest X-ray from 10/11/2021:**\n\n[Clinical information, question, justifying indication:]{.underline}\nCOVID pneumonia, insertion of a central venous catheter (CVC)\n\n**Assessment**: Comparison with 10/05/21: Endotracheal tube identical,\ngastric tube seen extending well into the abdomen, left CVC currently\npositioned in the brachiocephalic vein region, right CVC via internal\njugular vein with tip in superior vena cava. No pneumothorax, no\neffusions, increasing consolidation of infiltrates in the right lower\nlobe and retrocardially on the left without significant cavitation as\nfar as can be assessed. Left heart without significant central\ncongestion.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under intensive care treatment from 09/28/2021 to 10/12/2021 and\nin our intensive care unit from 10/13/2021 to 10/21/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The initial hospital admission of the patient was\nthrough our emergency department due to severe respiratory insufficiency\nin the context of COVID-19 pneumonia.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Skin/Mucous Membranes]{.underline}: Warm, Skin Perfusion: Good\nperfusion, Edema: Lower legs\n\n[Head]{.underline}: Mobility: Active and passive free movement, Tongue:\nMoist\n\n[Thorax]{.underline}: Auscultation: Clear bilaterally\n\n[Abdomen]{.underline}: Soft, no guarding, Bowel Sounds: Sparse\nperistalsis, Tenderness: None\n\n[Neurology]{.underline}: Pupil Shape: Round, Pupil Size: Moderate, Light\nReaction: Both sides +++\n\nAlertness: Awake\n\n**ECG on admission:** Tachycardic sinus rhythm with 107/min, Left type,\nP-wave normally configured, normal PQ interval, no pathological Q as in\nPardee-Q, narrow QRS, regular R progression, R/S transition in V3/4, no\nS persistence, no ST segment changes, no discordant T-negatives.\n\n**Therapy and Progression:** Despite intensified oxygen therapy with\nnasal high-flow and mask CPAP, adequate oxygenation could not be\nachieved, and the patient was intubated on 09/29/21. Leading oxygenation\nimpairment led to lung-protective ventilation with inhaled supportive NO\ntherapy and conservative ARDS therapy, including positioning therapy (a\ntotal of 9 prone positions, 16 hours each, from 09/29/21 to 10/8/21).\n\nDue to elevated procalcitonin, the patient received empirical antibiotic\ntreatment with Piperacillin/Tazobactam starting from 10/2/21, which was\nescalated to Meropenem on 10/5/21 and continued until 10/14/21.\n\nAfter the detection of Aspergillus in tracheobronchial secretions and\nBAL, the patient received Voriconazole since 10/7/2021 (treatment\nduration formally 4-6 weeks). Most recently, the level was\nsubtherapeutic, so the dose was adjusted to 2 x 400 mg daily.\n\nThe immunosuppressive therapy with Methotrexate and Prednisolone for\nrheumatoid arthritis was switched to Dexamethasone (09/29 to 10/8) and,\nsince 10/09, Prednisolone monotherapy. After controlling the fungal\ninfection, a rheumatology re-consultation was planned. Furthermore,\nsubtherapeutic anticoagulation with Fraxiparine was initiated for the\nprevention of thrombotic complications in the context of COVID-19.\n\nUnder this treatment regimen, gas exchange continuously improved, and on\n10/12/21, the patient was transferred with low catecholamine\nrequirements for ventilation and sedation weaning. Mr. Carter was\nextubated on 12/13/21 and now maintains good oxygenation with less than\n3L oxygen via nasal cannula. Delirium symptoms after extubation\ncompletely regressed within a few days.\n\nSevere dysphagia was observed after invasive ventilation, leading to a\nspeech therapy consultation. Oral feeding is currently not possible, so\nMr. Carter is receiving parenteral nutrition. As a result, there was a\nparavasate in the upper right extremity with painful erythema. Adequate\npain control was achieved with local cooling and Piritramide as needed.\nDue to continued dietary restrictions, a central venous catheter was\nplaced on 10/20/2021 for parenteral nutrition.\n\nWe request continued speech therapy treatment.\n\nOn 10/21/21, Staphylococcus aureus was detected in blood culture, so we\ninitiated the administration of Flucloxacillin. The MRSA rapid test was\nnegative.\n\nWe are transferring Mr. Carter on 10/21/21 in stable condition, awake,\nand appropriately responsive for further treatment. We appreciate the\ntransfer of our patient and are available for any further questions.\n\n**Current Recommendations:**\n\n- Continuation of antifungal therapy for a total of at least 4-6 weeks\n\n- Voriconazole level measurement\n\n- Speech therapy consultation\n\n- Rheumatology re-consultation\n\n- Follow-up blood cultures upon detection of Staph. aureus\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Brian Carter, born on 04/24/1956, who was under\nour inpatient care from 10/21/2021 to 11/08/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Transfer for continuation of antimicrobial\ntherapy for MSSA bacteremia. Transesophageal echocardiogram planned for\ntomorrow. Cleared for full diet by speech therapy today. Patient\nmobilized to standing position for the first time today. Overall,\nmobility is significantly limited, but the patient can mobilize to the\nedge of the bed independently. No pain, no fever, mild cough without\nsputum. No shortness of breath. Mood is significantly depressed, but\nthis is a known issue. Before COVID-19, he was heavily affected by\nrheumatoid arthritis.\n\n**Medical History:** The patient was transferred to our COVID ward after\na positive SARS-CoV-2 RNA PCR test in the naso-oropharyngeal swab and\nrespiratory failure. On physical examination, he had a reduced general\ncondition. Respiratory rate was 24/min, and oxygen saturation was 97% on\n4 L/min of O2 via nasal cannula. Oxygen supply of 4 L via nasal cannula\ncould not be reduced during the course. A chest X-ray performed on 11/21\nshowed increasingly loosened infiltrates in the left basal region and a\nminimal effusion at the base.\n\nA SARS-CoV-2 RNA PCR test from 11/10/2020 was negative, so Mr. Carter\nwas no longer in isolation.\n\nDue to the detection of Aspergillus fumigatus in bronchoalveolar lavage,\nintravenous Voriconazole therapy initiated on 10/07/2021 was continued\nand was planned to be adjusted according to drug level monitoring.\nAdditionally, Staph. aureus was identified in a blood culture, and\nStaph. epidermidis. Antibiotic therapy with Cefazolin was started on\n10/22 and was to be continued for a total of 14 days after the first\nnegative blood culture. The central venous catheter, likely the source\nof infection, was removed on 10/22, and microbiological examination of\nthe catheter tip indicated suspicion of Staphylococci. To rule out\nendocarditis, a transesophageal echocardiogram was scheduled for 10/24.\nMr. Carter has already been informed about this intervention, and\nFraxiparine was to be paused on the evening of 10/24 and the morning of\n10/27, with the patient kept fasting.\n\nThere is also a known history of rheumatoid arthritis, which was treated\non an outpatient basis with Methotrexate and Prednisolone. Due to the\ncurrent infection, Methotrexate was paused, and after consultation with\nthe rheumatologists, it was decided to continue with prednisolone 5mg.\nAfter complete pulmonary recovery, a rheumatology re-consultation was\nplanned, and the resumption of methotrexate was considered.\n\nUpon admission, the patient had significant dysphagia, which improved\nduring the course. A flexible endoscopic swallowing examination\nperformed on 10/24/2021 by speech therapists and phoniatrics revealed a\nnormal swallow reflex. Mr. Carter can now resume a regular diet.\n\n**Physical Examination:** Weight: 83 kg, Height: 182 cm. Temperature:\n36.5°C, Heart rate: 80/min, Respiratory rate: 25/min, Blood pressure:\n130/80 mmHg, Oxygen saturation: 98% with 2 L/min O2\n\n[Skin/mucous membranes:]{.underline} No edema, no skin abnormalities.\nCentral venous catheter exit site on the neck is unremarkable.\n\n[Head/neck:]{.underline} Own teeth, intact mucous membranes\n\n[Heart]{.underline}: Rhythmic, tachycardic up to 100/min, clear heart\nsounds, no murmurs\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no adventitious\nsounds\n\n[Abdomen]{.underline}: Soft, active bowel sounds, no tenderness, no\nresistance\n\n[Lymph nodes:]{.underline} Cervical, axillary nodes not palpable\n\n[Vessels]{.underline}: Foot pulses palpable\n\n[Musculoskeletal:]{.underline} Muscle strength reduced due to CIP/CIM.\nCan mobilize to the bedside independently\n\n[Basic neurological examination:]{.underline} Alert, oriented, friendly\n\n[Psychological state]{.underline}: Depressed mood\n\n**Therapy and Progression:** The emergency presentation of Mr. Carter\nwas on 09/28/2021 due to severe dyspnea and respiratory insufficiency.\nAfter direct transfer to Intensive Care Unit, despite intensified oxygen\ntherapy with nasal high flow and mask CPAP, adequate oxygenation could\nnot be achieved, leading to intubation on 10/29/21.\n\nLung-protective ventilation was initiated due to leading oxygenation\nimpairment, with inhalational supportive NO therapy and conservative\nARDS therapy, including positional changes (a total of 9 sessions of 16\nhours each from 09/29/21 to 10/08/21). Due to elevated PCT levels, the\npatient received empiric antibiotic therapy with\nPiperacillin/Tazobactam, escalated to Meropenem. Voriconazole was\ninitiated on 10/07/2021 after the detection of Aspergillus in\ntracheobronchial secretions and BAL (intended treatment duration 4-6\nweeks).\n\nSubtherapeutic anticoagulation with Fraxiparine was administered for the\nprevention of thrombotic complications in the context of COVID-19. Under\nthis treatment regimen, gas exchange steadily improved, and on 10/12/21,\nthe patient was transferred with low catecholamine requirements for\nweaning from mechanical ventilation and sedation. There, he was\nextubated on 10/13/21.\n\nAfter extubation, severe dysphagia was observed, and speech therapy was\nconsulted. Oral diet is currently not possible, so Mr. Carter is on\nparenteral nutrition. This led to a paravasate in the right upper\nextremity with painful erythema. Adequate pain control was achieved with\nlocal cooling and subcutaneous Piritramide, as needed.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- ------------ ---------------------\n Absolute Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.3 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.61 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\>90 \\>90\n BUN 23 mg/dL 17-48 mg/dL\n Total Bilirubin 0.18 mg/dL \\< 1.20 mg/dL\n C-Reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 6.1 ng/L \\< 14 ng/L\n ALT 50 U/L \\< 41 U/L\n AST 40 U/L \\< 50 U/L\n Alkaline Phosphatase 111 U/L 40-130 U/L\n Gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cells 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.56 K/µL 3.90-10.50 K/µL\n Platelets 280 K/µL 150-370 K/µL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Prothrombin Time 89% 78-123%\n INR 1.09 0.90-1.25\n Activated Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n**Imaging:**\n\n**Chest X-ray bedside on 09/29/2021:** CT scan of the chest from\n9/28/2021 is available for comparison. Tracheal tube tip supracarinal.\nCentral venous catheter (CVC) via right internal jugular vein, tip in\nthe confluence of veins. Gastric tube tip infradiaphragmatic. Patchy\nconfluent bilateral lung infiltrates, mainly perihilar, left and right\nupper and lower fields. No significant changes compared to the previous\nday. Small bilateral pleural effusions. No pneumothorax in the lying\nposition. Left-sided heart prominence with mild stasis/capillary leak.\n\n**Chest X-ray bedside on 10/3/2021:**\n\n[Findings]{.underline}: Compared to 09/29/2021. Tracheal tube with tip\napproximately 4 cm above the carina. Gastric tube slightly retracted,\ntip located just below the diaphragm. Central venous catheter via the\nright internal jugular vein, currently with the tip in the superior vena\ncava. Regression and loosening of infiltrates (mainly in the lower\nfields on both sides). No significant effusion or pneumothorax. No\nsubstantial volume overload.\n\n**Chest X-ray bedside on 10/6/2021:**\n\n[Findings]{.underline}: Compared to the previous examination on\n11/4/2020. New central venous catheter (CVC) from the left internal\njugular vein with tip in the confluence. No pneumothorax in the lying\nposition, no large pleural effusions. Progressive infiltrates in the\nright lower field, perihilar regions on both sides. No significant\ncentral stasis. Heart not enlarged, mediastinum slim.\n\n**Chest X-ray bedside on 10/11/2021:**\n\n[Findings]{.underline}: Compared to 10/5/2021. Tracheal tube and gastric\ntube as before. Left CVC with the tip currently in the region of the\nbrachiocephalic vein, right CVC via the internal jugular vein with the\ntip in the superior vena cava. No pneumothorax, no effusions, increasing\nconsolidation of infiltrates in the right lower field and retrocardial\nleft with no significant cavitation. Left-biased heart without\nsignificant central congestion.\n\n**Chest X-ray bedside on 10/16/2021:**\n\n[Findings]{.underline}: Compared to previous examinations on 10/11/2021.\nHeart borderline enlarged. Mediastinum, as far as can be assessed from\nslightly rotated images, appears central and slim. Increasing\nconsolidation in the right lower lobe and left lower lobe, which is well\ncompatible with pneumonic infiltrates. At most, a small pleural effusion\non the left. No pneumothorax in the lying position. No signs of\nsignificant congestion. Right jugular catheter projecting into the\nsuperior vena cava. Tracheal tube and left jugular catheter have been\nremoved since the last examination.\n\n**Chest X-ray bedside on 10/20/2021:**\n\n[Findings]{.underline}: Compared to the examination on 10/16/2021. In\nthe course of known COVID pneumonia, there is an increasingly loosened\nappearance of infiltrates in the left basal region. A small effusion\ncontinues to drain basally. Otherwise, no significant changes in the\nshort-term follow-up. Right jugular catheter projecting into the\nsuperior vena cava, as before.\n\n**EKG on 10/27/2021:** Normal sinus rhythm, 86/min. Indeterminate axis.\nPQ interval: 108ms QRS duration: 108ms. QTc interval: 484ms. Peripheral\nlow voltage. Delayed R progression up to and including V3. RS transition\nin V4. No significant ST-T wave changes.\n\n**Ultrasound Abdomen on 11/01/2021:**\n\n[Reason for referral:]{.underline} History of COVID, Aspergillosis\n\n[Liver]{.underline}: Vertical diameter in the midclavicular line on the\nright is 120 mm.\n\n[Biliary tract]{.underline}: Well visualized. No abnormalities in the\nintrahepatic and extrahepatic bile ducts. Maximum width of the common\nbile duct is 3 mm.\n\n[Gallbladder]{.underline}: Well visualized. Normal findings.\n\n[Pancreas]{.underline}: Maximum diameters - Head: 17 mm, Body: 12 mm,\nTail: 15 mm. Well visualized. Normal findings.\n\n[Spleen]{.underline}: Normal size, normal homogeneous internal echo\npattern, no focal changes, hilum is free. Organ size: 120 mm x 38 mm.\n\n[Right kidney:]{.underline} Partially assessable, as far as\nrecognizable, parenchymal edge is age-appropriate, smooth organ contour,\nno urinary obstruction, no stones. Size: 120 mm x 45 mm, parenchymal\nthickness 21 mm.\n\n[Left kidney:]{.underline} Partially assessable, as far as recognizable,\nparenchymal edge is age-appropriate, smooth organ contour, no urinary\nobstruction, no stones. Size: 115 mm x 61 mm, parenchymal thickness 19\nmm.\n\n[Bladder:]{.underline} Well visualized, orthotopically located, normal\nwall proportions, no pathological echo structures in the lumen, normal\norgan size.\n\n[Abdominal vessels:]{.underline} Normal findings.\n\n[Abdominal lymph nodes:]{.underline} No evidence of enlarged lymph nodes\nin the subphrenic region.\n\n[Peritoneum]{.underline}: No free fluid.\n\n[Color duplex sonography of the portal vein:]{.underline} Orthograde\nflow, no evidence of thrombosis.\n\n[Assessment]{.underline}: In the right lower lobe cranial-lateral\n(segment VII), there is an entirely echo-free cystic structure with a\nslightly lobulated contour. There is no \\\"double wall,\\\" and there are\nno features suggestive of Echinococcus. This is most likely a congenital\ncyst. The overall structure, architecture, and texture of the liver are\nnormal, with no other focal abnormalities. In the rest of the abdomen,\nthere are no other pathological findings.\n\n**Cardiology Consultation on 10/29/2021:**\n\n**Medical History:** The patient reports thoracic complaints following\nthe intensive care unit stay post-COVID. These pains have been noticed\nwith mild exertion and are described as retrosternal with radiation to\nthe left chest. This last occurred on Sunday afternoon, lasting for\napproximately 1 hour and then spontaneously resolving at rest. This pain\ncannot be induced by a change in position, coughing, or deep\ninspiration. Dyspnea is continuously present, and the patient still\nrequires oxygen. Dyspnea worsens when lying down.\n\n**Cardiovascular risk factors**: Mildly elevated blood pressure\n(hypertension) since May of this year, managed with half a tablet\naccording to self-measurements (averaging 120/80 mmHg, rarely in the\n130s). Lipid profile checked by the general practitioner earlier this\nyear, presumably with good results. No known diabetes. Former smoker\nuntil 2007, but it is difficult to estimate the pack-years, as smoking\noccurred on occasions and during stressful times, less than 15\npack-years. No family history of cardiovascular diseases.\nUveitis/scleritis/episcleritis managed with 10mg MTX per week and 5 mg p\n\nPrednisolone orally daily, well-controlled without recurrence.\n\n**Physical Examination**: Lungs with moist rales bilaterally. Cardiac\nexamination with faint heart sounds. Regular heart rate of 80/min. No\npericardial rub. Pale-gray skin color. Respiratory rate of 15/min while\nsitting. Radial pulses palpable bilaterally. Groin pulses not examined.\nAllen\\'s test operable on the right, borderline on the left.\n\n**ECG**: tachycardic sinus rhythm with a heart rate of 109/min, left\naxis deviation, regular R-wave progression in chest leads, mild\nS-persistence in V6, no significant ST-T wave changes.\n\n**Transthoracic and transesophageal echocardiography on 11/27/2020**:\n\n[Kinetics]{.underline}: Hypokinesia of the lateral and anterior walls,\notherwise normokinetic and synergistic. Systolic function (right\nventricle): TAPSE 18 mm (\\> 16 mm), RV-S\\' 17.6 cm/s (\\> 10 cm/s).\n\n[Valves]{.underline}: Mitral valve - Delicate leaflets, good opening\nmotion, no significant insufficiency. Lambl\\'s excrescences on the\natrial side. Small fluttering structure at the subvalvular apparatus,\ncompatible with chordae tendineae. Aortic valve - Tricuspid, delicate\nvalve. Functionally intact (AV Vmax 1.0 m/s). Tricuspid valve -\nMorphologically normal. Mild insufficiency. TR Vmax 1.9 m/s, sPAP 15\nmmHg + CVP. Pulmonic valve - Morphologically and functionally normal.\n\n[Other Findings:]{.underline} No pericardial effusion. Small Persistent\nForamen Ovale. Left atrial appendage free of intracavitary thrombi at\n60°/90°/150°. Thoracic aorta with smooth-walled plaques, no dissections\nor thrombi.\n\n[Assessment]{.underline}: No structures suggestive of endocarditis. No\nrelevant valvular abnormalities. Incidentally, there is a moderately\nreduced LVEF with wall motion abnormalities in the RIVA (right\nventricular anterior) region. We request a cardiology consultation and\nfurther diagnostics.\n\n**Phoniatric Consultation on 10/24/2021:**\n\n[Medical History:]{.underline} Patient with a history of COVID\npneumonia, twice tested negative. Currently, the patient has Aspergillus\nand pneumonia. Previously, the patient was in the ICU and intubated for\ntwo weeks due to COVID. Following speech therapy for dysphagia, a\nflexible endoscopic evaluation of swallowing (FEES) is requested.\n\n[Findings]{.underline}: FEES reveals a normal configuration of the\nlarynx with good mobility of the tongue and lips. Normal gross mobility\nof the vocal cords during phonation and respiration transitions. Full\nglottic closure appears complete. Flexible transnasal swallow evaluation\n(FEES) with blue dye: Sufficient oral bolus control for liquids, purees,\nand solids. No drooling or leakage. Swallow reflex present. Voluntary\ninitiation of the swallow act is possible. Side-by-side swallowing of\ntest substances over the valleculae without evidence of\npre-/intra-/post-deglutitive penetration or aspiration for all test\nconsistencies. Rosenbeck\\'s Penetration-Aspiration Scale score: 1\n(Minimal retention in the valleculae with puree, which can be completely\ncleared by swallowing). Normal sensitivity, strong cough reflex. No\nnasal regurgitation.\n\n[Assessment]{.underline}: Normal swallowing function.\n\n[Current Recommendations:]{.underline} Able to consume regular diet and\nthin liquids, as well as medications with water.\n\n**Therapy and Progression:** The patient was admitted for further\ntreatment. Upon admission, the patient was in a reduced general\ncondition with significant mobility limitations.\n\nStaphylococcus aureus was detected in a blood culture, leading to a\ntransesophageal echocardiogram (TEE) on 11/26/2020. No vegetations were\nfound, but a moderate hypokinesia of the left ventricle in the RIVA area\nwas observed. Cardiac enzymes were within normal limits. This was\ninterpreted as post-COVID myocarditis, differential diagnosis myocardial\ninjury in severe ARDS, coronary artery disease, or mixed picture.\n\nIn consultation with the cardiology colleagues, a cautious heart failure\nmedication regimen with beta-blockers and ACE inhibitors was initiated.\nWe recommend an elective coronary angiography in the future. Currently,\nthe patient was symptom-free with low cardiac markers and a normal ECG,\nso acute diagnostic procedures were not indicated.\n\nThe antibiotic therapy with Cefazolin was continued until 11/05/2021\n(last sterile blood cultures from 10/24/2021). Staphylococcus\nepidermidis detected in the blood culture on 10/20/21 and at the tip of\nthe central venous catheter on 10/22/21 were considered\ncatheter-associated. The catheter was immediately removed. The patient\ndid not develop a fever during the hospital stay. Inflammatory markers\nimproved over time.\n\nAn abdominal ultrasound was performed due to an unclear liver lesion,\nwhich was found to be a congenital cyst. Echinococcus serology was\nnegative.\n\nIn consultation with the psychiatric colleagues, Quetiapine medication\nwas cautiously resumed for known depression, but it had to be\ndiscontinued later due to significant QTc prolongation. Long-term oxygen\ntherapy of 2 liters was indicated.\n\nOur ophthalmology colleagues recommended the resumption of MTX therapy\ngiven the patient\\'s stable vision. We request this therapy be initiated\nand an outpatient follow-up appointment in ophthalmology arranged after\nthe patient completes rehabilitation.\n\nWith physiotherapy, the patient achieved mobilization up to walking.\nSwallowing and articulation difficulties also significantly improved.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency** **Route**\n ---------------------------------- --------------- ------------------------------ ------------\n Metoprolol Succinate (Toprol XL) 23.8 mg 1-0-1-0 Oral\n Dicloxacillin Sodium (Dynapen) 2176 mg 1-1-1-0 Oral\n Voriconazole (Vfend) 200 mg 2-0-2-0 Oral\n Acetaminophen (Tylenol) 500 mg As needed Oral\n Ipratropium Bromide (Atrovent) 0.26 mg/2 ml 6-0-0-0 Inhalation\n Albuterol Sulfate (ProAir) 1.5 mg/2.5 ml 6-0-0-0 Inhalation\n Amitriptyline (Elavil) 28.3 mg 0-0-1-0 Oral\n Citalopram (Celexa) 50 mg 1-0-0-0 Oral\n Melatonin 2 mg 0-0-2-0 Oral\n Montelukast (Singulair) 10 mg 1-0-0-0 Oral\n Pantoprazole (Protonix) 45 mg 0-0-1-0 Oral\n Eplerenone (Inspra) 25 mg 1-0-0-0 Oral\n Ramipril (Altace) 2.5 mg 0-0-1-0 Oral\n Folic Acid 5 mg 0-0-1-0 48h after MTX intake Oral\n Methotrexate (Trexall) 15 mg 1-0-0-0 Once a Week Oral\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient, Mr. Brian Carter, born on\n04/24/1956 to our outpatient care on 02/03/2022.\n\n**Diagnoses**: Suspected Post-Intensive-Care Syndrome with:\n\n- Dysphagia\n\n- ICU-acquired weakness\n\n- Depressive mood, anxiety\n\n**Other Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n<!-- -->\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** Mr. Carter was treated in the intensive care unit\nfor a total of 24 days in September and October 2021 due to COVID-19.\nFollowing intensive care treatment, he underwent neurological\nrehabilitation from 11/08/2021 to 01/18/2022, with the following\nrehabilitation results: \\\"Mr. I. benefited well from the therapies.\nParticularly, physiotherapy helped regain confidence in walking. During\ntreatment, breathing difficulties improved, and oxygen supplementation\nwas no longer necessary.\\\" An antidepressant therapy with Mirtazapine\nwas initiated for sleep disorders and mood swings, resulting in a\nreduction in sleep disturbances.\n\n**Assessment**: Since the illness, Mr. Carter reports general fatigue,\nquick fatigue, and weakness, especially in the lower extremities. He is\ncurrently not undergoing physiotherapy or any other treatments.\nRegarding psychopharmacological therapy, the patient has been seeing a\npsychiatrist once a month based on anamnesis. After a short exertion, he\nexperiences dyspnea and regularly needs to take breaks. Room air\nsaturation was at 94%. Physical examination revealed significant\nexpiratory wheezing and prolonged expiration bilaterally. Furthermore,\nthe patient reports cognitive impairments with marked forgetfulness and\ndifficulty concentrating. This is evident in the reduced results of the\nMiniCog (2/3 words, normal clock, 4 points) and animal naming tests\n(correct single naming of 10 animals, 3 points). Additionally, the\npatient reports an exacerbation of symptoms of depression known since\n2011, including sadness, fatigue, sleep disturbances, and anxiety. These\nworsened during the ICU stay. The current medication includes Citalopram\n40 mg and Mirtazapine 7.5 mg, which have somewhat improved previously\nworsened sleep disturbances. Psychotherapy is not currently taking place\nbut is strongly recommended.\n\nDysphagia diagnosed during the intensive care unit stay has slightly\nimproved, allowing Mr. Carter to consume regular food again. However, he\nstill experiences dysphagia and coughing during each meal. An\nappointment at the swallowing clinic has been scheduled by us (see\nbelow).\n\n**Current Recommendations:**\n\nAs swallowing difficulties persist, an appointment has been scheduled at\nour local swallowing clinic. We also recommend a pulmonary evaluation.\nContact has already been made, and the colleagues from Pulmonology will\nget in touch with Mr. Carter. Furthermore, due to a previously existing\ndepressive mood with currently exacerbated symptoms, we recommend\nconnecting the patient with an outpatient psychotherapist. Some\ntherapists have already been suggested by the patient\\'s general\npractitioner, and we strongly recommend further contact. A prescription\nfor physiotherapy has been issued for pronounced muscle weakness and\nsuspected ICU-acquired weakness. Further physiotherapeutic engagement\nwith the general practitioner\\'s assistance is urgently required.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------- ------------- ---------------------\n Neutrophils 49.0 % 42.0-77.0 %\n Lymphocytes 31.9 % 20.0-44.0 %\n Monocytes 7.2 % 2.0-9.5 %\n Basophils 0.7 % 0.0-1.8 %\n Eosinophils 10.8 % 0.5-5.5 %\n Immature Granulocytes 0.4 % 0.0-1.0 %\n Sodium 139 mEq/L 136-145 mEq/L\n Potassium 3.5 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.99 mg/dL 0.70-1.20 mg/dL\n BUN 25 mg/dL 17-48 mg/dL\n Total Bilirubin 0.45 mg/dL \\< 1.20 mg/dL\n CRP 3.9 mg/dL \\< 5.0 mg/dL\n ALT 21 U/L \\< 41 U/L\n AST 20 U/L \\< 50 U/L\n Alkaline Phosphatase 65 U/L 40-130 U/L\n Gamma-GT 38 U/L 8-61 U/L\n LDH 160 U/L 135-250 U/L\n Lipase 20 U/L 13-60 U/L\n Procalcitonin 0.03 µg/L \\< 0.50 µg/L\n Hemoglobin 13.2 g/dL 13.5-17.0 g/dL\n Hematocrit 44.2 % 39.5-50.5 %\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 7.62 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n\n\n\n\nHere is the query:\nWhat was the significant clinical finding in the Fist Closure Test performed on Mr. Rudolph?\n\nChoose the correct answer from the following options:\nA. Bilateral triphasic flow in the subclavian arteries\nB. Subclavian stenosis\nC. Reversed flow in the left vertebral artery\nD. Blood pressure differences between right and left arms\nE. Presence of arm claudication\n\n\nYour response:\n", "role": "user" }, { "content": "Bilateral triphasic flow in the subclavian arteries", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, ****Dear colleague, **\n\n \n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who was treated in our clinic from 05/28/14 to 06/20/14.\n\n \n\n**Diagnoses: **\n\n- pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left\n midline tongue carcinoma\n\n- Arterial hypertension\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Idiopathic thrombocytopenia\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Hypothyroidism\n\n- Nicotine abuse\n\n<!-- -->\n\n- Panendoscopy with sampling on 04/14/2014 and 04/26/2014\n\n \n\n**Current Presentation**: With histologically confirmed carcinoma in the\nregion of the base of the tongue on the left side, Mr. Doe presents for\nsurgical treatment of the findings. In accordance with the tumor board\ndecision, resection is performed via a lateral pharyngotomy and neck\ndissection on both sides.\n\n \n\n**Physical Examination:** Patient in stable general condition (85 kg,\n188 cm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I° (L-thyroxine increased to 150 μg 1-0-0), hoarseness\n0°, hearing loss 0° (subjectively reduced), dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\nA tumorous mass can be inspected at the base of the left tongue. Tongue\nmobility is unremarkable.\n\n**CT chest, abdomen, pelvis on 05/28/14:**\n\nEmphasized mediastinal as well as abdominal lymph\nnodes.** **Vasosclerosis. Otherwise, there is no evidence for the\npresence of distant metastases with a suspected base of tongue\ncarcinoma. Liver cirrhosis.\n\n \n\n**CT neck on 06/11/14:**\n\nSuspected left tongue base carcinoma crossing midline with extension\ninto the left vallecula and compression of the left piriform sinus with\nsuspected lymph node metastases in levels I-III ipsilateral.\nContralateral prominent but not certainly suspicious lymph nodes. The\nprominent structure on the left supraclavicular side can also be\ninterpreted as circumscribed cystiform ectasia of the thoracic duct.\n\n \n\n**Ultrasound abdomen on 06/15/14:**\n\nImage of liver cirrhosis status post cholecystectomy.\nHepatosplenomegaly. Moderate aortic sclerosis.\n\n \n\n**X-ray pap swallow on 06/17/14:**\n\nClear tracheal aspiration in the absence of epiglottis envelope. The\ncough reflex is preserved. Otherwise, essentially unremarkable\nswallowing act. \n\n \n\n**Histology**: Invasive, moderately differentiated, squamous cell\ncarcinoma with keratinization of the medial left base of the tongue,\nmaximum extent 1.0 cm. Carcinoma- and dysplasia-free biopsies of the\nleft tonsil, the oropharyngeal tumor/tongue base on the left, deep\nresection of the tumor, lower tonsillar pole transition on the left\ntongue base, tongue base on the left and medial left tongue base, as\nwell as median tongue base.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** pT1. pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n \n\n**Therapy and Progression**: After the usual clinical and laboratory\npreparations, we performed the above-mentioned therapy on 05/29/14 in\nintubation anesthesia without complications. For perioperative infection\nprophylaxis, the patient received intravenous antibiotic therapy with\nAmpicillin and Sulbactam 3g three times daily for the duration of his\nhospital stay.\n\nDuring this procedure, the left lingual artery was interrupted\nprophylactically. No postoperative bleeding and no wound healing\ndisturbances occurred.\n\nA porridge swallow examination showed no evidence of a fistula. On the\nfollowing day, the patient was decannulated in consultation with the\ncolleagues of the speech therapy. After this, a food build-up was\ncarried out in cooperation with speech therapists. At the time of\ndischarge, the patient was receiving regular oral nutrition. The stoma\ncontinued to shrink. The patient was monitored, and if necessary, the\ntracheostoma was closed with local anesthesia. Histological findings\nwere pT1. Due to an RX status, adjuvant radiotherapy will be performed\nas decided by the tumor board. A prophylactic presentation at the\ncolleagues of the MKG as a preparatory measure for the upcoming\nradiotherapy. We asked for a control re-presentation in our outpatient\nclinic on 06/26/14 at 3:00 PM. Further controls take place at the half\nand at the end of the radiotherapy and further in 4-6 weeks rhythm. In\ncase of acute complaints, an immediate re-presentation is possible at\nany time.\n\n \n\n**Type of surgery**: Lateral pharyngotomy with resection of the base of\nthe tongue on the left as well as selective neck dissection on both\nsides level II-IV with ligature of the lingual artery on the left side,\ncreation of a stable tracheostoma and tonsillectomy on the left side.\n\n**Surgery report: **First, tracheotomy in a typical manner. A horizontal\nincision was made on the skin, positioned approximately two transverse\nfinger widths above the jugulum. Subsequently, the subcutaneous tissue\nand the platysma colli were incised. To facilitate access to the\ntrachea, the laryngeal muscles were carefully displaced to the side. The\nthyroid isthmus was undermined and clamped bilaterally. A precise\ntransection of the thyroid isthmus followed, with both halves of the\nthyroid gland being meticulously sutured using 0- Vicryl. The thyroid\nhalves were repositioned to expose the trachea. A visceral tracheotomy\nwas performed, and re-intubation was achieved utilizing a U-tube. The\nsurgical procedure then transitioned to a neck dissection on the left\nside. This phase began with an incision along the anterior edge of the\nsternocleidomastoid muscle. The subcutaneous tissue and platysma colli\nwere carefully cut, with due respect to the auricularis magnus nerve.\nDissection continued dorsally along the sternocleidomastoid muscle to\nreach the anterior border of the trapezius muscle. Further exposure\ninvolved the accessorius nerve in a cranialward direction, with\npreservation of this neural structure. Dissection proceeded along the\ncervical vascular sheath, revealing the common carotid artery, internal\njugular vein, and vagus nerve up to the digastric muscle. Below this\nlevel, exposure of the hypoglossal nerve was achieved.\n\nSuccessive dissection involved the lymph node fat package, progressing\nfrom level II to level IV in a cranial to caudal and ventral to dorsal\ndirection. Throughout this process, careful attention was paid to\nsparing the aforementioned neural and vascular structures. Subsequently,\naccess to the lateral pharyngectomy area was gained, allowing\nvisualization of the external carotid artery along with its branches,\nincluding the superior thyroid artery, superior laryngeal artery, and\nlingual artery. Notably, the lingual artery was interrupted during this\nstage.\n\nFurther exploration revealed the superior laryngeal nerve and\nhypoglossal nerve intersecting in a loop above the internal carotid\nartery and externally below the external jugular vein. Additional\ndissection in a ventral direction followed. The hypoglossal nerve was\nprepared meticulously. Exposure of the hyoid bone was achieved, with a\nposterior resection of half of the hyoid bone. Importantly, the\nhypoglossal nerve was spared during this procedure. Subsequent to these\nsteps, the lateral pharynx wall was opened, exposing the base of the\nhyoid. The next phase of the procedure involved enoral tumor\ntonsillectomy on the left side. Starting from the left side, the\nsurgical team identified the tonsil capsule at the anterior palatal arch\nusing a Henke spatula. The upper tonsillar pole was then dislodged and\ndissected with the Rosenblatt instrument, proceeding from cranial to\ncaudal. Hemostasis was meticulously achieved through swab pressure and\nelectrocautery. The excised tonsil tissue was sent for frozen section\nexamination for further analysis.\n\n**Frozen Section Report: **No evidence of malignancy was found. The\nresection was carried out at the junction of the caudal tonsillar pole\nand the base of the tongue. At this location, tissue from the base of\nthe tongue was resected and sent for a frozen section examination, which\nrevealed no indication of malignancy. Subsequently, a medial resection\nof the base of the tongue was performed, confirming the presence of\nsquamous cell carcinoma in the frozen section analysis. Mucosal suturing\nwith inverting sutures was then conducted. On the left side, a neck\ndissection procedure was performed. The dissection extended along the\nsternocleidomastoid muscle, reaching dorsally to the anterior border of\nthe trapezius muscle. This approach allowed for cranial exposure of the\naccessorius nerve while sparing the same. Dissection continued along the\ncervical vascular sheath, exposing the common carotid artery, internal\njugular vein, and the vagus nerve up to the digastric muscle. Below\nthis, the hypoglossal nerve was exposed. Subsequently, the lymph node\nfat package was dissected systematically from level II to level IV,\nprogressing from cranial to caudal and ventral to dorsal, while\ncarefully preserving the mentioned structures. The surgical procedure\nconcluded with the placement of a drain, subcutaneous suturing, and skin\nsuturing.\n\n**Frozen section report:** Invasive squamous cell carcinoma.\n\n \n\n**Microscopy:**\n\nEven after paraffin embedding, mucosal cross-sections show a covering of\nstratified, non-keratinizing squamous epithelium with occasional\nsignificant stratification disturbances extending into superficial cell\nlayers. This transitions into invasive growth with solid clusters of\npolygonal tumor cells, some of which exhibit identifiable intercellular\nbridges. The cell nuclei are enlarged, round to oval, with occasional\nsmall nucleoli and mild to moderate nuclear pleomorphism. Dyskeratosis\nis observed in some areas.\n\n**Lab results upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- ----------------------- -----------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.0 mg/dL 0.7 - 1.3 mg/dL\n Calcium 9.04 mg/dL 8.8 - 10.6 mg/dL\n GFR (MDRD) \\> 60 mL/min/1.73m\\^2 \\> 60 mL/min/1.73m\\^2\n GFR (CKD-EPI,CREA) 80 mL/min/1.73m\\^2 \\> 90 mL/min/1.73m\\^2\n C-reactive protein 1.0 mg/dL \\< 0.5 mg/dL\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who presented to our outpatient clinic on 09/14/2014.\n\n**Diagnosis: **Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21)\nL0 V0 Pn0 G2 RX\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n- Since 03/2014: Odynophagia\n\n<!-- -->\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Histology:**\n\nInvasive, moderately differentiated, squamous cell carcinoma with\nkeratinization of the medial left base of the tongue, maximum extent 1.0\ncm. Carcinoma- and dysplasia-free biopsies of the left tonsil, the\noropharyngeal tumor/tongue base on the left, deep resection of the\ntumor, lower tonsillar pole transition on the left tongue base, tongue\nbase on the left and medial left tongue base, as well as median tongue\nbase.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** min pT1, pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n**Current Radiotherapy:**\n\n**Indication**: According to the decision made by the interdisciplinary\ntumor board for head and neck tumors, it was determined by our medical\nteam that, in the postoperative condition following the resection of a\ntongue base carcinoma with an unclear resection status, there is an\nindication for radiation therapy of the former tumor site.\n\n**Technique:** Percutaneous radiotherapy of the former primary tumor\nregion with 6-MeVPhotons, in Rapid-Arc technique, with a single dose of\n2 Gy up to a total dose of 60 Gy.\n\n**Radiotherapy 07/27/2014 - 09/06/2014:**\n\nDuring the course of radiotherapy, the patient experienced enoral\nmucositis (grade II according to CTCAE) leading to subsequent\nodynophagia and dysphagia. We managed these symptoms with oral rinses\nand initiated pain management using Acetaminophen, resulting in an\nacceptable reduction of pain over time. At the end of the therapy, the\npatient\\'s general condition remained stable (ECOG performance status:\n70%). Second-degree mucositis enoral persisted, causing ongoing\ndysphagia and odynophagia. Additionally, the patient exhibited localized\nradiodermatitis (grade II according to CTCAE) within the radiation\nfield. The patient did not report xerostomia or dysgeusia.\n\n**Current Recommendations:**\n\nThe patient received comprehensive instructions on continued skincare\nand side-effect management. An initial follow-up appointment with the\nradio-oncology team has been scheduled in our outpatient clinic. We\nkindly request the patient to provide a renewed referral for\nradiotherapy on the day of the appointment.\n\nThe ongoing oncological treatment plan will be determined by the\npatient\\'s Ear, Nose, and Throat specialists. Regular follow-up\nexaminations are strongly recommended. Additionally, for patients who\nhave completed radiation therapy in the ENT region, we advise lifelong\nadherence to fluoride prophylaxis and antibiotic therapy during any\ndental procedures.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965, who presented\nto our outpatient clinic for phoniatrics and pedaudiology on 10/10/2014.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Medical History: **We may kindly assume the detailed history as known.\n\n**Phoniatrics: Fiberoptic endoscopic swallow examination:**\n\nTongue motor function is well preserved, sensitivity of lip and tongue\nlaterally equal,\n\nMucous membranes non-irritant on all sides. Tracheal mucosa\nnon-irritant, no evidence of saliva intratracheal. Neopharynx\ninconspicuous, air bubbles visible above Provox outlet on pressing\nattempt. Tongue retraction slightly limited. Velopharyngeal closure\ngood.\n\n**Therapy and Course:** After completion of the adjuvant radiotherapy\napproximately 6 weeks ago, phonation via the Provox voice prosthesis was\nno longer possible after this had initially worked after the operation.\nAdditionally, there were issues with regurgitation of ingested\nsubstances, regardless of their consistency. In some cases, nasal\npenetration with fluids occurred. There were no indications of\naspiration. A self-assessment, involving the use of blue-colored liquid,\nrevealed no signs of leakage from the Provox device.\n\n**Current Recommendations:** Oncological follow-up in 12 months.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965 who presented\nat our outpatient clinic for radio-oncological follow-up on 10/09/2020.\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n \n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for a radio-oncological follow-up on 10/09/2020 in the\npresence of his wife.\n\n**Physical Examination**: Patient in stable general condition (85 kg,188\ncm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I°, hoarseness 0°, hearing loss 0° (subjectively\nreduced), dyspnea: 0°, pneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\n**MRI scan of the neck from 10/09/2020:** \n\nClear post-therapeutic changes in the resection and radiation area after\nadjuvant RTx following tumor resection with laryngectomy for extensive\nrecurrence of oropharyngeal cancer. \n\nSize constant, but still clearly accentuated lymph nodes in level Ib/IIa\non the left. Regredience of seroma formation under the left\nsternocleidomastoid muscle.\n\n**Current Recommendations: **Primary oncological care and follow-up,\nincluding imaging, will be provided by the ENT clinic according to the\nguidelines. A re-appointment for a further radio-oncological follow-up\nat the follow-up appointment at the Radiation Therapy Tumor Therapy\nCenter has been scheduled. After head and neck radiation therapy,\nregular fluoridation of the teeth and guideline-based antibiotic\nprophylaxis is required prior to major dental procedures. We also\nrecommend temporomandibular joint opening exercises to prevent\ntemporomandibular joint fibrosis and consecutive temporomandibular joint\nopening obstruction. We also refer to regular control of thyroid\nfunction parameters and, if necessary, initiation of substitution\ntherapy after radiotherapy to the neck.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe hereby report on our patient Mr. Paul Doe, born 08/08/1965 for\nradio-oncological follow-up on 09/24/2021.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for radio-oncological follow-up on 09/24/2021. \n\n**Physical Examination: **Patient in reduced general condition (KPS 60%,\n86 kg,188 cm). Weight loss 0°, MUST score: 0, pain VAS 1-2/10, fatigue\nI°, dysphagia I° with solid food (liquids occasionally flow out of the\nnose again when swallowing), aspiration 0°, ulcer 0°, trismus 0°, taste\ndisorder I° (present in approx. 80%), xerostomia I°, osteonecrosis 0°,\nhypothyroidism II°, hoarseness II°, hearing loss, I°, dyspnea: 0°,\npneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**MR neck plain + contrast agent on 09/24/2021**:\n\n[Technique]{.underline}: STIR triplanar, T1 ax -/+ contrast agent, T1\nmDixon cor after\n\ncontrast agent.\n\n[Findings]{.underline}: Known status post tumor resection with\nlaryngectomy for extensive recurrence of oropharyngeal Carcinoma;\nFollow-up after RTx. Somewhat increasing swelling of nasopharynx to\noropharynx. From the uvula the swelling is stable. As far as can be\nassessed, no clear recurrence-specific tissue proliferation or contrast\nuptake. Unchanged accentuated lymph nodes in level Ib/IIa on the left\n(one exemplary measured lymph node borderline large, idem to preliminary\nexamination). Mastoid cells minimally displaced on the left. Moderate\ndegenerative changes of the cervical spine. Assessment. Increasing\nswelling of the naso- to oropharynx. Neopharynx unchanged swollen. No\nevidence of malignancy-suspicious lymph nodes.\n\n**CT scan of the thorax on 09/24/2021**:\n\nSize-constant visualization of interlobar oval compaction in the left\nupper lobe corresponding to an interlobar lymph node. New to the\nprevious examination, two small nodular condensations appear, basal in\nthe right and in the left lower lobe, differentially inflammatory;\nfollow-up is recommended. Unchanged the prominent mediastinal lymph\nnodes, constant in size and number.\n\n**Current Recommendations:**\n\nPrimary oncologic care and follow-up including imaging will take place\nvia the ENT clinic on 01/14/22 at 11:00 AM. A re-appointment for the\nnext radio-oncological follow-up has been arranged for 01/14/2022 at\n1:00 PM in our radiotherapy outpatient clinic in the Tumor Therapy\nCenter.\n\n**Lab results upon Discharge:**\n\n**Hematology**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- -----------------------\n WBC 6,900 /μL 4,500 - 11,000 /μL\n RBC 2.7M /μL 4.5M - 5.9M /μL\n Hemoglobin 8.2 g/dL 14 - 18 g/dL\n Hematocrit 25.1 % 40 - 48 %\n MCH 31.27 pg 27 - 33 pg\n MCV 94 fL 82 - 92 fL\n MCHC 32.7 g/dL 32 - 36 g/dL\n Platelets 638,000 /μL 150,000 - 450,000 /μL\n\n**Serum chemistry**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ -----------------\n Sodium 144 mEq/L 135 - 145 mEq/L\n Potassium 4.8 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.3 mg/dL 0.7 - 1.3 mg/dL\n ALT 21 U/L 10 - 50 U/L\n eGFR 55 mL/min \\> 90 mL/min\n CRP 2.9 mg/dL \\< 0.5 mg/dL\n\n**Coagulation**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ ---------------\n PT 93 % 70 - 120 %\n INR 1.1 0.8 - 1.2\n aPTT 31 sec 26 - 37 sec\n\n**Thyroid hormones**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- ------------------\n TSH 1.16 μIU/mL 0.4 - 4.2 μIU/mL\n fT3 2.38 pg/mL 2.3 - 4.2 pg/mL\n fT4 1.70 ng/dL 0.9 - 1.7 ng/dL\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who was admitted\nto our hospital from 01/10/2022 to 01/27/2022.\n\n**Diagnosis**: Metachronous pulmonary metastatic squamous cell carcinoma\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014 Odynophagia\n\n- 05/14/2014 Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014 Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Planned Surgical Procedure:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Medical History**: Mr. Paul Doe initially presented with a diagnosis\nof pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left midline\ntongue carcinoma. Panendoscopy with specimen collection on 04/14/2014\nand 04/26/2014 confirmed carcinoma.\n\nSurgical resection was performed via lateral pharyngotomy and neck\ndissection. Histology confirmed squamous cell carcinoma. He subsequently\nreceived radiotherapy.\n\nDuring a follow-up CT examination, a suspicious lesion was identified in\nthe lung, which raised concerns regarding the possibility of metastasis\noriginating from the previously diagnosed left midline tongue carcinoma\n(pT1, pN0, G2, RX).\n\n**Current Presentation:** Mr. Doe was admitted for further examination\nand treatment to assess the behavior and extent of the lesion.\nClinically, Mr. Doe was in stable general condition and had no symptoms\nsuggestive of B symptoms.\n\n**Therapy and Progression**: The above-mentioned procedure was performed\nwithout complications on 01/10/2022. Histologically, the final resection\nspecimen confirmed the presence of a 2.9 cm squamous cell carcinoma,\nconsistent with a metastatic recurrence of the previously known\nhypopharyngeal carcinoma. The dissected lymph nodes were free of tumor.\nThe postoperative course was uneventful. In the absence of any\ncomplications, surgical sutures were removed on day 10 after surgery. A\ncurrent chest X-ray showed a regular postoperative outcome with\nsufficient expansion of the left lobe. Further monitoring is recommended\nby the treating colleagues in this regard. Mr. Doe is also connected to\nthe radiation therapy team for ongoing follow-up.\n\nIf there are any complications or questions, please contact the relevant\nward or reach out to our Central Patient Management. Outside regular\nworking hours, you can contact the on-call colleague in the Abdominal\nSurgery department for assistance.\n\nFor further information on the patient\\'s discharge management, treating\nproviders are available for inquiries from Monday to Friday, 9 AM to 7\nPM, as well as on weekends and holidays from 10 AM to 2 PM.\n\nMr. Doe was discharged from the hospital on 01/27/2022.\n\n**Addition:**\n\n**Histology Report:** Resected left upper lobe specimen with a 2.9 cm\nsolid carcinoma. The histological picture is consistent with a\nmetastasis from the previously diagnosed non-keratinizing squamous cell\ncarcinoma. There were focal vascular invasions. No pleural invasion was\nobserved. The resection was complete, with all dissected lymph nodes\nshowing no tumor involvement.\n\n**Chest X-ray, anterior-posterior view from 01/21/2022**:\n\n[Clinical Information:]{.underline} History of VATS with wedge\nresection, yesterday\\'s drain removal\n\n[Question:]{.underline} Follow-up, pneumothorax after drain removal?\nInfiltrates? Atelectasis?\n\n[Findings:]{.underline} Left chest drainage tube has been removed. Left\napical pneumothorax line, measuring approximately 2.3 cm. Continued\nextensive shadowing of the left upper field, most likely postoperative,\ninfiltrate cannot be definitively ruled out. Slightly hypotransparent\nleft lung in comparison, most likely due to residual postoperative\nreduced ventilation. No effusion. Widened cardiac silhouette. Regression\nof dystelectasis in the right lower field. No acute signs of pulmonary\nvenous congestion. Trachea is mid-positioned and not stenosed.\nLeft-sided port catheter still in place.\n\n[Summary]{.underline}: Left apical corax with a width of 2.3 cm.\nContinued extensive shadowing of the left upper field, most likely\npostoperative, with infiltrate not definitively excluded. Residual\npostoperative reduced ventilation on the left side. Regression of\ndystelectasis in the right lower field. No effusion. No acute signs of\npulmonary venous congestion. Follow-up recommended.\n\n**Examinations Chest X-ray, anterior-posterior view from 01/23/2022:**\n\n[Question]{.underline}**:** Follow-up.\n\n[Findings]{.underline}: Left apical pneumothorax, measuring\napproximately 1.4 cm. Extensive shadowing in projection onto the left\nupper lobe, differentials include postoperative changes, incipient\ninfiltrate not excluded. Dystelectasis of the right lower field. No\nevidence of pleural effusion or acute pulmonary venous congestion.\nCardiomegaly. Indwelling chest drainage with the catheter tip projecting\nonto the left upper lobe. Well-positioned port catheter tip projecting\nonto the right atrial entrance plane. No evidence of pleural effusion.\nAssessment Left apical pneumothorax, measuring approximately 1.4 cm,\nwith indwelling left chest drainage. Extensive shadowing in projection\nonto the left upper lobe, differentials include postoperative changes,\nincipient infiltrate not excluded. Dystelectasis of the right lower\nfield. No significant pleural effusion. No acute pulmonary venous\ncongestion. Cardiomegaly.\n\n**Chest X-ray, anterior-posterior view from 01/25/2022**\n\n[Previous Examinations]{.underline}: Appearance of a diffuse\npostoperative shadow in the left upper field. No evidence of pleural\neffusion, inflammatory infiltrate, or pulmonary venous congestion.\n\n[Findings]{.underline}: Left-sided chest port with the tip projecting\nonto the superior vena cava. The upper mediastinum is narrow, the\ntrachea is mid-positioned and patent.\n\n[Assessment]{.underline}: The pneumothorax appears to be largely\nresolved.\n\n**Urinanalysis**:\n\nMaterial: Urine, midstream sample collected on 01/11/2022\n\n- Antimicrobial inhibitors negative\n\n- No evidence of growth-inhibiting substances in the sample material.\n\n- Colony Count (CFU) / mL \\<1,000, Assessment: A low colony count\n typically does not support a urinary tract infection.\n\n- Epithelial cells (microscopic) \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic) \\<20 leukocytes/μL\n\n- Microorganisms (microscopic) 20-100 microorganisms/μL Pathogen\n Enterococci\n\n**Lab values upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- --------------------- ---------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n Calcium 10.4 mg/dL 8.8 - 10.6 mg/dL\n eGFR (MDRD) \\> 60 mL/min/1.73m² \\> 60 mL/min/1.73m²\n eGFR (CKD-EPI) 85 mL/min/1.73m² \\> 90 mL/min/1.73m²\n C-Reactive Protein 5.0 mg/dL \\< 0.5 mg/dL\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgical Procedure from 01/11/2022:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015: radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n- OSAS with CPAP incompliance\n\n<!-- -->\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for postoperative follow-up\nafter his left-sided videothoracoscopic upper lobe resection due to\npreviously diagnosed pulmonary metastatic hypopharyngeal carcinoma.\n\n**Medical History:** The patient\\'s general condition is good. He is\ncurrently on intermittent as-needed analgesia with Acetaminophen. The\nfinal resection specimen histologically confirmed the presence of a 2.9\ncm squamous cell carcinoma, consistent with a metastatic recurrence of\nthe previously known hypopharyngeal carcinoma. The dissected lymph nodes\nwere free of tumor.\n\n**Therapy and Progression**: During the follow-up appointment, Mr. Doe\nunderwent a clinical examination and a chest X-ray to assess his\npostoperative condition. The examination revealed no new concerning\nfindings, and Mr. Doe continued to remain in stable general condition.\nHis surgical incision site was inspected, showing signs of satisfactory\nhealing without any signs of infection or complications.\n\nFurthermore, Mr. Doe\\'s lung function was evaluated through spirometry,\nwhich indicated adequate pulmonary function post-surgery. He was also\nprovided with personalized recommendations for respiratory exercises to\noptimize his lung function during the recovery period.\n\n**Current Recommendations:**\n\n- Mr. Doe is connected to the radiation therapy team for ongoing\n follow-up.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgery on 01/11/2022:**\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015 Radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n**Other Diagnoses:**\n\n- OSAS with CPAP incompliance\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for routine follow-up.\nClinically, he remains in stable general condition, with no signs of\nB-symptoms.\n\n**Medical History**: The surgical procedure performed on 01/11/2022\ninvolved perioperative bronchoscopy, left VATS, pleurolysis, anatomical\nupper lobe resection, systematic mediastinal, hilar, and interlobar\nlymph node dissection, as well as the placement of double chest drains.\nHistologically, the final resection specimen confirmed a 2.9 cm solid\ncarcinoma, consistent with metastasis from the previously diagnosed\nsquamous cell carcinoma. Lymph nodes dissected during the procedure were\ntumor-free. Mr. Doe\\'s postoperative course was uneventful, and surgical\nsutures were removed on day 10 after surgery.\n\n**Physical Examination:** Patient in good general condition. Weight loss\n0°, MUST score: 0, pain VAS 1-2/10, fatigue I°, dysphagia I° with solid\nfood (liquids occasionally flow out of the nose again when swallowing),\naspiration 0°, ulcer 0°, trismus 0°, taste disorder I° (present in\napprox. 80%), xerostomia I°, osteonecrosis 0°, hypothyroidism II°,\nhoarseness II°, hearing loss, I°, dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**Current Recommendations:** Mr. Doe is advised to continue his\nfollow-up appointments.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------- ---------------------\n Neutrophils 72.2 % 42.0-77.0 %\n Lymphocytes 8.6 % 20.0-44.0 %\n Monocytes 11.6 % 2.0-9.5 %\n Basophils 1.4 % 0.0-1.8 %\n Eosinophils 6.0 % 0.5-5.5 %\n Immature Granulocytes 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 9.24 mg/dL 8.8-10.2 mg/dL\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n CRP 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n GGT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5 % 37.0-49.0 %\n RBC 3.3 M/µL 4.0-5.6 M/µL\n WBC 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Absolute Neutrophils 3.59 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.010 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.43 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.58 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.30 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94 % 0.50-2.00 %\n Ret-Hb 33.9 pg 28.5-34.5 pg\n PT 112 % \\> 78 %\n INR 0.95 \\< 1.25\n aPTT 30.2 sec. 25.0-38.0 sec.\n\n\n\n\nHere is the query:\nWhat was the date when Mr. Doe presented to the outpatient clinic for phoniatrics and pedaudiology?\n\nChoose the correct answer from the following options:\nA. 10/10/2012\nB. 10/10/2013\nC. 10/10/2014\nD. 10/10/2015\nE. 10/10/2016\n\n\nYour response:\n", "role": "user" }, { "content": "10/10/2014", "role": "assistant" } ]

[ { "content": "**Dear colleague, ****Dear colleague, **\n\n \n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who was treated in our clinic from 05/28/14 to 06/20/14.\n\n \n\n**Diagnoses: **\n\n- pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left\n midline tongue carcinoma\n\n- Arterial hypertension\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Idiopathic thrombocytopenia\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Hypothyroidism\n\n- Nicotine abuse\n\n<!-- -->\n\n- Panendoscopy with sampling on 04/14/2014 and 04/26/2014\n\n \n\n**Current Presentation**: With histologically confirmed carcinoma in the\nregion of the base of the tongue on the left side, Mr. Doe presents for\nsurgical treatment of the findings. In accordance with the tumor board\ndecision, resection is performed via a lateral pharyngotomy and neck\ndissection on both sides.\n\n \n\n**Physical Examination:** Patient in stable general condition (85 kg,\n188 cm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I° (L-thyroxine increased to 150 μg 1-0-0), hoarseness\n0°, hearing loss 0° (subjectively reduced), dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\nA tumorous mass can be inspected at the base of the left tongue. Tongue\nmobility is unremarkable.\n\n**CT chest, abdomen, pelvis on 05/28/14:**\n\nEmphasized mediastinal as well as abdominal lymph\nnodes.** **Vasosclerosis. Otherwise, there is no evidence for the\npresence of distant metastases with a suspected base of tongue\ncarcinoma. Liver cirrhosis.\n\n \n\n**CT neck on 06/11/14:**\n\nSuspected left tongue base carcinoma crossing midline with extension\ninto the left vallecula and compression of the left piriform sinus with\nsuspected lymph node metastases in levels I-III ipsilateral.\nContralateral prominent but not certainly suspicious lymph nodes. The\nprominent structure on the left supraclavicular side can also be\ninterpreted as circumscribed cystiform ectasia of the thoracic duct.\n\n \n\n**Ultrasound abdomen on 06/15/14:**\n\nImage of liver cirrhosis status post cholecystectomy.\nHepatosplenomegaly. Moderate aortic sclerosis.\n\n \n\n**X-ray pap swallow on 06/17/14:**\n\nClear tracheal aspiration in the absence of epiglottis envelope. The\ncough reflex is preserved. Otherwise, essentially unremarkable\nswallowing act. \n\n \n\n**Histology**: Invasive, moderately differentiated, squamous cell\ncarcinoma with keratinization of the medial left base of the tongue,\nmaximum extent 1.0 cm. Carcinoma- and dysplasia-free biopsies of the\nleft tonsil, the oropharyngeal tumor/tongue base on the left, deep\nresection of the tumor, lower tonsillar pole transition on the left\ntongue base, tongue base on the left and medial left tongue base, as\nwell as median tongue base.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** pT1. pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n \n\n**Therapy and Progression**: After the usual clinical and laboratory\npreparations, we performed the above-mentioned therapy on 05/29/14 in\nintubation anesthesia without complications. For perioperative infection\nprophylaxis, the patient received intravenous antibiotic therapy with\nAmpicillin and Sulbactam 3g three times daily for the duration of his\nhospital stay.\n\nDuring this procedure, the left lingual artery was interrupted\nprophylactically. No postoperative bleeding and no wound healing\ndisturbances occurred.\n\nA porridge swallow examination showed no evidence of a fistula. On the\nfollowing day, the patient was decannulated in consultation with the\ncolleagues of the speech therapy. After this, a food build-up was\ncarried out in cooperation with speech therapists. At the time of\ndischarge, the patient was receiving regular oral nutrition. The stoma\ncontinued to shrink. The patient was monitored, and if necessary, the\ntracheostoma was closed with local anesthesia. Histological findings\nwere pT1. Due to an RX status, adjuvant radiotherapy will be performed\nas decided by the tumor board. A prophylactic presentation at the\ncolleagues of the MKG as a preparatory measure for the upcoming\nradiotherapy. We asked for a control re-presentation in our outpatient\nclinic on 06/26/14 at 3:00 PM. Further controls take place at the half\nand at the end of the radiotherapy and further in 4-6 weeks rhythm. In\ncase of acute complaints, an immediate re-presentation is possible at\nany time.\n\n \n\n**Type of surgery**: Lateral pharyngotomy with resection of the base of\nthe tongue on the left as well as selective neck dissection on both\nsides level II-IV with ligature of the lingual artery on the left side,\ncreation of a stable tracheostoma and tonsillectomy on the left side.\n\n**Surgery report: **First, tracheotomy in a typical manner. A horizontal\nincision was made on the skin, positioned approximately two transverse\nfinger widths above the jugulum. Subsequently, the subcutaneous tissue\nand the platysma colli were incised. To facilitate access to the\ntrachea, the laryngeal muscles were carefully displaced to the side. The\nthyroid isthmus was undermined and clamped bilaterally. A precise\ntransection of the thyroid isthmus followed, with both halves of the\nthyroid gland being meticulously sutured using 0- Vicryl. The thyroid\nhalves were repositioned to expose the trachea. A visceral tracheotomy\nwas performed, and re-intubation was achieved utilizing a U-tube. The\nsurgical procedure then transitioned to a neck dissection on the left\nside. This phase began with an incision along the anterior edge of the\nsternocleidomastoid muscle. The subcutaneous tissue and platysma colli\nwere carefully cut, with due respect to the auricularis magnus nerve.\nDissection continued dorsally along the sternocleidomastoid muscle to\nreach the anterior border of the trapezius muscle. Further exposure\ninvolved the accessorius nerve in a cranialward direction, with\npreservation of this neural structure. Dissection proceeded along the\ncervical vascular sheath, revealing the common carotid artery, internal\njugular vein, and vagus nerve up to the digastric muscle. Below this\nlevel, exposure of the hypoglossal nerve was achieved.\n\nSuccessive dissection involved the lymph node fat package, progressing\nfrom level II to level IV in a cranial to caudal and ventral to dorsal\ndirection. Throughout this process, careful attention was paid to\nsparing the aforementioned neural and vascular structures. Subsequently,\naccess to the lateral pharyngectomy area was gained, allowing\nvisualization of the external carotid artery along with its branches,\nincluding the superior thyroid artery, superior laryngeal artery, and\nlingual artery. Notably, the lingual artery was interrupted during this\nstage.\n\nFurther exploration revealed the superior laryngeal nerve and\nhypoglossal nerve intersecting in a loop above the internal carotid\nartery and externally below the external jugular vein. Additional\ndissection in a ventral direction followed. The hypoglossal nerve was\nprepared meticulously. Exposure of the hyoid bone was achieved, with a\nposterior resection of half of the hyoid bone. Importantly, the\nhypoglossal nerve was spared during this procedure. Subsequent to these\nsteps, the lateral pharynx wall was opened, exposing the base of the\nhyoid. The next phase of the procedure involved enoral tumor\ntonsillectomy on the left side. Starting from the left side, the\nsurgical team identified the tonsil capsule at the anterior palatal arch\nusing a Henke spatula. The upper tonsillar pole was then dislodged and\ndissected with the Rosenblatt instrument, proceeding from cranial to\ncaudal. Hemostasis was meticulously achieved through swab pressure and\nelectrocautery. The excised tonsil tissue was sent for frozen section\nexamination for further analysis.\n\n**Frozen Section Report: **No evidence of malignancy was found. The\nresection was carried out at the junction of the caudal tonsillar pole\nand the base of the tongue. At this location, tissue from the base of\nthe tongue was resected and sent for a frozen section examination, which\nrevealed no indication of malignancy. Subsequently, a medial resection\nof the base of the tongue was performed, confirming the presence of\nsquamous cell carcinoma in the frozen section analysis. Mucosal suturing\nwith inverting sutures was then conducted. On the left side, a neck\ndissection procedure was performed. The dissection extended along the\nsternocleidomastoid muscle, reaching dorsally to the anterior border of\nthe trapezius muscle. This approach allowed for cranial exposure of the\naccessorius nerve while sparing the same. Dissection continued along the\ncervical vascular sheath, exposing the common carotid artery, internal\njugular vein, and the vagus nerve up to the digastric muscle. Below\nthis, the hypoglossal nerve was exposed. Subsequently, the lymph node\nfat package was dissected systematically from level II to level IV,\nprogressing from cranial to caudal and ventral to dorsal, while\ncarefully preserving the mentioned structures. The surgical procedure\nconcluded with the placement of a drain, subcutaneous suturing, and skin\nsuturing.\n\n**Frozen section report:** Invasive squamous cell carcinoma.\n\n \n\n**Microscopy:**\n\nEven after paraffin embedding, mucosal cross-sections show a covering of\nstratified, non-keratinizing squamous epithelium with occasional\nsignificant stratification disturbances extending into superficial cell\nlayers. This transitions into invasive growth with solid clusters of\npolygonal tumor cells, some of which exhibit identifiable intercellular\nbridges. The cell nuclei are enlarged, round to oval, with occasional\nsmall nucleoli and mild to moderate nuclear pleomorphism. Dyskeratosis\nis observed in some areas.\n\n**Lab results upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- ----------------------- -----------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.0 mg/dL 0.7 - 1.3 mg/dL\n Calcium 9.04 mg/dL 8.8 - 10.6 mg/dL\n GFR (MDRD) \\> 60 mL/min/1.73m\\^2 \\> 60 mL/min/1.73m\\^2\n GFR (CKD-EPI,CREA) 80 mL/min/1.73m\\^2 \\> 90 mL/min/1.73m\\^2\n C-reactive protein 1.0 mg/dL \\< 0.5 mg/dL\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Paul Doe, born on\n08/08/1965, who presented to our outpatient clinic on 09/14/2014.\n\n**Diagnosis: **Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21)\nL0 V0 Pn0 G2 RX\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n- Since 03/2014: Odynophagia\n\n<!-- -->\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Histology:**\n\nInvasive, moderately differentiated, squamous cell carcinoma with\nkeratinization of the medial left base of the tongue, maximum extent 1.0\ncm. Carcinoma- and dysplasia-free biopsies of the left tonsil, the\noropharyngeal tumor/tongue base on the left, deep resection of the\ntumor, lower tonsillar pole transition on the left tongue base, tongue\nbase on the left and medial left tongue base, as well as median tongue\nbase.\n\nMetastasis-free lymph nodes in Neck-dissection Level IIa to IV on the\nleft (0/16), Neck-dissection Level IIb on the left (0/1), and\nNeck-dissection Level II to IV on the right (0/3), occasionally with\nlymphofollicular hyperplasia. Carcinoma-free bone of the left lateral\nthigh of the hyoid.\n\n**Final UICC classification:** min pT1, pN0 (0/21). L0. V0. Pn0. G2. RX.\n\n**Current Radiotherapy:**\n\n**Indication**: According to the decision made by the interdisciplinary\ntumor board for head and neck tumors, it was determined by our medical\nteam that, in the postoperative condition following the resection of a\ntongue base carcinoma with an unclear resection status, there is an\nindication for radiation therapy of the former tumor site.\n\n**Technique:** Percutaneous radiotherapy of the former primary tumor\nregion with 6-MeVPhotons, in Rapid-Arc technique, with a single dose of\n2 Gy up to a total dose of 60 Gy.\n\n**Radiotherapy 07/27/2014 - 09/06/2014:**\n\nDuring the course of radiotherapy, the patient experienced enoral\nmucositis (grade II according to CTCAE) leading to subsequent\nodynophagia and dysphagia. We managed these symptoms with oral rinses\nand initiated pain management using Acetaminophen, resulting in an\nacceptable reduction of pain over time. At the end of the therapy, the\npatient\\'s general condition remained stable (ECOG performance status:\n70%). Second-degree mucositis enoral persisted, causing ongoing\ndysphagia and odynophagia. Additionally, the patient exhibited localized\nradiodermatitis (grade II according to CTCAE) within the radiation\nfield. The patient did not report xerostomia or dysgeusia.\n\n**Current Recommendations:**\n\nThe patient received comprehensive instructions on continued skincare\nand side-effect management. An initial follow-up appointment with the\nradio-oncology team has been scheduled in our outpatient clinic. We\nkindly request the patient to provide a renewed referral for\nradiotherapy on the day of the appointment.\n\nThe ongoing oncological treatment plan will be determined by the\npatient\\'s Ear, Nose, and Throat specialists. Regular follow-up\nexaminations are strongly recommended. Additionally, for patients who\nhave completed radiation therapy in the ENT region, we advise lifelong\nadherence to fluoride prophylaxis and antibiotic therapy during any\ndental procedures.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965, who presented\nto our outpatient clinic for phoniatrics and pedaudiology on 10/10/2014.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Medical History: **We may kindly assume the detailed history as known.\n\n**Phoniatrics: Fiberoptic endoscopic swallow examination:**\n\nTongue motor function is well preserved, sensitivity of lip and tongue\nlaterally equal,\n\nMucous membranes non-irritant on all sides. Tracheal mucosa\nnon-irritant, no evidence of saliva intratracheal. Neopharynx\ninconspicuous, air bubbles visible above Provox outlet on pressing\nattempt. Tongue retraction slightly limited. Velopharyngeal closure\ngood.\n\n**Therapy and Course:** After completion of the adjuvant radiotherapy\napproximately 6 weeks ago, phonation via the Provox voice prosthesis was\nno longer possible after this had initially worked after the operation.\nAdditionally, there were issues with regurgitation of ingested\nsubstances, regardless of their consistency. In some cases, nasal\npenetration with fluids occurred. There were no indications of\naspiration. A self-assessment, involving the use of blue-colored liquid,\nrevealed no signs of leakage from the Provox device.\n\n**Current Recommendations:** Oncological follow-up in 12 months.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe report about our patient, Mr. Doe, born on 08/08/1965 who presented\nat our outpatient clinic for radio-oncological follow-up on 10/09/2020.\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n \n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for a radio-oncological follow-up on 10/09/2020 in the\npresence of his wife.\n\n**Physical Examination**: Patient in stable general condition (85 kg,188\ncm). MUST score: 0, pain NRS 8/10 intermittent (adjusted with\nAcetaminophen) \\| fatigue I°, dysphagia I° \\| aspiration 0°, ulcer 0°,\ntrismus 0°, taste disturbance I°, xerostomia I°, osteonecrosis 0°,\nhypothyroidism I°, hoarseness 0°, hearing loss 0° (subjectively\nreduced), dyspnea: 0°, pneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable \\| movement restrictions 0°,\nsubcutaneous fibrosis: I°, hyperpigmentation: I° cervical, mucositis 0°,\nlymphedema I° (lymphatic drainage prescribed), telangiectasia 0°.\n\n**MRI scan of the neck from 10/09/2020:** \n\nClear post-therapeutic changes in the resection and radiation area after\nadjuvant RTx following tumor resection with laryngectomy for extensive\nrecurrence of oropharyngeal cancer. \n\nSize constant, but still clearly accentuated lymph nodes in level Ib/IIa\non the left. Regredience of seroma formation under the left\nsternocleidomastoid muscle.\n\n**Current Recommendations: **Primary oncological care and follow-up,\nincluding imaging, will be provided by the ENT clinic according to the\nguidelines. A re-appointment for a further radio-oncological follow-up\nat the follow-up appointment at the Radiation Therapy Tumor Therapy\nCenter has been scheduled. After head and neck radiation therapy,\nregular fluoridation of the teeth and guideline-based antibiotic\nprophylaxis is required prior to major dental procedures. We also\nrecommend temporomandibular joint opening exercises to prevent\ntemporomandibular joint fibrosis and consecutive temporomandibular joint\nopening obstruction. We also refer to regular control of thyroid\nfunction parameters and, if necessary, initiation of substitution\ntherapy after radiotherapy to the neck.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe hereby report on our patient Mr. Paul Doe, born 08/08/1965 for\nradio-oncological follow-up on 09/24/2021.\n\n**Diagnoses: **\n\n- Tongue base carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014: Odynophagia\n\n- 05/14/2014: Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation: **The patient presented to our general\noutpatient clinic for radio-oncological follow-up on 09/24/2021. \n\n**Physical Examination: **Patient in reduced general condition (KPS 60%,\n86 kg,188 cm). Weight loss 0°, MUST score: 0, pain VAS 1-2/10, fatigue\nI°, dysphagia I° with solid food (liquids occasionally flow out of the\nnose again when swallowing), aspiration 0°, ulcer 0°, trismus 0°, taste\ndisorder I° (present in approx. 80%), xerostomia I°, osteonecrosis 0°,\nhypothyroidism II°, hoarseness II°, hearing loss, I°, dyspnea: 0°,\npneumonitis 0°, nausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**MR neck plain + contrast agent on 09/24/2021**:\n\n[Technique]{.underline}: STIR triplanar, T1 ax -/+ contrast agent, T1\nmDixon cor after\n\ncontrast agent.\n\n[Findings]{.underline}: Known status post tumor resection with\nlaryngectomy for extensive recurrence of oropharyngeal Carcinoma;\nFollow-up after RTx. Somewhat increasing swelling of nasopharynx to\noropharynx. From the uvula the swelling is stable. As far as can be\nassessed, no clear recurrence-specific tissue proliferation or contrast\nuptake. Unchanged accentuated lymph nodes in level Ib/IIa on the left\n(one exemplary measured lymph node borderline large, idem to preliminary\nexamination). Mastoid cells minimally displaced on the left. Moderate\ndegenerative changes of the cervical spine. Assessment. Increasing\nswelling of the naso- to oropharynx. Neopharynx unchanged swollen. No\nevidence of malignancy-suspicious lymph nodes.\n\n**CT scan of the thorax on 09/24/2021**:\n\nSize-constant visualization of interlobar oval compaction in the left\nupper lobe corresponding to an interlobar lymph node. New to the\nprevious examination, two small nodular condensations appear, basal in\nthe right and in the left lower lobe, differentially inflammatory;\nfollow-up is recommended. Unchanged the prominent mediastinal lymph\nnodes, constant in size and number.\n\n**Current Recommendations:**\n\nPrimary oncologic care and follow-up including imaging will take place\nvia the ENT clinic on 01/14/22 at 11:00 AM. A re-appointment for the\nnext radio-oncological follow-up has been arranged for 01/14/2022 at\n1:00 PM in our radiotherapy outpatient clinic in the Tumor Therapy\nCenter.\n\n**Lab results upon Discharge:**\n\n**Hematology**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- -----------------------\n WBC 6,900 /μL 4,500 - 11,000 /μL\n RBC 2.7M /μL 4.5M - 5.9M /μL\n Hemoglobin 8.2 g/dL 14 - 18 g/dL\n Hematocrit 25.1 % 40 - 48 %\n MCH 31.27 pg 27 - 33 pg\n MCV 94 fL 82 - 92 fL\n MCHC 32.7 g/dL 32 - 36 g/dL\n Platelets 638,000 /μL 150,000 - 450,000 /μL\n\n**Serum chemistry**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ -----------------\n Sodium 144 mEq/L 135 - 145 mEq/L\n Potassium 4.8 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.3 mg/dL 0.7 - 1.3 mg/dL\n ALT 21 U/L 10 - 50 U/L\n eGFR 55 mL/min \\> 90 mL/min\n CRP 2.9 mg/dL \\< 0.5 mg/dL\n\n**Coagulation**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------ ---------------\n PT 93 % 70 - 120 %\n INR 1.1 0.8 - 1.2\n aPTT 31 sec 26 - 37 sec\n\n**Thyroid hormones**\n\n **Parameter ** **Result** **Reference**\n ---------------- ------------- ------------------\n TSH 1.16 μIU/mL 0.4 - 4.2 μIU/mL\n fT3 2.38 pg/mL 2.3 - 4.2 pg/mL\n fT4 1.70 ng/dL 0.9 - 1.7 ng/dL\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who was admitted\nto our hospital from 01/10/2022 to 01/27/2022.\n\n**Diagnosis**: Metachronous pulmonary metastatic squamous cell carcinoma\n\n**Diagnoses: **\n\n- Tongue base Carcinoma ICD-10: C01, stage: pT1 pN0 (0/21) L0 V0 Pn0\n G2 RX\n\n- Since 03/2014 Odynophagia\n\n- 05/14/2014 Panendoscopy, biopsy, and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014 Tumor resection and selective neck dissection LI-III\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Diabetes mellitus type II\n\n- Status post liver surgery 2013\n\n- Status post endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Planned Surgical Procedure:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Medical History**: Mr. Paul Doe initially presented with a diagnosis\nof pT1, pN0 (0/21, ECE negative), cM0, Pn0, G2, RX, L0, V0, left midline\ntongue carcinoma. Panendoscopy with specimen collection on 04/14/2014\nand 04/26/2014 confirmed carcinoma.\n\nSurgical resection was performed via lateral pharyngotomy and neck\ndissection. Histology confirmed squamous cell carcinoma. He subsequently\nreceived radiotherapy.\n\nDuring a follow-up CT examination, a suspicious lesion was identified in\nthe lung, which raised concerns regarding the possibility of metastasis\noriginating from the previously diagnosed left midline tongue carcinoma\n(pT1, pN0, G2, RX).\n\n**Current Presentation:** Mr. Doe was admitted for further examination\nand treatment to assess the behavior and extent of the lesion.\nClinically, Mr. Doe was in stable general condition and had no symptoms\nsuggestive of B symptoms.\n\n**Therapy and Progression**: The above-mentioned procedure was performed\nwithout complications on 01/10/2022. Histologically, the final resection\nspecimen confirmed the presence of a 2.9 cm squamous cell carcinoma,\nconsistent with a metastatic recurrence of the previously known\nhypopharyngeal carcinoma. The dissected lymph nodes were free of tumor.\nThe postoperative course was uneventful. In the absence of any\ncomplications, surgical sutures were removed on day 10 after surgery. A\ncurrent chest X-ray showed a regular postoperative outcome with\nsufficient expansion of the left lobe. Further monitoring is recommended\nby the treating colleagues in this regard. Mr. Doe is also connected to\nthe radiation therapy team for ongoing follow-up.\n\nIf there are any complications or questions, please contact the relevant\nward or reach out to our Central Patient Management. Outside regular\nworking hours, you can contact the on-call colleague in the Abdominal\nSurgery department for assistance.\n\nFor further information on the patient\\'s discharge management, treating\nproviders are available for inquiries from Monday to Friday, 9 AM to 7\nPM, as well as on weekends and holidays from 10 AM to 2 PM.\n\nMr. Doe was discharged from the hospital on 01/27/2022.\n\n**Addition:**\n\n**Histology Report:** Resected left upper lobe specimen with a 2.9 cm\nsolid carcinoma. The histological picture is consistent with a\nmetastasis from the previously diagnosed non-keratinizing squamous cell\ncarcinoma. There were focal vascular invasions. No pleural invasion was\nobserved. The resection was complete, with all dissected lymph nodes\nshowing no tumor involvement.\n\n**Chest X-ray, anterior-posterior view from 01/21/2022**:\n\n[Clinical Information:]{.underline} History of VATS with wedge\nresection, yesterday\\'s drain removal\n\n[Question:]{.underline} Follow-up, pneumothorax after drain removal?\nInfiltrates? Atelectasis?\n\n[Findings:]{.underline} Left chest drainage tube has been removed. Left\napical pneumothorax line, measuring approximately 2.3 cm. Continued\nextensive shadowing of the left upper field, most likely postoperative,\ninfiltrate cannot be definitively ruled out. Slightly hypotransparent\nleft lung in comparison, most likely due to residual postoperative\nreduced ventilation. No effusion. Widened cardiac silhouette. Regression\nof dystelectasis in the right lower field. No acute signs of pulmonary\nvenous congestion. Trachea is mid-positioned and not stenosed.\nLeft-sided port catheter still in place.\n\n[Summary]{.underline}: Left apical corax with a width of 2.3 cm.\nContinued extensive shadowing of the left upper field, most likely\npostoperative, with infiltrate not definitively excluded. Residual\npostoperative reduced ventilation on the left side. Regression of\ndystelectasis in the right lower field. No effusion. No acute signs of\npulmonary venous congestion. Follow-up recommended.\n\n**Examinations Chest X-ray, anterior-posterior view from 01/23/2022:**\n\n[Question]{.underline}**:** Follow-up.\n\n[Findings]{.underline}: Left apical pneumothorax, measuring\napproximately 1.4 cm. Extensive shadowing in projection onto the left\nupper lobe, differentials include postoperative changes, incipient\ninfiltrate not excluded. Dystelectasis of the right lower field. No\nevidence of pleural effusion or acute pulmonary venous congestion.\nCardiomegaly. Indwelling chest drainage with the catheter tip projecting\nonto the left upper lobe. Well-positioned port catheter tip projecting\nonto the right atrial entrance plane. No evidence of pleural effusion.\nAssessment Left apical pneumothorax, measuring approximately 1.4 cm,\nwith indwelling left chest drainage. Extensive shadowing in projection\nonto the left upper lobe, differentials include postoperative changes,\nincipient infiltrate not excluded. Dystelectasis of the right lower\nfield. No significant pleural effusion. No acute pulmonary venous\ncongestion. Cardiomegaly.\n\n**Chest X-ray, anterior-posterior view from 01/25/2022**\n\n[Previous Examinations]{.underline}: Appearance of a diffuse\npostoperative shadow in the left upper field. No evidence of pleural\neffusion, inflammatory infiltrate, or pulmonary venous congestion.\n\n[Findings]{.underline}: Left-sided chest port with the tip projecting\nonto the superior vena cava. The upper mediastinum is narrow, the\ntrachea is mid-positioned and patent.\n\n[Assessment]{.underline}: The pneumothorax appears to be largely\nresolved.\n\n**Urinanalysis**:\n\nMaterial: Urine, midstream sample collected on 01/11/2022\n\n- Antimicrobial inhibitors negative\n\n- No evidence of growth-inhibiting substances in the sample material.\n\n- Colony Count (CFU) / mL \\<1,000, Assessment: A low colony count\n typically does not support a urinary tract infection.\n\n- Epithelial cells (microscopic) \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic) \\<20 leukocytes/μL\n\n- Microorganisms (microscopic) 20-100 microorganisms/μL Pathogen\n Enterococci\n\n**Lab values upon Discharge: **\n\n **Parameter** **Result** **Reference Range**\n -------------------- --------------------- ---------------------\n Sodium 141 mEq/L 135 - 145 mEq/L\n Potassium 4.7 mEq/L 3.5 - 5.0 mEq/L\n Creatinine 1.1 mg/dL 0.7 - 1.3 mg/dL\n Calcium 10.4 mg/dL 8.8 - 10.6 mg/dL\n eGFR (MDRD) \\> 60 mL/min/1.73m² \\> 60 mL/min/1.73m²\n eGFR (CKD-EPI) 85 mL/min/1.73m² \\> 90 mL/min/1.73m²\n C-Reactive Protein 5.0 mg/dL \\< 0.5 mg/dL\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgical Procedure from 01/11/2022:**\n\n- Perioperative bronchoscopy\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Pleurolysis\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n- Placement of double chest drains\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015: radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n- OSAS with CPAP incompliance\n\n<!-- -->\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for postoperative follow-up\nafter his left-sided videothoracoscopic upper lobe resection due to\npreviously diagnosed pulmonary metastatic hypopharyngeal carcinoma.\n\n**Medical History:** The patient\\'s general condition is good. He is\ncurrently on intermittent as-needed analgesia with Acetaminophen. The\nfinal resection specimen histologically confirmed the presence of a 2.9\ncm squamous cell carcinoma, consistent with a metastatic recurrence of\nthe previously known hypopharyngeal carcinoma. The dissected lymph nodes\nwere free of tumor.\n\n**Therapy and Progression**: During the follow-up appointment, Mr. Doe\nunderwent a clinical examination and a chest X-ray to assess his\npostoperative condition. The examination revealed no new concerning\nfindings, and Mr. Doe continued to remain in stable general condition.\nHis surgical incision site was inspected, showing signs of satisfactory\nhealing without any signs of infection or complications.\n\nFurthermore, Mr. Doe\\'s lung function was evaluated through spirometry,\nwhich indicated adequate pulmonary function post-surgery. He was also\nprovided with personalized recommendations for respiratory exercises to\noptimize his lung function during the recovery period.\n\n**Current Recommendations:**\n\n- Mr. Doe is connected to the radiation therapy team for ongoing\n follow-up.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Paul Doe, born on 08/08/1965, who presented to\nour surgical outpatient clinic on 01/24/2022.\n\n**Diagnoses**: Metachronous pulmonary metastatic squamous cell carcinoma\nat the base of the tongue.\n\n**Surgery on 01/11/2022:**\n\n- Left-sided video-assisted thoracoscopic surgery\n\n- Anatomical upper lobe resection\n\n- Systematic mediastinal, hilar, and interlobar lymph node dissection\n\n**Previous Diagnoses and Therapies:**\n\n- Recurrent oropharyngeal carcinoma ICD-10: C01\n\n- Stage: rpT2 rpN2(2/24, ECE -) L1 V0 Pn0 G2 R0\n\n- Tumor localization: base of tongue, crossing midline\n\n- Since 04/2014: Odynophagia\n\n- 04/14/2014: Panendoscopy, biopsy and initial diagnosis of left\n tongue base carcinoma.\n\n- 05/29/2014: Tumor resection and selective neck dissection LI-III\n\n- 08-10/2015 Radiotherapy of former PTR with 60 Gy à 2 Gy.\n\n**Other Diagnoses:**\n\n- OSAS with CPAP incompliance\n\n- Liver cirrhosis with alcohol abuse\n\n- Non-insulin-dependent diabetes mellitus type II\n\n- Arterial hypertension\n\n- History of endoprosthetic hip treatment\n\n- Hypothyroidism\n\n- Oral thrush\n\n- Hypacusis\n\n**Current Presentation:** Mr. Doe presented for routine follow-up.\nClinically, he remains in stable general condition, with no signs of\nB-symptoms.\n\n**Medical History**: The surgical procedure performed on 01/11/2022\ninvolved perioperative bronchoscopy, left VATS, pleurolysis, anatomical\nupper lobe resection, systematic mediastinal, hilar, and interlobar\nlymph node dissection, as well as the placement of double chest drains.\nHistologically, the final resection specimen confirmed a 2.9 cm solid\ncarcinoma, consistent with metastasis from the previously diagnosed\nsquamous cell carcinoma. Lymph nodes dissected during the procedure were\ntumor-free. Mr. Doe\\'s postoperative course was uneventful, and surgical\nsutures were removed on day 10 after surgery.\n\n**Physical Examination:** Patient in good general condition. Weight loss\n0°, MUST score: 0, pain VAS 1-2/10, fatigue I°, dysphagia I° with solid\nfood (liquids occasionally flow out of the nose again when swallowing),\naspiration 0°, ulcer 0°, trismus 0°, taste disorder I° (present in\napprox. 80%), xerostomia I°, osteonecrosis 0°, hypothyroidism II°,\nhoarseness II°, hearing loss, I°, dyspnea: 0°, pneumonitis 0°,\nnausea/vomiting 0°.\n\nNo suspicious lymph nodes palpable, movement restrictions I° head\nreclination restricted with tension and pain, subcutaneous fibrosis: I°,\nhyperpigmentation: I°, mucositis 0°, lymphedema I° (lymphatic drainage),\ntelangiectasia 0°.\n\n**Current Recommendations:** Mr. Doe is advised to continue his\nfollow-up appointments.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------- ---------------------\n Neutrophils 72.2 % 42.0-77.0 %\n Lymphocytes 8.6 % 20.0-44.0 %\n Monocytes 11.6 % 2.0-9.5 %\n Basophils 1.4 % 0.0-1.8 %\n Eosinophils 6.0 % 0.5-5.5 %\n Immature Granulocytes 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 9.24 mg/dL 8.8-10.2 mg/dL\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n CRP 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 ng/mL \\< 4.40 ng/mL\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n GGT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 ng/mL 1.32-8.92 ng/mL\n TSH 1.42 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 28.5 % 37.0-49.0 %\n RBC 3.3 M/µL 4.0-5.6 M/µL\n WBC 4.98 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Absolute Neutrophils 3.59 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.010 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.43 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.58 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.30 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 31.3 K/µL 25.0-105.0 K/µL\n Reticulocyte % 0.94 % 0.50-2.00 %\n Ret-Hb 33.9 pg 28.5-34.5 pg\n PT 112 % \\> 78 %\n INR 0.95 \\< 1.25\n aPTT 30.2 sec. 25.0-38.0 sec.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953, who\nreceived an MRI of the right proximal thigh for further clarification of\na potential tumor.\n\n**MRI of the right thigh, plain and with contrast agent, on\n02/19/2017:**\n\n[Technique]{.underline}: Surface coil, localization scan, coronal T1 SE,\ntransverse, coronal, sagittal T2 TSE with fat suppression. After\nintravenous contrast administration, T1-TSE transverse and T1-TSE FS\n(coronal, T2 TSE FS coronal as an additional fat-saturated sequence in\nthe same section level for exploring relevant edema).\n\n[Findings]{.underline}: Normal bone marrow signal consistent with age.\nNo signs of fractures. Coexistence of moderate degenerative changes in\nthe hip joints, more pronounced on the right than on the left. Mild\nactivation of the muscles in the left proximal adductor region. Ventral\nto the gracilis muscle and dorsal to the sartorius muscle at the level\nof the middle third of the right thigh is a subfascial intermuscular\noval mass lesion with a high-signal appearance on T2-weighted images and\na low-signal appearance on T1-weighted images. It is partially septated,\nwell-demarcated, and shows strong contrast enhancement. No evidence of\nblood degradation products. Dimensions are 35 x 45 x 40 mm. No evidence\nof suspiciously enlarged lymph nodes. Other assessed soft tissues are\nunremarkable for the patient\\'s age.\n\n[Assessment]{.underline}: Overall, a high suspicion of a mucinous mass\nlesion in the region of the right adductor compartment. Differential\nDiagnosis: Mucinous liposarcoma. Further histological evaluation is\nstrongly recommended.\n\n**Current Recommendations:** Presentation at the clinic for surgery for\nfurther differential diagnostic clarification.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953. He was\nunder our inpatient care from 03/10/2017 to 03/12/2017.\n\n**Diagnosis:** Soft tissue tumor of the right proximal thigh\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Treatment**: Incisional biopsy on 03/10/2017\n\n**Histology:**\n\n[Microscopy]{.underline}: (Hematoxylin and Eosin staining):\nHistologically, an infiltrate of a mesenchymal neoplasm is evident in a\nsection prepared by us and stained with HE. There are areas with an\nestimated tumor percentage of approximately 90% that were selected and\nlabeled for molecular pathology analysis.\n\n[Molecular Pathology]{.underline}: After macrodissection of labeled\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused next-generation sequencing technology. The\nanalysis was performed using FusioPlex Sarcoma v2 assays, allowing\ndetection of fusions in 63 genes.\n\n**Medical History:** We may kindly assume that you are familiar with Mr.\nHavers's medical history. The patient presented to our surgery clinic\ndue to a mass in the right proximal thigh. The swelling was first\nnoticed approximately 3 months ago and has shown significant enlargement\nsince. The patient subsequently consulted a general surgeon, who\nreferred him to our center after performing an MRI, suspecting an\nintramuscular liposarcoma. After presenting the case to our\ninterdisciplinary tumor board, the decision was made to perform an\nincisional biopsy. The patient was admitted for the above procedure on\n03/10/2017.\n\n**Physical Examination:** On clinical examination, a patient in slightly\nreduced general and nutritional status was observed. Approximately 6 x 7\nx 4 cm-sized tumor in the right proximal thigh, well mobile,\nintramuscular. Numbness in both legs at L5/S1.\n\nNo change in skin color. No fluctuation or redness. The rest of the\nclinical examination was unremarkable.\n\n**Treatment and Progression:** Following routine preoperative\npreparations and informed consent, the above-mentioned procedure was\nperformed under general anesthesia on 03/10/2017. The intraoperative and\npostoperative courses were uncomplicated.\n\nInitial mild swelling regressed over time. The inserted drainage was\nremoved on the second postoperative day. The patient mobilized\nindependently on the ward. Pain management was provided as needed.\n\nWith the patient\\'s subjective well-being and inconspicuous wound\nconditions, we were able to discharge Mr. Havers on 03/12/2017 for\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- Suture material to be shortened on the 14th postoperative day.\n\n- Follow-up appointments in our outpatient clinic\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin Calcium (Lipitor) 21.7 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole Sodium (Protonix) 22.6 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Urea 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Complete Blood Count \\- \\-\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n Erythrocytes 5.2 M/µL 4.3-5.8 M/µL\n Leukocytes 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n INR 0.94 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n\n**Addition: Histology Report:**\n\n[Microscopy:]{.underline} (Hematoxylin and Eosin staining):\nHistologically, infiltrates of a mesenchymal neoplasm can be seen in a\nsection we prepared. Below this are areas estimated to contain 90%\ntumor, which have been selected and labeled for molecular pathological\nanalysis.\n\n[Molecular Pathology:]{.underline} After macrodissection of the marked\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused Next-Generation Sequencing technology. The\nexamination was performed using the FusioPlex Sarcoma v2 Assays, that\nallows for the detection of fusions involving 63 genes.\n\n[Diagnosis:]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma, Grade 1 according to\n FNCLCC (Sum score 2 + 0 + 1 = 3), with the detection of a FUS: DDIT3\n fusion transcript (right adductor compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue.\n\n- In addition to previous reports, myxoid neoplasm is characterized by\n minimal cell density/round cell areas, here less than 25%, according\n to FNCLCC (=2 points for tumor differentiation).\n\n- No evidence of necrosis (=0 points).\n\n- 2 mitotic figures in 10 high-power fields (=1 point).\n\n- Total score is 2 + 0 + 1 = 3, corresponding to Grade 1 according to\n FNCLCC.\n\n[Diagnosis]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma (right adductor\n compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue\n (subcutaneous).\n\n[Comment]{.underline}: The present biopsy material corresponds to Grade\n1 according to FNCLCC. A supplementary report follows.\n\n**Supplementary Report from: 03/29/2017:**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh. Encapsulated subfascial tumor, palpably indurated.\nAdipose tissue adjacent to the tumor, macroscopically lighter and finer\nthan the subcutaneous adipose tissue towards the skin.\n\n[Material]{.underline}: Microscopy and Molecular Pathology Interphase\nFISH analysis using a two-color break-apart probe to examine a\nchromosomal break in the FUS gene (chromosome 16p11.2) and in the DDIT3\ngene (chromosome 12q13.3-q14.1).\n\nInterphase FISH analysis reveals a specific break event in the FUS gene\n(FUS-FISH positive). This indicates the presence of a FUS translocation.\nSimilarly, in interphase FISH analysis, a specific break event is\ndetectable in the DDIT3 gene (DDIT3-FISH positive), indicating the\npresence of a DDIT3 translocation.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n[Comment]{.underline}: The cytogenetic findings are indicative of a\nmyxoid liposarcoma. Technical validation by RNA sequencing will be\nprovided in a supplemental report. This does not affect the above\ndiagnosis.\n\n**Supplementary Report from: 03/18/2017:**\n\n[Microscopy: MDM2, S100:]{.underline} Partial weak expression of S100\nprotein by the lesional cells, occasionally including pre-existing\nadipocytes. No abnormal expression of MDM2. No abnormal expression of\nMDM2 in mature adipose tissue.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n**Main Report from: 03/18/2017**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh, as per MRI 02/19/2017. Encapsulated subfascial tumor,\npalpably indurated located in the right adductor compartment. Adipose\ntissue adjacent to the tumor, macroscopically lighter and finer than the\nsubcutaneous adipose tissue towards the skin.\n\n[Macroscopy:]{.underline}\n\nTumor: Brown, nodular piece of tissue, 20 x 14 x 10 mm, with smooth and\nrough surface. Cut surface shiny and mottled, sometimes gray, sometimes\nbrown.\n\nSubcutaneous adipose tissue: A piece of adipose tissue, 25 x 20 x 5 mm.\n\n[Microscopy:]{.underline}\n\nModerately cell dense mesenchymal proliferation with a myxoid matrix.\nPredominantly round nuclei, moderately dense nuclear chromatin, slight\npleomorphism. Occasional adipocytic cells with univacuolar cytoplasm.\n\nPartially dense, ribbon-like connective tissue as well as mature\nunivacuolar adipose tissue.\n\n[Diagnosis:]{.underline}\n\nIncisional biopsy suspected of a myxoid liposarcoma. Predominantly\nmature fatty tissue as well as fascial tissue.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe would like to inform you about our patient Mr. John Havers, born on\n05/29/1953, who was admitted to our hospital from 03/29/2017 to\n04/05/2017.\n\n**Diagnoses**:\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n- Incisional biopsy on 03/10/2017\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Current Presentation**: Neoplasm of uncertain or unknown behavior.\n\n**Treatment**: On 04/01/2017, en bloc tumor excision with removal of the\nold biopsy scar, partial resection of the M. gracilis, fibers of the M.\nsartorius and M. adductor longus, and ligation of the V. saphena magna\nwas performed.\n\n**Histology from 04/11/2017**\n\nClinical Information: Myxoid liposarcoma, localized in the right thigh.\n\n[Macroscopy Tumor, right thigh]{.underline}: A triple surgical resection\nwas performed, removing skin and subcutaneous tissue and the underlying\nsoft tissue and muscle. The size of the excised skin spindle was 130 x\n45 mm with a resection depth of up to 48 mm. A wound 25 mm long and 6 mm\nwide was noted on the skin surface. The muscle attached\nlaterally/dorsally measured 75 x 25 x 6 mm. Two nodules were noted on\nthe cut surface. The larger nodule, located in the subcutaneous tissue,\nmeasured 33 mm (proximal/distal) x 36 mm (anterior/dorsal) x 30 mm. Its\ndistance from the proximal preparation cap was 26 mm, from the distal\npreparation cap more than 60 mm, from the ventral soft tissue 20 mm, and\nfrom the dorsal soft tissue 3 mm, with less than 1 mm basal extension.\nSuperficially, it was surrounded by a delicate capsule. A separate\nnodule measuring 20 mm (proximal/distal) x 24 mm (ventral/dorsal) x 20\nmm was found immediately ventro-distal to the first nodule. This nodule\nwas located more than 40 mm from the proximal preparation cap, more than\n50 mm from the distal preparation cap, 12 mm ventrally, 11 mm dorsally,\nand 5 mm basally. Consequently, the maximum size of the tumor from\nproximal to distal was 53 mm. No macroscopic necrotic areas were evident\non the cut surface of the nodule. However, partial necrosis of the\nsubcutaneous fatty tissue in the vicinity of the described wound was\nobserved.\n\n[Microscopy HE, PAS:]{.underline} Histomorphologically, there is a\nmoderately cell-dense proliferation with a significant myxoid matrix in\nthe area of the two confluent nodules, with a maximum diameter of 53 mm.\nThere are also areas with relative cell poverty. Within the myxoid\nmatrix, there are blood vessels with a distinct growth pattern referred\nto as the \\\"chicken wire pattern.\\\" No clear tumor necroses are evident.\nThe tumor cell nuclei have a round configuration with moderately dense\nchromatin. Apoptotic figures are increased. The number of mitoses is\nlow.The lesion was completely removed with a minimal margin of 0.5 mm\nfrom the posterior resection edge. In the superficial subcutaneous\ntissue, there is a band-like necrosis directly related to superficial\ngranulation tissue. The included skin spindle shows regular epidermal\ncovering and a largely unremarkable dermis.\n\n[Diagnosis]{.underline}: Skin/subcutaneous excision with a maximum 53 mm\nmyxoid liposarcoma that was completely removed (minimum distance to\nposterior cutoff plane 0.5 mm).\n\n[Comment]{.underline}: In view of the present morphology and knowledge\nof the molecular pathological examination results with proven break\nevents in the FUS gene and DDIT3 gene as part of interphase FISH\nanalysis, the diagnosed condition is myxoid liposarcoma.\n\nAccording to the FNCLCC grading scheme, this corresponds to grade 1:\nHistological type: 2 points + mitotic index 1 point + necrosis index 0\npoints = 3 points.\n\nICD-O-3 tumor classification: Myxoid liposarcoma TNM (8th edition): pT2\npNX L0 V0 Pn0 G1 R0\n\n**Medical History:** We assume that you are familiar with Mr. Havers's\nmedical history, and we refer to our previous correspondence.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds.\n\nHeart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys.\n\nNormal peripheral pulses; joints freely movable. Strength, motor\nfunction, and sensation are unremarkable.\n\n**Therapy and Progression**: The patient presented to our surgical\nclinic because of a mass in the right proximal thigh. The swelling was\nfirst noticed about 3 months ago and has increased significantly in size\nsince then. MRI findings raised suspicion of a liposarcoma. After\nconsultation in the interdisciplinary tumor board, the indication for\nincisional biopsy was performed on 03/10/2017. The histopathological\nexamination confirmed the presence of a myxoid liposarcoma, leading to\nthe decision for en bloc excision. The patient was extensively informed\nabout the procedure and the risks and gave his consent. The patient was\nadmitted for the procedure on 03/29/2017.\n\nUpon clinical examination, a patient in good general and nutritional\ncondition was noted. Other general clinical findings were unremarkable.\nA wound healing disorder of 2 cm was observed in the area of the wound\nafter incisional biopsy.\n\n**Sarcoma Tumor Board Recommendation dated 03/11/2017:** R0 G1 finding,\nstandard sarcoma follow-up.\n\n**Procedure**: Following standard preoperative preparations and informed\nconsent, the aforementioned procedure was performed on 03/01/2017 under\ngeneral anesthesia. The intraoperative and postoperative course was\nuneventful.\n\nOn the first postoperative day, there was slight swelling in the\naffected area, which gradually subsided. Analgesia was sufficient with\nAcetaminophen as needed. Thrombosis prophylaxis was administered with\nsubcutaneous Enoxaparin 0.4 mL. The patient mobilized independently on\nthe ward. The inserted drainage could not be removed so far due to\nexcessive drainage output. During the hospital stay, a staging CT of the\nchest and abdomen was performed. No thoracoabdominal metastases were\ndetected.\n\n**Summary**: With a good subjective well-being and unremarkable wound\nconditions, Mr. Havers was discharged on 04/05/2017 for further\noutpatient care. Clinical examination reveals slight swelling of the\nwound area. The wound is not dehiscent and shows no signs of irritation.\nThe patient is mobilizing independently.\n\n**CT Chest/Abdomen/Pelvis from 04/01/2017: **\n\n[Clinical Information, Question, Justification]{.underline}: Liposarcoma\nof the thigh. Staging.\n\n[Technique]{.underline}: Digital overview radiographs. Following\nintravenous contrast agent administration (100 ml Xenetix), CT of the\nchest and entire abdomen in the venous contrast phase. Reconstruction of\nthe primary dataset with a slice thickness of 0.625 mm. Multiplanar\nreconstruction. Total DLP: 885 mGy\\*cm.\n\n[Findings]{.underline}: There are no prior images available for\ncomparison.\n\n[Chest]{.underline}: Lungs are evenly ventilated and normally developed\nbilaterally. No pneumothorax on either side. Minimal right-sided pleural\neffusion. Mild basilar hypoventilation, particularly in the right lower\nlobe. Calcified granuloma in the apical right lower lobe. No suspicious\npulmonary nodules.\n\nHeart shows enlargement of the left ventricle and left atrium. Coronary\nartery sclerosis. Atherosclerosis of the aortic arch. No pericardial\neffusion. Aorta and pulmonary trunk have normal diameters. No central\npulmonary artery embolism. No pathologically enlarged mediastinal or\nhilar lymph nodes. Symmetric appearance of the neck soft tissues.\nThyroid gland without focal lesions. Axillary lymph nodes are of normal\nsize.\n\n[Abdomen]{.underline}: Liver is of normal size and has a smooth contour.\nNo signs of cholestasis. No portal vein thrombosis. No suspicious\nintrahepatic lesions. Gallbladder appears normal. Common bile duct is\nnot dilated. Spleen is not enlarged. Pancreas shows regular lobulation,\nand there is no dilatation of the pancreatic duct. Both kidneys are free\nfrom urinary tract obstruction. No solid intrarenal masses. Few renal\ncysts. Adrenal glands appear unremarkable. Urinary bladder shows no\nfocal wall thickening. Prostate is not enlarged. Advanced\natherosclerosis of the abdominal aorta and pelvic vessels. History of\nstenting of the left external iliac artery with no reocclusion.\nMesenteric, para-aortic, and parailiac lymph nodes are not\npathologically enlarged. No free intraperitoneal fluid or air is\ndetected. Osseous Structures: Degenerative changes in the spine. No\nevidence of suspicious osseous destruction suggestive of tumors. Soft\ntissue mantle appears unremarkable.\n\n**Assessment**: No thoracoabdominal metastases.\n\n**Current Recommendations**:\n\n- Regular wound inspections and dressing changes.\n\n- Documentation of drainage output and removal if the output is \\<20\n ml/24 hours, expected removal on 04/23/2017 at our outpatient\n clinic.\n\n- Removal of sutures is not required for absorbable sutures.\n\n- According to the tumor board decision dated 04/11/2017, we recommend\n regular follow-up according to the schedule.\n\n**Sarcoma Follow-up Schedule Stage I**\n\n- Local Follow-up:\n\n 1. MRI right thigh: Years 1-5: every 6 months\n\n 2. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 3. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 4. Years 6-10: every 12 months in alternation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ -------------------\n Aspirin 100 mg 1-0-0-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Enoxaparin (Lovenox) Variable 0-0-1-0\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Acetaminophen (Tylenol) 500 mg 2-2-2-2 if needed\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------- ---------------------\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.74 mg/dL 0.70-1.20 mg/dL\n Blood Urea Nitrogen 33 mg/dL 17-48 mg/dL\n C-Reactive Protein 1.7 mg/dL \\< 5.0 mg/dL\n Thyroid-Stimulating Hormone 3.58 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 16.5 g/dL 13.5-17.0 g/dL\n Hematocrit 49.3% 39.5-50.5%\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.63 K/µL 3.90-10.50 K/µL\n Platelets 301 K/µL 150-370 K/µL\n Mean Corpuscular Volume 95.7 fL 80.0-99.0 fL\n Mean Corpuscular Hemoglobin 32.0 pg 27.0-33.5 pg\n Mean Corpuscular Hemoglobin Concentration 33.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.4 fL 7.0-12.0 fL\n Red Cell Distribution Width 12.1% 11.6-14.4%\n Activated Partial Thromboplastin Time 32.4 sec 25.0-38.0 sec\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented to our outpatient surgery clinic on\n04/23/2017.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Medical History:** We kindly assume that you are familiar with the\npatient\\'s detailed medical history and refer to our previous discharge\nletter.\n\n**Current Presentation:** The patient presented today for a follow-up\nvisit in our clinic. He reported no complaints. The Redon drain has not\nproduced any secretions in the last 2 days.\n\nClinical examination revealed uneventful wound conditions with applied\nSteri-strips. There is no evidence of infection. The Redon drain\ncontains serous wound secretions.\n\nProcedure: The Redon drain is being removed today. With nearly fully\nhealed wound conditions, we recommend initiating scar massage with fatty\ntopical products in the near future.\n\n**MRI of the Right Thigh on** 04/23/2017**:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB. Recurrence? Regional behavior? Lymph nodes?\n\n[Technique]{.underline}: 3 Tesla MRI of the right thigh, both plain and\nafter the administration of 8 ml of Gadovist intravenously. Supine\nposition, surface coil.\n\nSequences: TIRM coronal and axial, T2-TSE coronal and axial, T1 VIBE\nDixon axial, EPI-DWI with ADC map axial, T1-Starvibe vascular images\nplain and post-contrast axial with subtraction images, T1-TSE FS\npost-contrast coronal.\n\n[Findings]{.underline}: Minor FLAIR hyperintense streaky signal\nalteration in the surgical area, most likely scar-related, with slight\ndiffusion restriction and streaky contrast enhancement. No evidence of a\nrecurrent suspicious substrate. No nodular contrast enhancement.\nSlightly accentuated inguinal lymph nodes on the right, most likely\nreactive. Unremarkable visualization of the remaining soft tissue.\nNormal bone marrow signal. Bladder filled. Unremarkable representation\nof the imaged pelvic organs.\n\n[Assessment]{.underline}: Following the resection of a myxoid\nliposarcoma on the right medial thigh, there is a regular postoperative\nfinding. No indication of local recurrence.\n\n**Chest X-ray in Two Planes on 04/23/2017: **\n\n[Clinical Background, Question, Justification]{.underline}: Myxoid\nliposarcoma of the right thigh, initial diagnosis in 2022. Follow-up.\nMetastases?\n\n[Findings]{.underline}: No corresponding prior images for comparison.\nThe upper mediastinum is centrally located and not widened. Hila are\nfree. No acute congestion. No confluent pneumonic infiltrate. No\nevidence of larger intrapulmonary lesions. A 7 mm spot shadow is noted\nright suprahilar, primarily representing a vascular structure. No\neffusions. No pneumothorax.\n\n**Current Recommendations:** The patient would like to continue\nfollow-up care with us, so we scheduled an MRI control appointment to\nassess the possibility of local recurrence. On this day, a two-view\nchest X-ray is also required.\n\n**We recommend the following follow-up schedule:**\n\n- Local Follow-up:\n\n 5. MRI right thigh: Years 1-5: every 6 months\n\n 6. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 7. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 8. Years 6-10: every 12 months in alternation\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented for tumor follow-up on 02/10/2018, in our\noutpatient surgery clinic for a discussion of findings.\n\n**Diagnosis**: Myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a regular postoperative finding on the\nright thigh.\n\nThe control MRI with contrast of the right thigh on 04/23/2017 revealed\nmorphologically:\n\n- No evidence of a local-regional recurrence.\n\n- In pulmonary follow-up using conventional chest X-ray on 04/23/2017,\n no signs of pulmonary metastasis were detected.\n\n**Current Recommendations:** Sarcoma Follow-up Schedule Stage I\n\n- Local Follow-up:\n\n 9. MRI right thigh: Years 1-5: every 6 months\n\n 10. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 11. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 12. Years 6-10: every 12 months in alternation\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting to you on our patient Mr. John Havers, born on\n05/29/1953, who presented himself on **08/01/2018** at our outpatient\nsurgery clinic for a discussion of findings as part of tumor follow-up.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a normal postoperative condition in\nthe right thigh.\n\n**MRI of the Right Thigh on 08/01/2018:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh. Progress\nassessment.\n\n[Method]{.underline}: 1.5 Tesla. Localization sequences. TIRM and T2 TSE\ncoronal. TIRM, T2 TSE, VIBE DIXON, and RESOLVE-DWI axial. StarVIBE FS\nbefore and after contrast + subtraction. T1 TSE FS coronal after\ncontrast.\n\n[Findings]{.underline}: Comparison with MRI from 04/23/2017.\nPost-resection of a myxoid liposarcoma in the proximal medial right\nthigh soft tissue. In the surgical area, there is no evidence of a\nsuspicious nodular, contrast-affine lesion, and no evidence of\nmalignancy-suspected diffusion restriction. Slight scar-related changes\nin the access path. Otherwise, unremarkable presentation of soft tissues\nand included bony structures. No inguinal lymphadenopathy. Assessment:\nFor myxoid liposarcoma, there has been consistent evidence since\n02/2018:\n\n**Chest CT on 08/01/2018**:\n\n[Clinical Background, Question, Justification: Liposarcoma on the thigh.\nStaging.]{.underline} After risk history assessment, oral and written\nexplanation of contrast agent application and examination procedure, as\nwell as potential risks of the examination (see also informed consent\nform). Written patient consent.\n\n[Method]{.underline}: Digital overview radiographs. After intravenous\ncontrast agent administration (80 ml of Imeron), CT of the chest in\nvenous contrast phase, reconstruction of the primary dataset with a\nslice thickness of 0.625 mm. Total DLP 185 mGy\\*cm.\n\n[Findings]{.underline}: For comparison, there is a CT of the\nchest/abdomen/pelvis from 04/01/2018. No evidence of suspicious\npulmonary nodules. Several partly calcified micronodules bipulmonary,\nespecially in the right lower lobe (ex. S303/IMA179). Partial\nunderventilation bipulmonary. No pleural effusion. No evidence of\npathologically enlarged lymph nodes. Constant calcified right hilar\nlymph nodes. Calcifying aortic sclerosis along with coronary sclerosis.\nHepatic steatosis. Individual renal cysts. Slightly shrunken left\nadrenal gland. Degenerative changes of the axial skeleton without\nevidence of a malignancy-suspected osseous lesion.\n\n[Assessment]{.underline}: No evidence of a new thoracic tumor\nmanifestation.\n\n**Recommendations:** Sarcoma Follow-up\n\n- Local Follow-up:\n\n 13. MRI right thigh: Years 1-5: every 6 months\n\n 14. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 15. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 16. Years 6-10: every 12 months in alternation\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n RBC 5.2 M/µL 4.3-5.8 M/µL\n WBC 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n International Normalized Ratio (INR) 0.94 0.90-1.25\n Activated Partial Thromboplastin Time (aPTT) 30.1 sec 25.0-38.0 sec\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who was admitted to our clinic from 08/14/2023 to\n09/02/2023.\n\n**Diagnosis:** Pulmonary Metastasis from Myxoid Liposarcoma\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n<!-- -->\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Medical History:** Mr. Havers has been under our care for myxoid\nliposarcoma, which was previously excised from his right medial thigh.\nHe had a stable postoperative course and was scheduled for regular\nfollow-up to monitor for any potential recurrence or metastasis.\n\n**Current Presentation:** During a follow-up appointment on 08/14/2023,\nMr. Havers complained of mild shortness of breath, occasional coughing,\nand intermittent chest discomfort. He reported no significant weight\nloss but noted a decrease in his overall energy levels. Physical\nexamination revealed decreased breath sounds in the right lung base.\n\n**Physical Examination:** Patient in adequate general condition.\nOriented in all aspects. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable. Lungs: Normal chest shape, moderately\nmobile, decreased breath sounds in the right lung base. Heart: Regular\nheart action, normal rate; heart sounds clear, no pathological sounds.\nAbdomen: Peristalsis and bowel sounds normal in all quadrants; soft\nabdomen, markedly obese, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation is unremarkable.\n\n**Chest X-ray (08/14/2023):** A chest X-ray was performed, which\nrevealed a suspicious opacity in the right lower lung field.\n\n**CT Chest (08/16/2023):** In light of the chest X-ray findings, a\ncontrast-enhanced CT scan of the chest was conducted to obtain more\ndetailed information. The CT imaging demonstrated a well-defined,\nirregularly shaped lesion in the right lower lobe of the lung, measuring\napproximately 2.5 cm in diameter. The lesion exhibited characteristics\nhighly suggestive of a metastatic deposit. There were no other\nsignificant abnormalities noted in the chest.\n\n**Histology (08/21/2023):** Based on the CT findings, a CT-guided core\nneedle biopsy of the pulmonary lesion was performed to confirm the\nnature of the lesion. Histopathological examination of the biopsy\nspecimen confirmed the presence of myxoid liposarcoma cells in the\npulmonary lesion. Immunohistochemical staining for MDM2 and CDK4\nsupported the diagnosis of metastatic myxoid liposarcoma.\n\n**Treatment Discussion:** Given the diagnosis of a pulmonary metastasis\nfrom myxoid liposarcoma, the case was reviewed in the interdisciplinary\ntumor board. The consensus decision was to pursue surgical resection of\nthe pulmonary metastasis, as it remained localized and resectable. The\npatient and his family were informed of the treatment options and\nassociated risks, and they provided informed consent for the procedure.\n\n**Surgery Report (08/29/2023):** Mr. Havers underwent a right lower\nlobectomy with lymph node dissection to remove the pulmonary metastasis.\nThe procedure was performed by our thoracic surgery team and was\ncompleted without any immediate complications. Intraoperative frozen\nsection analysis confirmed the presence of metastatic myxoid liposarcoma\nin the resected lung tissue.\n\n**Postoperative Course:** Mr. Havers postoperative course was\nuneventful, and he demonstrated good respiratory recovery. He was\nmanaged with adequate pain control and underwent chest physiotherapy to\nprevent postoperative complications. Pathological examination of the\nresected lung tissue confirmed the presence of metastatic myxoid\nliposarcoma, with clear surgical margins.\n\n**Current Recommendations:**\n\n1. **Follow-up:** A strict follow-up plan should be established for Mr.\n Havers to monitor for any potential recurrence or new metastatic\n lesions. This should include regular clinical assessments, chest\n imaging, and other relevant investigations.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n --------------------- ------------- ---------------------\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 39 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.5 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.6 g/dL 13.5-17.0 g/dL\n Hematocrit 49.4 % 39.5-50.5 %\n RBC 5.1 M/µL 4.3-5.8 M/µL\n WBC 10.04 K/µL 3.90-10.50 K/µL\n Platelets 166 K/µL 150-370 K/µL\n MCV 95.2 fL 80.0-99.0 fL\n MCH 32.6 pg 27.0-33.5 pg\n MCHC 33.2 g/dL 31.5-36.0 g/dL\n MPV 11.4 fL 7.0-12.0 fL\n RDW-CV 12.5 % 11.5-15.0 %\n Prothrombin Time 122 % 78-123 %\n INR 0.99 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n\n\n\n\nHere is the query:\nWhat is the grading of Mr. Havers' myxoid liposarcoma?\n\nChoose the correct answer from the following options:\nA. G0\nB. G1\nC. G2\nD. G3\nE. G4\n\n\nYour response:\n", "role": "user" }, { "content": "G1", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953, who\nreceived an MRI of the right proximal thigh for further clarification of\na potential tumor.\n\n**MRI of the right thigh, plain and with contrast agent, on\n02/19/2017:**\n\n[Technique]{.underline}: Surface coil, localization scan, coronal T1 SE,\ntransverse, coronal, sagittal T2 TSE with fat suppression. After\nintravenous contrast administration, T1-TSE transverse and T1-TSE FS\n(coronal, T2 TSE FS coronal as an additional fat-saturated sequence in\nthe same section level for exploring relevant edema).\n\n[Findings]{.underline}: Normal bone marrow signal consistent with age.\nNo signs of fractures. Coexistence of moderate degenerative changes in\nthe hip joints, more pronounced on the right than on the left. Mild\nactivation of the muscles in the left proximal adductor region. Ventral\nto the gracilis muscle and dorsal to the sartorius muscle at the level\nof the middle third of the right thigh is a subfascial intermuscular\noval mass lesion with a high-signal appearance on T2-weighted images and\na low-signal appearance on T1-weighted images. It is partially septated,\nwell-demarcated, and shows strong contrast enhancement. No evidence of\nblood degradation products. Dimensions are 35 x 45 x 40 mm. No evidence\nof suspiciously enlarged lymph nodes. Other assessed soft tissues are\nunremarkable for the patient\\'s age.\n\n[Assessment]{.underline}: Overall, a high suspicion of a mucinous mass\nlesion in the region of the right adductor compartment. Differential\nDiagnosis: Mucinous liposarcoma. Further histological evaluation is\nstrongly recommended.\n\n**Current Recommendations:** Presentation at the clinic for surgery for\nfurther differential diagnostic clarification.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, John Havers, born on 05/29/1953. He was\nunder our inpatient care from 03/10/2017 to 03/12/2017.\n\n**Diagnosis:** Soft tissue tumor of the right proximal thigh\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Treatment**: Incisional biopsy on 03/10/2017\n\n**Histology:**\n\n[Microscopy]{.underline}: (Hematoxylin and Eosin staining):\nHistologically, an infiltrate of a mesenchymal neoplasm is evident in a\nsection prepared by us and stained with HE. There are areas with an\nestimated tumor percentage of approximately 90% that were selected and\nlabeled for molecular pathology analysis.\n\n[Molecular Pathology]{.underline}: After macrodissection of labeled\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused next-generation sequencing technology. The\nanalysis was performed using FusioPlex Sarcoma v2 assays, allowing\ndetection of fusions in 63 genes.\n\n**Medical History:** We may kindly assume that you are familiar with Mr.\nHavers's medical history. The patient presented to our surgery clinic\ndue to a mass in the right proximal thigh. The swelling was first\nnoticed approximately 3 months ago and has shown significant enlargement\nsince. The patient subsequently consulted a general surgeon, who\nreferred him to our center after performing an MRI, suspecting an\nintramuscular liposarcoma. After presenting the case to our\ninterdisciplinary tumor board, the decision was made to perform an\nincisional biopsy. The patient was admitted for the above procedure on\n03/10/2017.\n\n**Physical Examination:** On clinical examination, a patient in slightly\nreduced general and nutritional status was observed. Approximately 6 x 7\nx 4 cm-sized tumor in the right proximal thigh, well mobile,\nintramuscular. Numbness in both legs at L5/S1.\n\nNo change in skin color. No fluctuation or redness. The rest of the\nclinical examination was unremarkable.\n\n**Treatment and Progression:** Following routine preoperative\npreparations and informed consent, the above-mentioned procedure was\nperformed under general anesthesia on 03/10/2017. The intraoperative and\npostoperative courses were uncomplicated.\n\nInitial mild swelling regressed over time. The inserted drainage was\nremoved on the second postoperative day. The patient mobilized\nindependently on the ward. Pain management was provided as needed.\n\nWith the patient\\'s subjective well-being and inconspicuous wound\nconditions, we were able to discharge Mr. Havers on 03/12/2017 for\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- Suture material to be shortened on the 14th postoperative day.\n\n- Follow-up appointments in our outpatient clinic\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin Calcium (Lipitor) 21.7 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole Sodium (Protonix) 22.6 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Urea 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Complete Blood Count \\- \\-\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n Erythrocytes 5.2 M/µL 4.3-5.8 M/µL\n Leukocytes 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n INR 0.94 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n\n**Addition: Histology Report:**\n\n[Microscopy:]{.underline} (Hematoxylin and Eosin staining):\nHistologically, infiltrates of a mesenchymal neoplasm can be seen in a\nsection we prepared. Below this are areas estimated to contain 90%\ntumor, which have been selected and labeled for molecular pathological\nanalysis.\n\n[Molecular Pathology:]{.underline} After macrodissection of the marked\ntumor areas from unstained consecutive sections, RNA was extracted and\nanalyzed using focused Next-Generation Sequencing technology. The\nexamination was performed using the FusioPlex Sarcoma v2 Assays, that\nallows for the detection of fusions involving 63 genes.\n\n[Diagnosis:]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma, Grade 1 according to\n FNCLCC (Sum score 2 + 0 + 1 = 3), with the detection of a FUS: DDIT3\n fusion transcript (right adductor compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue.\n\n- In addition to previous reports, myxoid neoplasm is characterized by\n minimal cell density/round cell areas, here less than 25%, according\n to FNCLCC (=2 points for tumor differentiation).\n\n- No evidence of necrosis (=0 points).\n\n- 2 mitotic figures in 10 high-power fields (=1 point).\n\n- Total score is 2 + 0 + 1 = 3, corresponding to Grade 1 according to\n FNCLCC.\n\n[Diagnosis]{.underline}\n\n1. Incisional biopsy from a myxoid liposarcoma (right adductor\n compartment).\n\n2. Predominantly mature fatty tissue as well as fascial tissue\n (subcutaneous).\n\n[Comment]{.underline}: The present biopsy material corresponds to Grade\n1 according to FNCLCC. A supplementary report follows.\n\n**Supplementary Report from: 03/29/2017:**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh. Encapsulated subfascial tumor, palpably indurated.\nAdipose tissue adjacent to the tumor, macroscopically lighter and finer\nthan the subcutaneous adipose tissue towards the skin.\n\n[Material]{.underline}: Microscopy and Molecular Pathology Interphase\nFISH analysis using a two-color break-apart probe to examine a\nchromosomal break in the FUS gene (chromosome 16p11.2) and in the DDIT3\ngene (chromosome 12q13.3-q14.1).\n\nInterphase FISH analysis reveals a specific break event in the FUS gene\n(FUS-FISH positive). This indicates the presence of a FUS translocation.\nSimilarly, in interphase FISH analysis, a specific break event is\ndetectable in the DDIT3 gene (DDIT3-FISH positive), indicating the\npresence of a DDIT3 translocation.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n[Comment]{.underline}: The cytogenetic findings are indicative of a\nmyxoid liposarcoma. Technical validation by RNA sequencing will be\nprovided in a supplemental report. This does not affect the above\ndiagnosis.\n\n**Supplementary Report from: 03/18/2017:**\n\n[Microscopy: MDM2, S100:]{.underline} Partial weak expression of S100\nprotein by the lesional cells, occasionally including pre-existing\nadipocytes. No abnormal expression of MDM2. No abnormal expression of\nMDM2 in mature adipose tissue.\n\n[Diagnosis:]{.underline} Incisional biopsy from a myxoid liposarcoma of\nthe right adductor compartment.\n\nPredominantly mature fatty tissue as well as fascial tissue.\n\n**Main Report from: 03/18/2017**\n\n[Clinical Information:]{.underline} Suspected liposarcoma of the right\nproximal thigh, as per MRI 02/19/2017. Encapsulated subfascial tumor,\npalpably indurated located in the right adductor compartment. Adipose\ntissue adjacent to the tumor, macroscopically lighter and finer than the\nsubcutaneous adipose tissue towards the skin.\n\n[Macroscopy:]{.underline}\n\nTumor: Brown, nodular piece of tissue, 20 x 14 x 10 mm, with smooth and\nrough surface. Cut surface shiny and mottled, sometimes gray, sometimes\nbrown.\n\nSubcutaneous adipose tissue: A piece of adipose tissue, 25 x 20 x 5 mm.\n\n[Microscopy:]{.underline}\n\nModerately cell dense mesenchymal proliferation with a myxoid matrix.\nPredominantly round nuclei, moderately dense nuclear chromatin, slight\npleomorphism. Occasional adipocytic cells with univacuolar cytoplasm.\n\nPartially dense, ribbon-like connective tissue as well as mature\nunivacuolar adipose tissue.\n\n[Diagnosis:]{.underline}\n\nIncisional biopsy suspected of a myxoid liposarcoma. Predominantly\nmature fatty tissue as well as fascial tissue.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient Mr. John Havers, born on\n05/29/1953, who was admitted to our hospital from 03/29/2017 to\n04/05/2017.\n\n**Diagnoses**:\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n- Incisional biopsy on 03/10/2017\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Current Presentation**: Neoplasm of uncertain or unknown behavior.\n\n**Treatment**: On 04/01/2017, en bloc tumor excision with removal of the\nold biopsy scar, partial resection of the M. gracilis, fibers of the M.\nsartorius and M. adductor longus, and ligation of the V. saphena magna\nwas performed.\n\n**Histology from 04/11/2017**\n\nClinical Information: Myxoid liposarcoma, localized in the right thigh.\n\n[Macroscopy Tumor, right thigh]{.underline}: A triple surgical resection\nwas performed, removing skin and subcutaneous tissue and the underlying\nsoft tissue and muscle. The size of the excised skin spindle was 130 x\n45 mm with a resection depth of up to 48 mm. A wound 25 mm long and 6 mm\nwide was noted on the skin surface. The muscle attached\nlaterally/dorsally measured 75 x 25 x 6 mm. Two nodules were noted on\nthe cut surface. The larger nodule, located in the subcutaneous tissue,\nmeasured 33 mm (proximal/distal) x 36 mm (anterior/dorsal) x 30 mm. Its\ndistance from the proximal preparation cap was 26 mm, from the distal\npreparation cap more than 60 mm, from the ventral soft tissue 20 mm, and\nfrom the dorsal soft tissue 3 mm, with less than 1 mm basal extension.\nSuperficially, it was surrounded by a delicate capsule. A separate\nnodule measuring 20 mm (proximal/distal) x 24 mm (ventral/dorsal) x 20\nmm was found immediately ventro-distal to the first nodule. This nodule\nwas located more than 40 mm from the proximal preparation cap, more than\n50 mm from the distal preparation cap, 12 mm ventrally, 11 mm dorsally,\nand 5 mm basally. Consequently, the maximum size of the tumor from\nproximal to distal was 53 mm. No macroscopic necrotic areas were evident\non the cut surface of the nodule. However, partial necrosis of the\nsubcutaneous fatty tissue in the vicinity of the described wound was\nobserved.\n\n[Microscopy HE, PAS:]{.underline} Histomorphologically, there is a\nmoderately cell-dense proliferation with a significant myxoid matrix in\nthe area of the two confluent nodules, with a maximum diameter of 53 mm.\nThere are also areas with relative cell poverty. Within the myxoid\nmatrix, there are blood vessels with a distinct growth pattern referred\nto as the \\\"chicken wire pattern.\\\" No clear tumor necroses are evident.\nThe tumor cell nuclei have a round configuration with moderately dense\nchromatin. Apoptotic figures are increased. The number of mitoses is\nlow.The lesion was completely removed with a minimal margin of 0.5 mm\nfrom the posterior resection edge. In the superficial subcutaneous\ntissue, there is a band-like necrosis directly related to superficial\ngranulation tissue. The included skin spindle shows regular epidermal\ncovering and a largely unremarkable dermis.\n\n[Diagnosis]{.underline}: Skin/subcutaneous excision with a maximum 53 mm\nmyxoid liposarcoma that was completely removed (minimum distance to\nposterior cutoff plane 0.5 mm).\n\n[Comment]{.underline}: In view of the present morphology and knowledge\nof the molecular pathological examination results with proven break\nevents in the FUS gene and DDIT3 gene as part of interphase FISH\nanalysis, the diagnosed condition is myxoid liposarcoma.\n\nAccording to the FNCLCC grading scheme, this corresponds to grade 1:\nHistological type: 2 points + mitotic index 1 point + necrosis index 0\npoints = 3 points.\n\nICD-O-3 tumor classification: Myxoid liposarcoma TNM (8th edition): pT2\npNX L0 V0 Pn0 G1 R0\n\n**Medical History:** We assume that you are familiar with Mr. Havers's\nmedical history, and we refer to our previous correspondence.\n\n**Physical Examination:** Patient in good general condition. Oriented in\nall aspects. No cyanosis. No edema. Warm and dry skin. Normal nasal and\npharyngeal findings. Pupils round, equal, and react promptly to light\nbilaterally. Moist tongue. Pharynx and buccal mucosa unremarkable. No\njugular vein distension. No carotid bruits heard. Palpation of lymph\nnodes unremarkable. Palpation of the thyroid gland unremarkable, freely\nmovable. Lungs: Normal chest shape, moderately mobile, vesicular breath\nsounds.\n\nHeart: Regular heart action, normal rate; heart sounds clear, no\npathological sounds. Abdomen: Peristalsis and bowel sounds normal in all\nquadrants; soft abdomen, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys.\n\nNormal peripheral pulses; joints freely movable. Strength, motor\nfunction, and sensation are unremarkable.\n\n**Therapy and Progression**: The patient presented to our surgical\nclinic because of a mass in the right proximal thigh. The swelling was\nfirst noticed about 3 months ago and has increased significantly in size\nsince then. MRI findings raised suspicion of a liposarcoma. After\nconsultation in the interdisciplinary tumor board, the indication for\nincisional biopsy was performed on 03/10/2017. The histopathological\nexamination confirmed the presence of a myxoid liposarcoma, leading to\nthe decision for en bloc excision. The patient was extensively informed\nabout the procedure and the risks and gave his consent. The patient was\nadmitted for the procedure on 03/29/2017.\n\nUpon clinical examination, a patient in good general and nutritional\ncondition was noted. Other general clinical findings were unremarkable.\nA wound healing disorder of 2 cm was observed in the area of the wound\nafter incisional biopsy.\n\n**Sarcoma Tumor Board Recommendation dated 03/11/2017:** R0 G1 finding,\nstandard sarcoma follow-up.\n\n**Procedure**: Following standard preoperative preparations and informed\nconsent, the aforementioned procedure was performed on 03/01/2017 under\ngeneral anesthesia. The intraoperative and postoperative course was\nuneventful.\n\nOn the first postoperative day, there was slight swelling in the\naffected area, which gradually subsided. Analgesia was sufficient with\nAcetaminophen as needed. Thrombosis prophylaxis was administered with\nsubcutaneous Enoxaparin 0.4 mL. The patient mobilized independently on\nthe ward. The inserted drainage could not be removed so far due to\nexcessive drainage output. During the hospital stay, a staging CT of the\nchest and abdomen was performed. No thoracoabdominal metastases were\ndetected.\n\n**Summary**: With a good subjective well-being and unremarkable wound\nconditions, Mr. Havers was discharged on 04/05/2017 for further\noutpatient care. Clinical examination reveals slight swelling of the\nwound area. The wound is not dehiscent and shows no signs of irritation.\nThe patient is mobilizing independently.\n\n**CT Chest/Abdomen/Pelvis from 04/01/2017: **\n\n[Clinical Information, Question, Justification]{.underline}: Liposarcoma\nof the thigh. Staging.\n\n[Technique]{.underline}: Digital overview radiographs. Following\nintravenous contrast agent administration (100 ml Xenetix), CT of the\nchest and entire abdomen in the venous contrast phase. Reconstruction of\nthe primary dataset with a slice thickness of 0.625 mm. Multiplanar\nreconstruction. Total DLP: 885 mGy\\*cm.\n\n[Findings]{.underline}: There are no prior images available for\ncomparison.\n\n[Chest]{.underline}: Lungs are evenly ventilated and normally developed\nbilaterally. No pneumothorax on either side. Minimal right-sided pleural\neffusion. Mild basilar hypoventilation, particularly in the right lower\nlobe. Calcified granuloma in the apical right lower lobe. No suspicious\npulmonary nodules.\n\nHeart shows enlargement of the left ventricle and left atrium. Coronary\nartery sclerosis. Atherosclerosis of the aortic arch. No pericardial\neffusion. Aorta and pulmonary trunk have normal diameters. No central\npulmonary artery embolism. No pathologically enlarged mediastinal or\nhilar lymph nodes. Symmetric appearance of the neck soft tissues.\nThyroid gland without focal lesions. Axillary lymph nodes are of normal\nsize.\n\n[Abdomen]{.underline}: Liver is of normal size and has a smooth contour.\nNo signs of cholestasis. No portal vein thrombosis. No suspicious\nintrahepatic lesions. Gallbladder appears normal. Common bile duct is\nnot dilated. Spleen is not enlarged. Pancreas shows regular lobulation,\nand there is no dilatation of the pancreatic duct. Both kidneys are free\nfrom urinary tract obstruction. No solid intrarenal masses. Few renal\ncysts. Adrenal glands appear unremarkable. Urinary bladder shows no\nfocal wall thickening. Prostate is not enlarged. Advanced\natherosclerosis of the abdominal aorta and pelvic vessels. History of\nstenting of the left external iliac artery with no reocclusion.\nMesenteric, para-aortic, and parailiac lymph nodes are not\npathologically enlarged. No free intraperitoneal fluid or air is\ndetected. Osseous Structures: Degenerative changes in the spine. No\nevidence of suspicious osseous destruction suggestive of tumors. Soft\ntissue mantle appears unremarkable.\n\n**Assessment**: No thoracoabdominal metastases.\n\n**Current Recommendations**:\n\n- Regular wound inspections and dressing changes.\n\n- Documentation of drainage output and removal if the output is \\<20\n ml/24 hours, expected removal on 04/23/2017 at our outpatient\n clinic.\n\n- Removal of sutures is not required for absorbable sutures.\n\n- According to the tumor board decision dated 04/11/2017, we recommend\n regular follow-up according to the schedule.\n\n**Sarcoma Follow-up Schedule Stage I**\n\n- Local Follow-up:\n\n 1. MRI right thigh: Years 1-5: every 6 months\n\n 2. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 3. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 4. Years 6-10: every 12 months in alternation\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------------------- ------------ -------------------\n Aspirin 100 mg 1-0-0-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Enoxaparin (Lovenox) Variable 0-0-1-0\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin Hydrochloride (Glucophage) 1000 mg 1-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Acetaminophen (Tylenol) 500 mg 2-2-2-2 if needed\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ------------------------------------------- ------------- ---------------------\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.74 mg/dL 0.70-1.20 mg/dL\n Blood Urea Nitrogen 33 mg/dL 17-48 mg/dL\n C-Reactive Protein 1.7 mg/dL \\< 5.0 mg/dL\n Thyroid-Stimulating Hormone 3.58 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 16.5 g/dL 13.5-17.0 g/dL\n Hematocrit 49.3% 39.5-50.5%\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.63 K/µL 3.90-10.50 K/µL\n Platelets 301 K/µL 150-370 K/µL\n Mean Corpuscular Volume 95.7 fL 80.0-99.0 fL\n Mean Corpuscular Hemoglobin 32.0 pg 27.0-33.5 pg\n Mean Corpuscular Hemoglobin Concentration 33.5 g/dL 31.5-36.0 g/dL\n Mean Platelet Volume 10.4 fL 7.0-12.0 fL\n Red Cell Distribution Width 12.1% 11.6-14.4%\n Activated Partial Thromboplastin Time 32.4 sec 25.0-38.0 sec\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented to our outpatient surgery clinic on\n04/23/2017.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Allergies**: Hay fever\n\n**Medical History:** We kindly assume that you are familiar with the\npatient\\'s detailed medical history and refer to our previous discharge\nletter.\n\n**Current Presentation:** The patient presented today for a follow-up\nvisit in our clinic. He reported no complaints. The Redon drain has not\nproduced any secretions in the last 2 days.\n\nClinical examination revealed uneventful wound conditions with applied\nSteri-strips. There is no evidence of infection. The Redon drain\ncontains serous wound secretions.\n\nProcedure: The Redon drain is being removed today. With nearly fully\nhealed wound conditions, we recommend initiating scar massage with fatty\ntopical products in the near future.\n\n**MRI of the Right Thigh on** 04/23/2017**:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB. Recurrence? Regional behavior? Lymph nodes?\n\n[Technique]{.underline}: 3 Tesla MRI of the right thigh, both plain and\nafter the administration of 8 ml of Gadovist intravenously. Supine\nposition, surface coil.\n\nSequences: TIRM coronal and axial, T2-TSE coronal and axial, T1 VIBE\nDixon axial, EPI-DWI with ADC map axial, T1-Starvibe vascular images\nplain and post-contrast axial with subtraction images, T1-TSE FS\npost-contrast coronal.\n\n[Findings]{.underline}: Minor FLAIR hyperintense streaky signal\nalteration in the surgical area, most likely scar-related, with slight\ndiffusion restriction and streaky contrast enhancement. No evidence of a\nrecurrent suspicious substrate. No nodular contrast enhancement.\nSlightly accentuated inguinal lymph nodes on the right, most likely\nreactive. Unremarkable visualization of the remaining soft tissue.\nNormal bone marrow signal. Bladder filled. Unremarkable representation\nof the imaged pelvic organs.\n\n[Assessment]{.underline}: Following the resection of a myxoid\nliposarcoma on the right medial thigh, there is a regular postoperative\nfinding. No indication of local recurrence.\n\n**Chest X-ray in Two Planes on 04/23/2017: **\n\n[Clinical Background, Question, Justification]{.underline}: Myxoid\nliposarcoma of the right thigh, initial diagnosis in 2022. Follow-up.\nMetastases?\n\n[Findings]{.underline}: No corresponding prior images for comparison.\nThe upper mediastinum is centrally located and not widened. Hila are\nfree. No acute congestion. No confluent pneumonic infiltrate. No\nevidence of larger intrapulmonary lesions. A 7 mm spot shadow is noted\nright suprahilar, primarily representing a vascular structure. No\neffusions. No pneumothorax.\n\n**Current Recommendations:** The patient would like to continue\nfollow-up care with us, so we scheduled an MRI control appointment to\nassess the possibility of local recurrence. On this day, a two-view\nchest X-ray is also required.\n\n**We recommend the following follow-up schedule:**\n\n- Local Follow-up:\n\n 5. MRI right thigh: Years 1-5: every 6 months\n\n 6. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 7. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 8. Years 6-10: every 12 months in alternation\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who presented for tumor follow-up on 02/10/2018, in our\noutpatient surgery clinic for a discussion of findings.\n\n**Diagnosis**: Myxoid liposarcoma on the right medial thigh, pT2 pNX L0\nV0 Pn0 G1 R0, Stage IB\n\n- Following incisional biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus\n\n- Coronary artery disease with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a regular postoperative finding on the\nright thigh.\n\nThe control MRI with contrast of the right thigh on 04/23/2017 revealed\nmorphologically:\n\n- No evidence of a local-regional recurrence.\n\n- In pulmonary follow-up using conventional chest X-ray on 04/23/2017,\n no signs of pulmonary metastasis were detected.\n\n**Current Recommendations:** Sarcoma Follow-up Schedule Stage I\n\n- Local Follow-up:\n\n 9. MRI right thigh: Years 1-5: every 6 months\n\n 10. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 11. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 12. Years 6-10: every 12 months in alternation\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting to you on our patient Mr. John Havers, born on\n05/29/1953, who presented himself on **08/01/2018** at our outpatient\nsurgery clinic for a discussion of findings as part of tumor follow-up.\n\n**Diagnosis**: Myxoid liposarcoma, right medial thigh, pT2 pNX L0 V0 Pn0\nG1 R0, Stage IB\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Summary**: Clinically, there is a normal postoperative condition in\nthe right thigh.\n\n**MRI of the Right Thigh on 08/01/2018:**\n\n[Clinical Background, Question, Justification:]{.underline} Sarcoma\nfollow-up for myxoid liposarcoma on the right medial thigh. Progress\nassessment.\n\n[Method]{.underline}: 1.5 Tesla. Localization sequences. TIRM and T2 TSE\ncoronal. TIRM, T2 TSE, VIBE DIXON, and RESOLVE-DWI axial. StarVIBE FS\nbefore and after contrast + subtraction. T1 TSE FS coronal after\ncontrast.\n\n[Findings]{.underline}: Comparison with MRI from 04/23/2017.\nPost-resection of a myxoid liposarcoma in the proximal medial right\nthigh soft tissue. In the surgical area, there is no evidence of a\nsuspicious nodular, contrast-affine lesion, and no evidence of\nmalignancy-suspected diffusion restriction. Slight scar-related changes\nin the access path. Otherwise, unremarkable presentation of soft tissues\nand included bony structures. No inguinal lymphadenopathy. Assessment:\nFor myxoid liposarcoma, there has been consistent evidence since\n02/2018:\n\n**Chest CT on 08/01/2018**:\n\n[Clinical Background, Question, Justification: Liposarcoma on the thigh.\nStaging.]{.underline} After risk history assessment, oral and written\nexplanation of contrast agent application and examination procedure, as\nwell as potential risks of the examination (see also informed consent\nform). Written patient consent.\n\n[Method]{.underline}: Digital overview radiographs. After intravenous\ncontrast agent administration (80 ml of Imeron), CT of the chest in\nvenous contrast phase, reconstruction of the primary dataset with a\nslice thickness of 0.625 mm. Total DLP 185 mGy\\*cm.\n\n[Findings]{.underline}: For comparison, there is a CT of the\nchest/abdomen/pelvis from 04/01/2018. No evidence of suspicious\npulmonary nodules. Several partly calcified micronodules bipulmonary,\nespecially in the right lower lobe (ex. S303/IMA179). Partial\nunderventilation bipulmonary. No pleural effusion. No evidence of\npathologically enlarged lymph nodes. Constant calcified right hilar\nlymph nodes. Calcifying aortic sclerosis along with coronary sclerosis.\nHepatic steatosis. Individual renal cysts. Slightly shrunken left\nadrenal gland. Degenerative changes of the axial skeleton without\nevidence of a malignancy-suspected osseous lesion.\n\n[Assessment]{.underline}: No evidence of a new thoracic tumor\nmanifestation.\n\n**Recommendations:** Sarcoma Follow-up\n\n- Local Follow-up:\n\n 13. MRI right thigh: Years 1-5: every 6 months\n\n 14. Years 6-10: every 12 months\n\n- Pulmonary Follow-up:\n\n 15. Chest X-ray, CT chest with contrast agent Years 1-5: every 6\n months in alternation\n\n 16. Years 6-10: every 12 months in alternation\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------------- ------------- ---------------------\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.9 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.81 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 38 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.6 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.7 g/dL 13.5-17.0 g/dL\n Hematocrit 49.5% 39.5-50.5%\n RBC 5.2 M/µL 4.3-5.8 M/µL\n WBC 10.07 K/µL 3.90-10.50 K/µL\n Platelets 167 K/µL 150-370 K/µL\n MCV 95.4 fL 80.0-99.0 fL\n MCH 32.2 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 11.7 fL 7.0-12.0 fL\n RDW-CV 12.6% 11.5-15.0%\n Prothrombin Time 120% 78-123%\n International Normalized Ratio (INR) 0.94 0.90-1.25\n Activated Partial Thromboplastin Time (aPTT) 30.1 sec 25.0-38.0 sec\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on our patient Mr. John Havers, born\non 05/29/1953, who was admitted to our clinic from 08/14/2023 to\n09/02/2023.\n\n**Diagnosis:** Pulmonary Metastasis from Myxoid Liposarcoma\n\n- Myxoid liposarcoma on the right medial thigh, pT2 pNX L0 V0 Pn0 G1\n R0, Stage IB\n\n<!-- -->\n\n- Post-incision biopsy\n\n- After en bloc tumor excision with removal of the previous biopsy\n scar, partial resection of the gracilis, sartorius and adductor\n longus muscles and ligation of the great saphenous vein.\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Non-insulin-dependent diabetes mellitus (NIDDM)\n\n- Coronary artery disease (CAD) with stent placement\n\n- Nicotine abuse (80-100 pack-years)\n\n- Arterial hypertension\n\n- Status post apoplexy\n\n- Status post cataract surgery\n\n- Status post right hip total hip replacement (THR)\n\n- Status post Polypectomy for polyposis coli (minimal dysplasia)\n\n- Status post appendectomy\n\n- M. Meniere\n\n**Medical History:** Mr. Havers has been under our care for myxoid\nliposarcoma, which was previously excised from his right medial thigh.\nHe had a stable postoperative course and was scheduled for regular\nfollow-up to monitor for any potential recurrence or metastasis.\n\n**Current Presentation:** During a follow-up appointment on 08/14/2023,\nMr. Havers complained of mild shortness of breath, occasional coughing,\nand intermittent chest discomfort. He reported no significant weight\nloss but noted a decrease in his overall energy levels. Physical\nexamination revealed decreased breath sounds in the right lung base.\n\n**Physical Examination:** Patient in adequate general condition.\nOriented in all aspects. No cyanosis. No edema. Warm and dry skin.\nNormal nasal and pharyngeal findings. Pupils round, equal, and react\npromptly to light bilaterally. Moist tongue. Pharynx and buccal mucosa\nunremarkable. No jugular vein distension. No carotid bruits heard.\nPalpation of lymph nodes unremarkable. Palpation of the thyroid gland\nunremarkable, freely movable. Lungs: Normal chest shape, moderately\nmobile, decreased breath sounds in the right lung base. Heart: Regular\nheart action, normal rate; heart sounds clear, no pathological sounds.\nAbdomen: Peristalsis and bowel sounds normal in all quadrants; soft\nabdomen, markedly obese, no tenderness, no palpable masses, liver and\nspleen not palpable due to limited access, non-tender kidneys. Normal\nperipheral pulses; joints freely movable. Strength, motor function, and\nsensation is unremarkable.\n\n**Chest X-ray (08/14/2023):** A chest X-ray was performed, which\nrevealed a suspicious opacity in the right lower lung field.\n\n**CT Chest (08/16/2023):** In light of the chest X-ray findings, a\ncontrast-enhanced CT scan of the chest was conducted to obtain more\ndetailed information. The CT imaging demonstrated a well-defined,\nirregularly shaped lesion in the right lower lobe of the lung, measuring\napproximately 2.5 cm in diameter. The lesion exhibited characteristics\nhighly suggestive of a metastatic deposit. There were no other\nsignificant abnormalities noted in the chest.\n\n**Histology (08/21/2023):** Based on the CT findings, a CT-guided core\nneedle biopsy of the pulmonary lesion was performed to confirm the\nnature of the lesion. Histopathological examination of the biopsy\nspecimen confirmed the presence of myxoid liposarcoma cells in the\npulmonary lesion. Immunohistochemical staining for MDM2 and CDK4\nsupported the diagnosis of metastatic myxoid liposarcoma.\n\n**Treatment Discussion:** Given the diagnosis of a pulmonary metastasis\nfrom myxoid liposarcoma, the case was reviewed in the interdisciplinary\ntumor board. The consensus decision was to pursue surgical resection of\nthe pulmonary metastasis, as it remained localized and resectable. The\npatient and his family were informed of the treatment options and\nassociated risks, and they provided informed consent for the procedure.\n\n**Surgery Report (08/29/2023):** Mr. Havers underwent a right lower\nlobectomy with lymph node dissection to remove the pulmonary metastasis.\nThe procedure was performed by our thoracic surgery team and was\ncompleted without any immediate complications. Intraoperative frozen\nsection analysis confirmed the presence of metastatic myxoid liposarcoma\nin the resected lung tissue.\n\n**Postoperative Course:** Mr. Havers postoperative course was\nuneventful, and he demonstrated good respiratory recovery. He was\nmanaged with adequate pain control and underwent chest physiotherapy to\nprevent postoperative complications. Pathological examination of the\nresected lung tissue confirmed the presence of metastatic myxoid\nliposarcoma, with clear surgical margins.\n\n**Current Recommendations:**\n\n1. **Follow-up:** A strict follow-up plan should be established for Mr.\n Havers to monitor for any potential recurrence or new metastatic\n lesions. This should include regular clinical assessments, chest\n imaging, and other relevant investigations.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------------------- ------------ ---------------\n Empagliflozin (Jardiance) 10 mg 1-0-0-0\n Metformin (Glucophage) 1000 mg 1-0-1-0\n Atorvastatin (Lipitor) 20 mg 0-0-1-0\n Metoprolol Tartrate (Lopressor) 50 mg 0.5-0-0.5-0\n Aspirin 100 mg 1-0-0-0\n Pantoprazole (Protonix) 20 mg 1-0-0-0\n\n**Lab results upon Discharge: **\n\n **Parameter** **Results** **Reference Range**\n --------------------- ------------- ---------------------\n Sodium 135 mEq/L 136-145 mEq/L\n Potassium 4.4 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.82 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\- \\-\n Blood Urea Nitrogen 39 mg/dL 17-48 mg/dL\n C-Reactive Protein 2.5 mg/dL \\< 5.0 mg/dL\n Hemoglobin 16.6 g/dL 13.5-17.0 g/dL\n Hematocrit 49.4 % 39.5-50.5 %\n RBC 5.1 M/µL 4.3-5.8 M/µL\n WBC 10.04 K/µL 3.90-10.50 K/µL\n Platelets 166 K/µL 150-370 K/µL\n MCV 95.2 fL 80.0-99.0 fL\n MCH 32.6 pg 27.0-33.5 pg\n MCHC 33.2 g/dL 31.5-36.0 g/dL\n MPV 11.4 fL 7.0-12.0 fL\n RDW-CV 12.5 % 11.5-15.0 %\n Prothrombin Time 122 % 78-123 %\n INR 0.99 0.90-1.25\n aPTT 30.1 sec 25.0-38.0 sec\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n\n\n\n\nHere is the query:\nWhat is the initial imaging finding suggestive of tuberculosis in Mr. Hurley?\n\nChoose the correct answer from the following options:\nA. Splenomegaly\nB. Mediastinal lymph node conglomerate\nC. Liver tuberculosis\nD. Bronchial and vascular stenosis\nE. Neck/Thorax CT showing regression of pulmonary infiltrates\n\n\nYour response:\n", "role": "user" }, { "content": "Mediastinal lymph node conglomerate", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nPatient: Miller, John, born 04/07/1961\n\nWe report to you about our common patient, Mr. John Miller, who is in\nour inpatient treatment since 07/30/2019.\n\n**Diagnoses:**\n\n\\- Suspected right cerebral glioblastoma (first diagnosis)\n\n\\- Symptoms: Aphasia, passive confusion\n\n**Patient history: **\n\nMr. Miller was admitted as an emergency. He was on the phone with a\nfriend when he suddenly began to exhibit speech difficulties and\nstruggled to find the right words. Consequently, his friend called 911.\n\nUpon the ambulance\\'s arrival, Mr. Miller was disoriented and exhibited\naggressive behavior. There was evidence of a torn door. He had blood on\nhis right forearm and around his mouth, but there were no indications of\na tongue bite or urinary incontinence.\n\nUpon admission, Mr. Miller was coherent and showed no speech issues. He\nattributed a mild weakness in his right arm to pre-existing pain in the\nupper arm. An immediate CT scan revealed a mass suggestive of a\nglioblastoma in the right cerebral hemisphere, leading to a\nneurosurgical consultation.\n\nGiven the possibility of an epileptic seizure, Mr. Miller was\nhospitalized and started on Levetiracetam. He is currently unaware of\nhis regular medications but takes antihypertensives and diabetes\nmedications, among others. His friend and brother have been notified and\nare ensuring that a detailed medication list is provided.\n\nAfter a brief stay in ward ABC, Mr. Miller was transferred to the\nneurosurgery team for further evaluation and treatment. We appreciate\nthe prompt transfer and are available for any further inquiries.\n\nPlanned Procedures:\n\n-Schedule EEG\n\n-Clarify routine medications\n\n**Surgery Report**\n\n**Diagnosis:** Suspected HGG (high-grade glioma) of the right hemisphere\n\n**Procedure:** Microsurgical navigation-guided resection of the tumor\nwith intraoperative neuromonitoring (stable MEPs) and intraoperative MRI\nusing 5-ALA. Pathology samples taken (Preliminary: HGG; Final to be\nconfirmed). Resection was followed by duragen placement, watertight\ndural closure, and multilayer wound closure, with skin sutures.\n\n**Time:**\n\n-Start: 11:12 am\n\n-Finish: 3:54 pm\n\n-Duration: 4 hours 42 minutes\n\n**Assessment:**\n\nMr. Miller presented with a seizure characterized by speech disturbance\nand disorientation. Imaging revealed a significant right hemispheral\nmass, likely representing a high-grade brain tumor. The need for\nsurgical resection was determined following discussions at our\ninterdisciplinary tumor board. After being informed about the procedure,\nalternative treatments, the operation\\'s urgency, benefits, and\npotential risks, Mr. Miller provided written consent following ample\ntime for consideration and the opportunity to ask further questions.\n\n**Procedure Details:**\n\nThe patient was positioned supine with his head secured in a Nova clamp.\nNavigation data were read, followed by skin preparation, and the\nsurgical field was sterilized and draped. An arch-shaped incision was\nmade, followed by hemostasis, deep tissue dissection, placement of a\nburr hole, and the creation of a large bone flap over the lesion. The\nbone flap was then elevated. Multiple washings were performed, followed\nby dural opening under microscopic visualization. A corticotomy was\ncarried out with bipolar forceps, CUSA, and suction to progressively\nreduce the tumor, utilizing 5-ALA fluorescence and continuous\nneurophysiological monitoring. An intraoperative MRI showed residual\ntumor, prompting further resection. Hemostasis was achieved, and the\nwound was closed using tabotamp, followed by duragen placement and dural\nsuturing. The bone flap was refixed using Dogbone plates. The wound area\nwas irrigated extensively once more, followed by subcutaneous and skin\nsutures.\n\n**Date:** 10/01/2019\n\n**Clinical Indication:**Suspected recurrence of GBM in the right\nhemisphere\n\n**Requested Imaging:**cMRI with or without contrast + DTI.\n\n**Findings:***Imaging Modality (GE 3.0T):* 3D FLAIR, DTI, SWI, T2\\*\nperfusion, 3D T1 with and without contrast, 3D T2,\nsubtraction.Following resection of a right hemispheric glioblastoma in\n08/19, and compared to the last two scans (external: 07/19, internal:\n08/19), there is a notable expansion of the prior detected flair\nhyperintense regions. These now span from the right parietal-subcortical\narea across the right basal ganglia to the right temporo-occipital/right\ntemporal pole. Specifically, at the dorsocranial edge of the resection\ncavity, the hyperintense regions appear to have grown since 08/19. These\ncoincide with hyperperfused regions in the T2\\* perfusion. Linear SWI\nsignal changes are suggestive of mild post-surgical bleeding. No\nsignificant postoperative hemorrhage or territorial ischemia is\ndetected. A normal venous sinus drainage is observed. Right temporal\nhorn appears congested, possibly due to CSF trapping.\n\n**Assessment:**\n\nFollowing the resection of the right hemispheric glioblastoma in 08/19:\n\n-Markedly progressive flair edema and evolving barrier disturbance.\nRegions especially towards the dorsal side of the resection cavity show\nthis alongside associated hyperperfusion. With the recent PET imaging\nfrom 10/19, there is an indication of progressive disease as per RANO\ncriteria.\n\n-Long-term progressive congestion of the right temporal horn, likely CSF\ntrapping.\n\n**Surgery Report****Diagnosis:**Tumor recurrence after resection of a\nglioblastoma (IDH wild type, WHO CNS grade 4) of the right hemisphere in\n08/2019. The patient underwent combined radiochemotherapy at the local\nclinical center.\n\n**Procedure:**Navigated, microsurgical resection supported by 5-ALA,\nwith stable MEPs through the previous right temporal access. iMRI\nconducted between 11:10 and 11:50. Used Duragen/TachoSil, dog bones for\nclosure, followed by layered wound closure and skin sutures.\n\n**Timing:**\n\n-Incision: 09:23 am on 10/12/19\n\n-Suture: 12:32 pm on 10/12/19\n\n**Assessment:**The patient had previously undergone surgery for a\nglioblastoma and a recurrence was detected on imaging. The tumor board\nhad already deliberated on the surgery. The patient was informed about\nthe surgical procedure, particularly about conducting an extensive\nresection caudally without impacting function post-mapping. The patient\nconsented, understanding the potential for longer progression-free\nsurvival.\n\n**Procedure Details:**The patient was placed in a supine position with\nthe head turned to the side and fixed using the Noras clamp. The right\nshoulder was padded. The surgical area was prepared by trimming hair\naround the previous scar, followed by sterilization and draping. After a\nteam time-out, prophylactic antibiotics were administered. The previous\nscar was reopened and old plates were removed. The microscope was then\nswung into position and the dura was opened. Navigation proceeded\nbeneath the labbé vein, with tumor resection as guided by ALA\nfluorescence. Post-tumor removal, extensive hemostasis was achieved\nusing absorbent cotton and TABOTAMP. Intraoperative MRI confirmed a\ncomplete resection of the tumor. The dura was sealed using DuraGen,\nensuring a watertight closure. The bone flap was reinserted, followed by\nsubcutaneous suturing, skin suturing, and sterile dressing of the wound.\n\n\n\n\n### text_1\n**Dear colleague, **\n\nWe write to update you regarding our shared patient, Mr. John Miller,\nborn on 07/04/1961, who visited us on 12/02/2019.\n\n**Diagnosis:**Glioblastoma recurrence, IDH 1 wild type.\n\n**Tumor Location:**Right hemisphere including temporal regions.\n\n**Clinical History & Treatment:**\n\n-07/2019: Mr. Miller experienced speech disturbances and confusion.\n\n-08/01/2019: Brain PET-MRI revealed a suspected malignancy in the right\nhemisphere, including temporal areas.\n\n-08/11/2019: Glioblastoma was resected at our facility.\n\n-08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy\nwith a boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local\nclinical center.\n\n-10/01/2019: cMRI with suspected recurrence.\n\n-10/12/2019: A recurrent resection was performed at our facility.\n\n-11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n**Recent Evaluation (12/01/2019):**Mr. Miller visited our facility with\nhis brother. Our assessment, based on CTCAE criteria, indicated that he\nis in a fair but stable general and nutritional health (KPS 70-80%,\nweight undisclosed, height 175 cm). Neurological and general evaluations\nrevealed a degree of aphasia, mainly with word-finding difficulty, and\nshort-term memory impairment. However, he remains fully oriented and\nindependent in daily life.\n\n**Additional Observations:**\n\nHis surgical wound has healed well.\n\n**Pre-existing Conditions:** Arterial hypertension, Diabetes Mellitus\nType II\n\n**Allergies:** None\n\n**Current Medications:** Antihypertensive drugs and insulin.\n\nPostoperatively, Mr. Miller remains in good health. A recent brain MRI\nnoted that the suspected recurring GBM lesion near the superior border\nof the surgical site was entirely resected. Furthermore, CT scans at the\nanterior medial and lateral edges suggest that a complete resection was\nmost likely achieved.\n\nGiven the presumed complete resection of the glioblastoma recurrence, we\nhave recommended Mr. Miller for a neuro-oncology review and a follow-up\nwith PET-MRI in three months.\n\n**Next Steps:**\n\n-He has a scheduled appointment in neuro-oncology on 01/23/2020 at 10:00\nAM.\n\n-A follow-up PET-MRI is set for 01/29/2020 at 12:45 PM. We have advised\nMr. Miller to fast for 4 hours prior and to bring a referral from his\nprimary care physician, along with a recent creatinine test result.\n\n-A review of these findings will be held in our outpatient department on\n01/30/2020 at 2:00 PM.\n\nThank you for your continued care and collaboration. Please do not\nhesitate to reach out for any additional information.\n\nWarm regards,\n\n\n\n### text_2\n**Dear colleague, **\n\nRegarding our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nGlioblastoma recurrence, IDH 1 wild type\n\n**Tumor Location**:\n\nRight hemisphere/temporal.\n\n**Medical History**:\n\n07/2019: Onset of speech arrest and confusion.\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\nMr. Miller came in on 12/01/2019 with his brother. Clinical examination\nfindings are as follows:\n\n-General health: Stable with reduced vitality.\n\n-Nutritional status: Stable (KPS 70-80%, weight in kg, height 169 cm).\n\n-No evident motor, sensory, visual, or cranial nerve deficits.\n\n-Neurocognitive deficits: Short-term memory issues.\n\n-Aphasia: Grade II (mainly word-finding disorders). The patient is fully\noriented and independent in daily life.\n\n-No evidence of recurrence in PET-MRI. Next imaging scheduled in\n03/2020.\n\n**Past Medical Conditions**:\n\n-Hypertension\n\n-Type II Diabetes Mellitus\n\n**Allergies**: None.\n\n**Medications**:\n\n-Antihypertensive medications\n\n-Insulin\n\nBest Regards,\n\n\n\n\n### text_3\n**Dear colleague, **\n\nUpdating you on our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nRecurrent Glioblastoma, IDH 1 wild type (ICD-10: 71.8).\n\n**Molecular Pathology**:\n\nNo p.R132H mutation in IDH.\n\nNo combined 1p/19q loss.\n\nSuspected CDKN2A/B deletion.\n\n**Medical History**:\n\nNo pain or B symptoms.\n\nIntermittent dizziness and headaches since the last check-up.\n\n**Neurological Findings**:\n\nPatient is alert and oriented.\n\nWeight: 80 kg (total loss: 15 kg), Height: 175 cm.\n\nKarnofsky Performance Score: 80%.\n\nMotor function and sensory assessments were unremarkable.\n\n**Allergies**: None.\n\n**Medications**:\n\nLisinopril 10mg once daily in the morning\n\nBisoprolol 2.5mg once daily at bedtime\n\nJanuvia 50mg twice daily\n\nAllopurinol 100mg once daily in the morning\n\nEzetimibe 10mg once daily at bedtime\n\nLevetiracetam 1000mg once daily in the morning Insulin as per regimen\n\n**Secondary Diagnoses**:\n\nHypertension\n\nType II Diabetes Mellitus\n\n**Medical Course**:\n\nDetails from 07/2019 through 03/2020 provided, including surgeries,\nradiochemotherapies, and diagnostics.\n\nIn summary, Mr. Miller\\'s glioblastoma diagnosis in 07/2019 led to\nvarious treatments, including radiochemotherapy and surgeries. His\nrecent PET/MRI on 01/2020 indicates potential recurrent areas.\n\nBest regards,\n\n**Patient:** John Miller\n\n**DOB:** 04/07/1961\n\n**Admission Date:** 04/11/2020\n\n**Discharge Date:** 04/18/2020\n\n**Admission Diagnosis:**\n\nRecurrent tumor in the hippocampal region and along the prior resection\ncavity.\n\nHistory of glioblastoma (IDH wild type, WHO CNS grade 4) in the right\nhemisphere, resected on 08/2019.\n\nHistory of combined radiochemotherapy with Temodar (Temozolomide) from\nAugust to September 2019 at the local clinical center.\n\nSubsequent first re-resection in 10/2019.\n\n**Presenting Complaint:**\n\nMr. Miller presented to the neurosurgical outpatient department\naccompanied by his wife. Recent imaging indicated a potential recurrence\nof the glioblastoma. The neuro-oncological board on 04/12/2020\nrecommended a re-resection.\n\n**Physical eon Admission:**\n\nAlert, oriented x4, cooperative.\n\nNon-fluent aphasia.\n\nCranial nerves intact.\n\nNo sensory or motor deficits in the extremities.\n\nSurgical scar clean and dry.\n\nNo signs of neurogenic bladder or rectal dysfunction.\n\nKPSS 70%.\n\n**Medications on Admission:**\n\n-Lisinopril 10mg daily\n\n-Bisoprolol 2.5mg nightly\n\n-Januvia 50mg twice daily\n\n-Allopurinol 100mg daily\n\n-Atorvastatin 40mg nightly\n\n-Ezetimibe 10mg nightly\n\n-Levetiracetam 1000mg twice daily\n\n-Actraphane insulin as prescribed\n\n**Surgical Intervention (04/12/2020):**\n\nNavigated microsurgical resection of tumor spots assisted with 5-ALA.\nStable MEPs were maintained. An intraoperative MRI (iMRI) was utilized.\nPost-resection, the surgical area was managed using Tabotamp, Duragen,\nTachoSil, and dog-bone plates, concluding with layered wound closure.\n\n**Postoperative Course:**\n\nUncomplicated recovery.\n\nPost-op MRI showed no residual tumor.\n\nSurgical site remained clean, dry, and showed no signs of infection or\nirritation.\n\n**Discharge Diagnosis:**\n\nRecurrence of known glioblastoma, WHO CNS grade 4.\n\n**Interdisciplinary Neuro-oncological Tumor Board Recommendation\n(04/20/2020):**\n\nMolecular tumor board review.\n\nOffer reinitiation of Temozolomide chemotherapy.\n\n**Physical Examination on Discharge:**\n\nSimilar to admission, with suture in place and wound site in good\ncondition.\n\nKPSS 70%.\n\n**Medications on Discharge:**\n\n-Allopurinol 100mg daily (morning)\n\n-Atorvastatin 40mg nightly (evening)\n\n-Bisoprolol 2.5mg nightly (evening)\n\n-Ezetimibe 10mg nightly (evening)\n\n-Sitagliptin (Januvia) 50mg twice daily (morning and evening)\n\n-Levetiracetam (Keppra) 1000mg twice daily (morning and evening)\n\n-Lisinopril 10mg daily (morning)\n\n-Acetaminophen 500mg as needed for pain or fever\n\n-Actraphane insulin as prescribed\n\n**Surgery Report **\n\n**Diagnosis**:\n\nTumor recurrence in the right hippocampal region and along the resection\ncavity post glioblastoma resection on 8/11/2019.\n\nPrevious treatments include radiochemotherapy at our clinic. Local\ntherapy center (from August to September 2019) and re-resection on\n10/12/2019.\n\n**Surgery Type**:\n\nRe-opening of the temporal region with navigation, microsurgery using\n5-ALA assistance, iMRI, and re-resection, among other procedures.\n\n**Procedure Details**:\n\nStart: 11:50 pm on 04/12/2020\n\nEnd: 4:00 pm on 04/12/2020\n\nDuration: 4 hours 10 minutes.\n\n**Assessment**:\n\nEvidence of recurrent glioblastoma areas warranted another biopsy and\nresection. After informing Mr. Miller about the procedure\\'s risks and\nbenefits, he provided written consent.\n\n**Operation**:\n\nDetails on the positioning, pre-operative preparations, resection, and\npost-operative procedures are provided.\n\nBest regards,\n\nMEDICAL HISTORY:\n\nMr. Miller underwent surgery because of tumor recurrence in the right\nhemisphere last November to treat a right temporal glioblastoma. He\npresented to our private outpatient clinic due to a wound complication,\nspecifically a wound dehiscence measuring about 1 cm. On closer\nexamination, pus was noted. Despite being symptom-free otherwise, a\nconsultation with Dr. Doe was scheduled. After discussion, it was\ndecided to clean the wound, trim the deteriorated wound edges, and clean\nthe bone flap with an antibiotic solution before reinserting it. The\npatient was thoroughly educated about the nature and risks of the\nprocedure and gave consent.\n\nOPERATION:\n\nThe patient was placed in a supine position. The hair surrounding the\nsurgical site was trimmed, followed by skin disinfection and sterile\ndraping. The bicoronal skin incision was reopened. Deteriorated wound\nedges were excised and the wound was extensively cleaned with\nirrigation. The bone flap was removed and immersed in a Refobacin\nsolution. The epidural pannus tissue was removed. The dura was\ncompletely sutured. Multiple samples were collected both subgaleally and\nepidurally. A sponge was applied, followed by the reinsertion of the\nbone flap using a dog bone miniplate fixation and local application of\nvancomycin powder. A subgaleal drain was placed, and the skin was closed\nusing Donati continuous sutures. A sterile staple dressing was applied,\nand the patient was transferred to recovery.\n\nCLINICAL NOTES:\n\nEpidural pannus suggestive of infection. Past surgical history includes\nglioblastoma removal in 8/11/2019 and subsequent surgeries because of\nrecurrence, the last of these in 04/12/2020. Nature and type of growth?\n\nMACROSCOPIC EXAMINATION:\n\nFixed tissue samples measuring 1.2 x 1.0 x 0.4 cm were entirely\nembedded.\n\nSTAINING: 1 block, Hematoxylin & Eosin (HE), Periodic Acid Schiff (PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology shows entirely necrotic tissue and some bony fragments. No\nmicroorganisms were detected in the PAS stain.\n\nFINDINGS:\n\nFully necrotic tissue. No signs of inflammation or malignancy in the\navailable samples.\n\nOPERATIVE REPORT:\n\nDiagnosis: Wound healing disruption high on the forehead, following a\nresection of recurrent gioblastoma in the right hemisphere in\n04/12/2020.\n\nProcedure: Wound revision, thorough wound cleaning, reinsertion of the\nautologous bone flap.\n\nTime of incision: 3:30 PM, 06/01/2020\n\nTime of suture completion: 4:35, 06/01/2020\n\nDuration: 65 minutes\n\nPATIENT HISTORY:\n\nThe patient had two prior surgeries with our team. The most recent was a\nrevision due to a wound healing complication. The patient was informed\nabout the procedure\\'s nature, extent, risks, and potential outcomes,\nand was given ample opportunity to ask questions. After thoughtful\nconsideration, written consent was obtained.\n\nOPERATION:\n\nThe patient was positioned supine with the head in a neutral position.\nThe surgical area was sterilized and draped. Antibiotic prophylaxis was\nadministered, and a timeout procedure was conducted. The old wound was\nreopened and slightly extended by about 1 cm in both directions. The\nbone flap was removed, inspected, and cleaned. It was then reinserted\nafter refreshing the bone edges. The wound edges were refreshed, and the\nwound was irrigated again before closure.\n\nSUMMARY:\n\nSuccessful wound revision without complications for a wound healing\ncomplication post-glioblastoma surgery.\n\nCLINICAL NOTES:\n\nComplication in wound healing after glioblastoma removal and radiation\ntherapy. Possible inflammation? Evaluate for pus. Nature and type of\ngrowth?\n\nMACROSCOPIC EXAMINATION:\n\nSubcutaneous tissue samples, 1.2 x 1.0 x 0.4 cm, were completely\nembedded after being cut into two.\n\nEpidural tissue samples, 5.6 x 5.3 x 1.0 cm, were partially embedded.\n\nSTAINING: 2 blocks, Hematoxylin & Eosin (HE), Periodic Acid Schiff\n(PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology displays connective tissue surrounded by a pronounced\ninflammatory infiltrate, comprised of neutrophils, lymphocytes, and\nnumerous eosinophils. Additionally, budding capillaries were seen. No\nspecific findings in the PAS stain.\n\nHistologically, connective tissue infiltrated by predominantly\nlymphocytic inflammation was observed. Eosinophils and abundant necrotic\ntissue were also seen. Additionally, polarizable material was noted,\noccasionally engulfed by multinucleated giant cells. Hemorrhagic signs\nwere indicated by hemosiderin deposits. No specific findings in the PAS\nstain.\n\nFINDINGS:\n\n1 & 2. Soft tissue displays acute phlegmonous inflammation and chronic\ngranulating inflammation.\n\n**Brief report (07/15/2020): **\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 06/01/2020.\n\nWound healing disorder right parietal at the site of previous right-side\nglioblastoma, last revision 04/12/2020.\n\n-Single right body focal seizure 04/20/2020, single generalized seizure\n05/12/2020\n\n-Previous resection on 10/12/2019\n\n-Wound healing disorder with subsequent wound revision (06/2020)\n\n-Last cMRI on 05/03/2020: no recurrence observed.\n\nSecondary diagnoses:\n\nHypothyroidism\n\nSurgery type: injection of Ropivacaine, smear for microbiology,\nreadaptation of three small wound dehiscence, tobacco bag suture,\noverlay polyhexanide gel, plaster application\n\nInstructions: Return next Tuesday for wound check. Sutures to remain in\nplace for 10 days. Check microbiology results on Thursday. Clinically,\nno signs of infection observed.\n\nSurgical report:\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 04/20/2020.\n\nASSESSMENT:\n\nThe patient was presented at the emergency unit after observing a small\nwound dehiscence after the aforementioned surgery for a wound healing\ndisorder. The treating surgeon recommended a second local wound revision\nattempting to readapt the wound with a minor surgery. The patient\nprovided written consent for the procedure. The intervention was\nconducted with standard coagulation parameters.\n\nSURGERY:\n\nSterile preparation and draping of the surgical area. Initial injection\nof Ropivacaine. This was followed by swab collection for microbiology.\nThe wound edges were excised and the wound dehiscence was readapted\nusing a tobacco bag suture. Afterward, polyhexanide gel was applied,\nfollowed by a sterile plaster dressing.\n\nSurgery report:\n\nDiagnosis: significant scalp wound healing disorder in the prior\nsurgical access area post-resection and irradiation of a glioblastoma\nmultiforme.\n\nOperating time: 49 minutes\n\n\n\n### text_4\n**Dear colleague, **\n\nwe report on Mr. Miller, John, born 04/07/1961, who was in our inpatient\ntreatment from 09/12/2020 to 10/07/2020.\n\nDischarge diagnosis: Recurrence of the pre-described glioblastoma right\ninsular, WHO CNS grade 4 (IDH wild type, MGMT methylated).\n\nPhysical examination on admission:\n\nPatient awake, fully oriented, cooperative. Non-fluent aphasia. Speech\nclear and fluent. Latent left hemisymptomatic with strength grades 4+/5,\nstance and gait unsteady. Cranial nerve status regular. Scar conditions\nnon-irritant except for frontal superficial erosion at frontal wound\npole of pterional approach. Karnofsky 70%.\n\nMedication on Admission:\n\nLevothyroxine sodium 50 μg/1 pc (Synthroid® 50 micrograms, tablets)\n1-0-0-0\n\nLorazepam 0.5 mg/1 pc (Ativan® 0.5 mg, tablets) 1-1-1-1\n\nLacosamide 100 mg/1 pc (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\n**Imaging: **\n\ncMRI +/- contrast agent dated 09/15/2020: There is a contrast enhancing\nformation on the right temporo-mesial with approach to the insular\ncistern with suspected tumor recurrence.\n\nPET dated 09/10/2020 (external): Significant tracer multinodulation with\nactive areas in the islet region is seen.\n\n**Surgery of 09/18/2020: **\n\nReopening of existing skin incision and extension of craniotomy\ncranially, microsurgical navigated tumor resection right insular (IONM:\nMEP waste lower extremity with incomplete recovery) CUSA; extensive\nhemostasis, intraoperative MRI, sutures, reimplantation of bone flap\nwith multilayer wound closure. Skin suture.\n\nHistopathological report:\n\nRecurrence of pre-described glioblastoma, WHO CNS grade 4 (IDH wild\ntype, MGMT methylated).\n\nCourse:\n\nThe patient initially presented postoperatively with left hemiplegia in\nthe sense of SMA. This regressed significantly during the inpatient\nstay. Postoperative imaging revealed a regular resection finding. In\ncase of a possible adjustment disorder, the patient was treated with\nsertraline and lorazepam. The wound was dry and non-irritant during the\ninpatient stay. The patient received regular physiotherapeutic exercise.\nThe patient\\'s case was discussed in our neuro-oncological tumor board\non 09/29/2020, where the decision was made for adjuvant definitive\nradiochemotherapy. An inpatient transfer was offered by the colleagues\nof radiotherapy.\n\nProcedure:\n\nWe transfer Mr. Miller today in good clinical general condition to your\nfurther treatment and thank you for the kind takeover. We ask for\nregular wound controls as well as regular ECG controls to exclude a\nQTc-time prolongation under sertraline. Furthermore, the medication with\nlorazepam should be further phased out in the course of time. In case of\nacute neurological deterioration, a re-presentation in our neurosurgical\noutpatient clinic or surgical emergency room is possible at any time.\n\nClinical examination findings at discharge:\n\nPatient awake, fully oriented, cooperative. Speech clear and fluent.\nCranial nerve status without pathological findings. Hemiparesis\nleft-sided strength grade 4/5, right-sided no sensorimotor deficit.\nStance and gait unsteady. Non-fluent aphasia. Wound dry, without\nirritation. Karnofsky 70%.\n\n**Medication at Discharge:**\n\nLevothyroxine sodium 50 μg (Synthroid® 50 micrograms, tablets) 1-0-0-0\n\nLorazepam 0.5 mg (Ativan® 0.5 mg, tablets) as needed\n\nLacosamide 100 mg (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\nAcetaminophen 500 mg (Tylenol® 500 mg tablets) 1-1-1-1\n\nSertraline 50 mg (Zoloft® 50 mg film-coated tablets) by regimen\n\n**Magnetic Resonance Imaging (MRI) Report**\n\nDate of Examination: 02/02/2021\n\nClinical Indication: Multifocal glioblastoma WHO grade IV, IDH wild\ntype, MGMT methylated.\n\nClinical Query: Hemiparesis on the right side. Is there a structural\ncorrelate? Tumor progression?\n\n**Previous Imaging**: Multiple prior studies. The most recent contrasted\nMRI was on 09/15/2020.\n\n**Findings**:\n\n**Imaging Device**: GE 3T; Protocol: 3D FLAIR, 3D T1 Mprage with and\nwithout contrast, SWI, DWI, 3D T2, axial T2\\*, perfusion, DTI.\n\n1. **Report: **\n\n Known multimodal pretreated GBM since 2019, recently post-surgical\n resection for tumor progression in the frontotemporal region on\n 09/18/2020. Also noted is a post-surgical resection of additional\n foci in the right insular region. The resection cavity in the right\n frontal, insular, and temporal regions appears unchanged in size and\n configuration. Residual blood products are noted within.\n\n There are increased areas of contrast enhancement compared to the\n immediate post-operative images. There is a minor growth in a\n nodular enhancement posterior to the right middle cerebral artery.\n Adjacent to this, there\\'s a new nodular enhancement, which could be\n a postoperative reactive change or a new tumor lesion.\n\n Ongoing diffusion abnormalities are observed in the right caput\n nuclei caudatus, putamen, and globus pallidus, especially pronounced\n in posterior sections.\n\n Persistent FLAIR-hyperintense peritumoral edema in the right\n hemisphere remains unchanged. The midline shift is approximately 9mm\n to the left, which remains unchanged.\n\n Post-operative swelling and fluid accumulation are noted at the\n surgical entry point. The bone flap is in place. The width of both\n the internal and external CSF spaces remains constant, with no\n evidence of obstruction.\n\n The orbital contents are symmetrical. Paranasal sinuses and mastoid\n air cells are aerated appropriately.\n\n**Impression**:\n\nResidual tumor segments along the right middle cerebral artery showing\ngrowth. Adjacent to it, a new nodular area of contrast enhancement\nsuggests either a postoperative change or a new tumor lesion.\n\nPreviously identified ischemic changes in the right caput nuclei\ncaudatus, putamen, and globus pallidus. Persistent brain edema with a\nleftward midline shift of approximately 9mm remains unchanged.\n\n\n\n### text_5\n**Dear colleague, **\n\nHerewith we report on our common patient Mr. John Miller, born\n04/07/1961, who was at our clinic between 02/04/2021 to 04/22/2021.\n\n-Recurrent manifestation of a glioblastoma\n\n-Stage: WHO CNS grade 4\n\n**Histology:**\n\nRecurrence of the pre-described glioblastoma, WHO CNS grade 4.\n\nMolecular pathological findings:\n\nIDH status: no p.R132H mutation (immunohistochemical).\n\nATRX: preservation of nuclear expression (immunohistochemical).\n\np53: technically not evaluable (immunohistochemical).\n\n1p/19q status: no combined loss (850k methylation analysis).\n\nCDKN2A/B: Deleted (850k methylation analysis).\n\nMGMT promoter: Methylated (850k methylation analysis).\n\nTumor localization: Islet/frontal right\n\nSecondary diagnoses:\n\nSymptomatic epilepsy\n\nHypothyroidism\n\nNausea\n\nLeukopenia I° (CTCAE)\n\nAnemia II° (CTCAE)\n\nPrevious course / therapies:\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n03/2020: Suspected recurrence\n\n04/2020: Revision surgery\n\n06-07/2020 Wound revisions and flap plasty for atrophic wound healing\ndisorder\n\n02/2021: Suspected recurrence with new FLAIR-positive tumor\nmanifestation insular on the right side. Stereotactic biopsy with\nevidence of glioblastoma.\n\nPathology: Renewed manifestation of a glioblastoma.\n\nRecommended radiochemotherapy.\n\nAccording to the interdisciplinary neuro-oncology board of 01/26/2021,\nwe gave the indication for adjuvant radiochemotherapy for the recurrence\nof glioblastoma.\n\n**Radiochemotherapy: **\n\nTechnique:\n\n1\\) Percutaneous intensity-modulated radiotherapy was administered to the\nformer recurrence tumor region in the frontal/insular right after CT-\nand MRI-guided radiation planning with 6 MV-photons in helical\ntomotherapy technique with a single dose of 2 Gy up to a total dose of\n60 Gy with 5 fractions per week. Daily position controls by CT.\n\n2\\) Subsequently, local dose saturation of the macroscopic tumor remnant\nwas performed.\n\nInsular right stereotactic ablative radiosurgery at the gamma knee to\nsaturate the macroscopic GammaKnife (Cobalt-60: 1.17 MeV and 1.33 MeV\nphotons) in mask fixation after CT- and MRI-guided radiotherapy planning\nunder image-guided setting (ConeBeam-CT) with a dose of 6 Gy in 2 Gy\nsingle dose to the 68% isodose up to a total cumulative dose of 66 Gy.\n\nChemotherapy:\n\nConcurrent chemotherapy with 75mg/m²KOF temozolomide daily (120 mg\ndaily).\n\nAbsolute dose: 5000 mg.\n\nTreatment Period:\n\nRadiotherapy 03/09/2021 -- 04/21/2021\n\nChemotherapy 03/09/2021 -- 04/21/2021\n\n**Course under therapy:**\n\nWe took over Mr. Miller on 03/06/2021 in reduced general and slightly\nreduced nutritional condition (Kanofsky index: 70 %, BMI: 18.5 kg/m²)\nfrom the Clinic for Neurosurgery for adjuvant re-radiochemotherapy on\nour radiooncology ward. At the time of admission, the patient had arm\n\nright hemiparesis (strength grades arm: 2/5, leg: 3/5). The patient was\nambulatory with assistance. Cranial nerve status was unremarkable.\nHeadache, nausea or dizziness were denied.\n\nOn 09/03/2021, combined re-radiochemotherapy was initiated.\n\nDuring the course of therapy with temozolomide, mild nausea occurred,\nwhich was treated with ondansetron 4mg as needed and dimenhydrinate\nSustained-release tablets 150 mg as needed. Under this treatment the\nsymptoms clearly regressed. Mild constipation was treated. Laboratory\ntests revealed mild leukopenia I° and anemia II° (CTCAE).\n\nOtherwise, the re-radiochemotherapy was very well tolerated overall.\n\nMr. Miller received physiotherapeutic exercise and psychotherapy during\nthe entire physiotherapeutic training and psycho-oncological support.\nUnder the physiotherapeutic treatment, his motor skills improved\nsignificantly. At the end of the therapy, the patient was also mobile\noutside the\n\nhouse without any aids.\n\nOn 04/22/2021 we discharged Mr. Miller to the outpatient care by his\nfamily doctor.\n\n04/11/2021: MR brain post contrast\n\nAfter renewed radiochemotherapy for a glioblastoma recurrence, a\nresidual suspicious barrier disturbance adjacent to the adjacent to the\nright cerebral artery. Stable nodular contrast enhancement\n\nPostoperative/reactive changes as described above. MR perfusion\nsequences show residual, contrast-absorbing tumor portions along the\nright A. cerebri media. Lateral to this, new nodular contrast-absorbing\nlesion, possibly postoperative reactive change. Previously known\nischemia at the right caput nuclei caudatii, putamen, and globus\npallidus. Unchanged medullary edema with midline shift to the left by\napproximately 9mm.\n\nLast lab:\n\nMCHC 29.4 g/dL (32 - 36) 04/20/2021\n\nMCH 25 pg (27 - 32) 04/20/2021\n\nLeukocytes 3.32 G/l (4.0 - 9.0) 04/20/2021\n\nHematocrit 31.6 % (37 - 43) 04/20/2021\n\nHemoglobin 9.3 g/dL (12 - 16) 04/20/2021\n\nErythrocytes 3.7 T/l (4.1 - 5.4) 04/20/2021\n\nUric acid 2.2 mg/dl (2.5 - 5.5) 04/20/2021\n\n**Further Procedure:**\n\nFurther skin care and behavior regarding side effects were explained to\nthe patient in detail.\n\nA first radiooncological control appointment was scheduled for\n06/05/2021 at 12:00 AM in our outpatient clinic. Prior to this, on\n06/02/2021 at 10:30 AM, an imaging exam (brain MRI) is scheduled.\n\nA further neuro-oncological connection is planned close to home via the\ntreating oncologist.\n\nAfter radiation therapy, we recommend annual ophthalmological check-ups\nand annual endocrinologic.\n\nwith testing of the hypothalamic-pituitary hormone axes.\n\n\n\n### text_6\n**Dear colleague, **\n\nThis is a report on our mutual patient, Mr. John Miller, born\n04/07/1961:\n\nDiagnosis:\n\nRecurrent manifestation of glioblastoma\n\nWHO CNS grade 4\n\nTumor localization: Right isle/frontal\n\nSecondary diagnoses: Symptomatic epilepsy\n\nHypothyroidism Previous\n\nTreatments / Therapies\n\nResection and revisions\n\nAdjuvant radiochemotherapy\n\nTwo wound revisions and flap plasty for atrophic wound healing disorder\n\nNew FLAIR-positive tumor manifestation insular on the right side\n(02/2021)\n\nStereotactic biopsy with histopathology with evidence of glioblastoma\n\nTumor Board: Recommended new radiochemotherapy up to a total dose of 60\nGy à 2 Gy single dose. Subsequent local dose saturation of the\nmacroscopic tumor remnant as radiosurgery on GammaKnife with a dose of 6\nGy à 2 Gy single dose (\\@68% isodose).\n\n03-4/2021 Repeat stereotactic RTx in the area of the basal ganglia and\nthe resection cavity right frontal on the Gamma Knife with 46 Gy à 2 Gy;\n3 doses of Bevacizumab 7.5 mg/kg i.v.\n\n**Summary:**\n\nOn 07/03/2023, we conducted an initial telephone follow-up with the\npatient, Mr. Miller, for a radio-oncology consultation. Presently, Mr.\nMiller is undergoing rehabilitation, from which he feels he is deriving\nsubstantial benefits. His recent radiotherapy was well-received without\nany complications. Since the onset of his symptoms, there have been no\nnew developments. Symptoms related to intracranial pressure or new\nneurological deficits were denied. Fortunately, while on anticonvulsant\ntherapy with Lacosamide, Mr. Miller experienced no epileptic seizures.\nHis skin condition is normal. However, Mr. Miller did mention some\ncognitive challenges that minimally impact his daily activities,\nalongside feelings of fatigue and grade I CTCAE symptoms. The cMRI scan\nfrom 06/02/2021 revealed a notable reduction in the barrier disturbance\nof the right-sided basal ganglia. This was accompanied by small, mildly\nhyperperfused residual findings near the third ventricle. Moreover, the\npinpoint contrast enhancement in the left parietal lobe appeared\nunchanged, suggesting it is a scarring reaction. In collaboration with\nthe neurooncology team, Mr. Miller has discussed starting chemotherapy.\nThe next imaging assessment is scheduled for mid-September. We have also\nscheduled another radio-oncologic follow-up with Mr. Miller for\nSeptember 28th, per his preference, via telephone. For patient safety,\nMr. Miller is prohibited from operating private or commercial vehicles\nfor 3 months post-intracerebral radiotherapy. This duration may extend\nif there are existing or progressing brain conditions. Following\nradiotherapy, we are mandated by the Radiation Protection Act to\nfacilitate regular checks. Hence, we encourage enrollment in the\naftercare calendar, prompt reporting of any significant findings, and\nattendance of scheduled follow-ups. Alongside these, regular oncological\ncheck-ups by specialist practitioners are mandatory. Mr. Miller has been\nduly informed of all these requirements.\n\n\n\n\nHere is the query:\nWhich of the following medications was increased in dosage during Mr. Miller's therapy?\n\nChoose the correct answer from the following options:\nA. Allopurinol\nB. Bisoprolol\nC. Levetiracetam\nD. Januvia\nE. Lisinopril\n\n\nYour response:\n", "role": "user" }, { "content": "Levetiracetam", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nPatient: Miller, John, born 04/07/1961\n\nWe report to you about our common patient, Mr. John Miller, who is in\nour inpatient treatment since 07/30/2019.\n\n**Diagnoses:**\n\n\\- Suspected right cerebral glioblastoma (first diagnosis)\n\n\\- Symptoms: Aphasia, passive confusion\n\n**Patient history: **\n\nMr. Miller was admitted as an emergency. He was on the phone with a\nfriend when he suddenly began to exhibit speech difficulties and\nstruggled to find the right words. Consequently, his friend called 911.\n\nUpon the ambulance\\'s arrival, Mr. Miller was disoriented and exhibited\naggressive behavior. There was evidence of a torn door. He had blood on\nhis right forearm and around his mouth, but there were no indications of\na tongue bite or urinary incontinence.\n\nUpon admission, Mr. Miller was coherent and showed no speech issues. He\nattributed a mild weakness in his right arm to pre-existing pain in the\nupper arm. An immediate CT scan revealed a mass suggestive of a\nglioblastoma in the right cerebral hemisphere, leading to a\nneurosurgical consultation.\n\nGiven the possibility of an epileptic seizure, Mr. Miller was\nhospitalized and started on Levetiracetam. He is currently unaware of\nhis regular medications but takes antihypertensives and diabetes\nmedications, among others. His friend and brother have been notified and\nare ensuring that a detailed medication list is provided.\n\nAfter a brief stay in ward ABC, Mr. Miller was transferred to the\nneurosurgery team for further evaluation and treatment. We appreciate\nthe prompt transfer and are available for any further inquiries.\n\nPlanned Procedures:\n\n-Schedule EEG\n\n-Clarify routine medications\n\n**Surgery Report**\n\n**Diagnosis:** Suspected HGG (high-grade glioma) of the right hemisphere\n\n**Procedure:** Microsurgical navigation-guided resection of the tumor\nwith intraoperative neuromonitoring (stable MEPs) and intraoperative MRI\nusing 5-ALA. Pathology samples taken (Preliminary: HGG; Final to be\nconfirmed). Resection was followed by duragen placement, watertight\ndural closure, and multilayer wound closure, with skin sutures.\n\n**Time:**\n\n-Start: 11:12 am\n\n-Finish: 3:54 pm\n\n-Duration: 4 hours 42 minutes\n\n**Assessment:**\n\nMr. Miller presented with a seizure characterized by speech disturbance\nand disorientation. Imaging revealed a significant right hemispheral\nmass, likely representing a high-grade brain tumor. The need for\nsurgical resection was determined following discussions at our\ninterdisciplinary tumor board. After being informed about the procedure,\nalternative treatments, the operation\\'s urgency, benefits, and\npotential risks, Mr. Miller provided written consent following ample\ntime for consideration and the opportunity to ask further questions.\n\n**Procedure Details:**\n\nThe patient was positioned supine with his head secured in a Nova clamp.\nNavigation data were read, followed by skin preparation, and the\nsurgical field was sterilized and draped. An arch-shaped incision was\nmade, followed by hemostasis, deep tissue dissection, placement of a\nburr hole, and the creation of a large bone flap over the lesion. The\nbone flap was then elevated. Multiple washings were performed, followed\nby dural opening under microscopic visualization. A corticotomy was\ncarried out with bipolar forceps, CUSA, and suction to progressively\nreduce the tumor, utilizing 5-ALA fluorescence and continuous\nneurophysiological monitoring. An intraoperative MRI showed residual\ntumor, prompting further resection. Hemostasis was achieved, and the\nwound was closed using tabotamp, followed by duragen placement and dural\nsuturing. The bone flap was refixed using Dogbone plates. The wound area\nwas irrigated extensively once more, followed by subcutaneous and skin\nsutures.\n\n**Date:** 10/01/2019\n\n**Clinical Indication:**Suspected recurrence of GBM in the right\nhemisphere\n\n**Requested Imaging:**cMRI with or without contrast + DTI.\n\n**Findings:***Imaging Modality (GE 3.0T):* 3D FLAIR, DTI, SWI, T2\\*\nperfusion, 3D T1 with and without contrast, 3D T2,\nsubtraction.Following resection of a right hemispheric glioblastoma in\n08/19, and compared to the last two scans (external: 07/19, internal:\n08/19), there is a notable expansion of the prior detected flair\nhyperintense regions. These now span from the right parietal-subcortical\narea across the right basal ganglia to the right temporo-occipital/right\ntemporal pole. Specifically, at the dorsocranial edge of the resection\ncavity, the hyperintense regions appear to have grown since 08/19. These\ncoincide with hyperperfused regions in the T2\\* perfusion. Linear SWI\nsignal changes are suggestive of mild post-surgical bleeding. No\nsignificant postoperative hemorrhage or territorial ischemia is\ndetected. A normal venous sinus drainage is observed. Right temporal\nhorn appears congested, possibly due to CSF trapping.\n\n**Assessment:**\n\nFollowing the resection of the right hemispheric glioblastoma in 08/19:\n\n-Markedly progressive flair edema and evolving barrier disturbance.\nRegions especially towards the dorsal side of the resection cavity show\nthis alongside associated hyperperfusion. With the recent PET imaging\nfrom 10/19, there is an indication of progressive disease as per RANO\ncriteria.\n\n-Long-term progressive congestion of the right temporal horn, likely CSF\ntrapping.\n\n**Surgery Report****Diagnosis:**Tumor recurrence after resection of a\nglioblastoma (IDH wild type, WHO CNS grade 4) of the right hemisphere in\n08/2019. The patient underwent combined radiochemotherapy at the local\nclinical center.\n\n**Procedure:**Navigated, microsurgical resection supported by 5-ALA,\nwith stable MEPs through the previous right temporal access. iMRI\nconducted between 11:10 and 11:50. Used Duragen/TachoSil, dog bones for\nclosure, followed by layered wound closure and skin sutures.\n\n**Timing:**\n\n-Incision: 09:23 am on 10/12/19\n\n-Suture: 12:32 pm on 10/12/19\n\n**Assessment:**The patient had previously undergone surgery for a\nglioblastoma and a recurrence was detected on imaging. The tumor board\nhad already deliberated on the surgery. The patient was informed about\nthe surgical procedure, particularly about conducting an extensive\nresection caudally without impacting function post-mapping. The patient\nconsented, understanding the potential for longer progression-free\nsurvival.\n\n**Procedure Details:**The patient was placed in a supine position with\nthe head turned to the side and fixed using the Noras clamp. The right\nshoulder was padded. The surgical area was prepared by trimming hair\naround the previous scar, followed by sterilization and draping. After a\nteam time-out, prophylactic antibiotics were administered. The previous\nscar was reopened and old plates were removed. The microscope was then\nswung into position and the dura was opened. Navigation proceeded\nbeneath the labbé vein, with tumor resection as guided by ALA\nfluorescence. Post-tumor removal, extensive hemostasis was achieved\nusing absorbent cotton and TABOTAMP. Intraoperative MRI confirmed a\ncomplete resection of the tumor. The dura was sealed using DuraGen,\nensuring a watertight closure. The bone flap was reinserted, followed by\nsubcutaneous suturing, skin suturing, and sterile dressing of the wound.\n\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe write to update you regarding our shared patient, Mr. John Miller,\nborn on 07/04/1961, who visited us on 12/02/2019.\n\n**Diagnosis:**Glioblastoma recurrence, IDH 1 wild type.\n\n**Tumor Location:**Right hemisphere including temporal regions.\n\n**Clinical History & Treatment:**\n\n-07/2019: Mr. Miller experienced speech disturbances and confusion.\n\n-08/01/2019: Brain PET-MRI revealed a suspected malignancy in the right\nhemisphere, including temporal areas.\n\n-08/11/2019: Glioblastoma was resected at our facility.\n\n-08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy\nwith a boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local\nclinical center.\n\n-10/01/2019: cMRI with suspected recurrence.\n\n-10/12/2019: A recurrent resection was performed at our facility.\n\n-11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n**Recent Evaluation (12/01/2019):**Mr. Miller visited our facility with\nhis brother. Our assessment, based on CTCAE criteria, indicated that he\nis in a fair but stable general and nutritional health (KPS 70-80%,\nweight undisclosed, height 175 cm). Neurological and general evaluations\nrevealed a degree of aphasia, mainly with word-finding difficulty, and\nshort-term memory impairment. However, he remains fully oriented and\nindependent in daily life.\n\n**Additional Observations:**\n\nHis surgical wound has healed well.\n\n**Pre-existing Conditions:** Arterial hypertension, Diabetes Mellitus\nType II\n\n**Allergies:** None\n\n**Current Medications:** Antihypertensive drugs and insulin.\n\nPostoperatively, Mr. Miller remains in good health. A recent brain MRI\nnoted that the suspected recurring GBM lesion near the superior border\nof the surgical site was entirely resected. Furthermore, CT scans at the\nanterior medial and lateral edges suggest that a complete resection was\nmost likely achieved.\n\nGiven the presumed complete resection of the glioblastoma recurrence, we\nhave recommended Mr. Miller for a neuro-oncology review and a follow-up\nwith PET-MRI in three months.\n\n**Next Steps:**\n\n-He has a scheduled appointment in neuro-oncology on 01/23/2020 at 10:00\nAM.\n\n-A follow-up PET-MRI is set for 01/29/2020 at 12:45 PM. We have advised\nMr. Miller to fast for 4 hours prior and to bring a referral from his\nprimary care physician, along with a recent creatinine test result.\n\n-A review of these findings will be held in our outpatient department on\n01/30/2020 at 2:00 PM.\n\nThank you for your continued care and collaboration. Please do not\nhesitate to reach out for any additional information.\n\nWarm regards,\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nRegarding our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nGlioblastoma recurrence, IDH 1 wild type\n\n**Tumor Location**:\n\nRight hemisphere/temporal.\n\n**Medical History**:\n\n07/2019: Onset of speech arrest and confusion.\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\nMr. Miller came in on 12/01/2019 with his brother. Clinical examination\nfindings are as follows:\n\n-General health: Stable with reduced vitality.\n\n-Nutritional status: Stable (KPS 70-80%, weight in kg, height 169 cm).\n\n-No evident motor, sensory, visual, or cranial nerve deficits.\n\n-Neurocognitive deficits: Short-term memory issues.\n\n-Aphasia: Grade II (mainly word-finding disorders). The patient is fully\noriented and independent in daily life.\n\n-No evidence of recurrence in PET-MRI. Next imaging scheduled in\n03/2020.\n\n**Past Medical Conditions**:\n\n-Hypertension\n\n-Type II Diabetes Mellitus\n\n**Allergies**: None.\n\n**Medications**:\n\n-Antihypertensive medications\n\n-Insulin\n\nBest Regards,\n\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nUpdating you on our mutual patient, Mr. John Miller, born 04/07/1961:\n\n**Diagnosis**:\n\nRecurrent Glioblastoma, IDH 1 wild type (ICD-10: 71.8).\n\n**Molecular Pathology**:\n\nNo p.R132H mutation in IDH.\n\nNo combined 1p/19q loss.\n\nSuspected CDKN2A/B deletion.\n\n**Medical History**:\n\nNo pain or B symptoms.\n\nIntermittent dizziness and headaches since the last check-up.\n\n**Neurological Findings**:\n\nPatient is alert and oriented.\n\nWeight: 80 kg (total loss: 15 kg), Height: 175 cm.\n\nKarnofsky Performance Score: 80%.\n\nMotor function and sensory assessments were unremarkable.\n\n**Allergies**: None.\n\n**Medications**:\n\nLisinopril 10mg once daily in the morning\n\nBisoprolol 2.5mg once daily at bedtime\n\nJanuvia 50mg twice daily\n\nAllopurinol 100mg once daily in the morning\n\nEzetimibe 10mg once daily at bedtime\n\nLevetiracetam 1000mg once daily in the morning Insulin as per regimen\n\n**Secondary Diagnoses**:\n\nHypertension\n\nType II Diabetes Mellitus\n\n**Medical Course**:\n\nDetails from 07/2019 through 03/2020 provided, including surgeries,\nradiochemotherapies, and diagnostics.\n\nIn summary, Mr. Miller\\'s glioblastoma diagnosis in 07/2019 led to\nvarious treatments, including radiochemotherapy and surgeries. His\nrecent PET/MRI on 01/2020 indicates potential recurrent areas.\n\nBest regards,\n\n**Patient:** John Miller\n\n**DOB:** 04/07/1961\n\n**Admission Date:** 04/11/2020\n\n**Discharge Date:** 04/18/2020\n\n**Admission Diagnosis:**\n\nRecurrent tumor in the hippocampal region and along the prior resection\ncavity.\n\nHistory of glioblastoma (IDH wild type, WHO CNS grade 4) in the right\nhemisphere, resected on 08/2019.\n\nHistory of combined radiochemotherapy with Temodar (Temozolomide) from\nAugust to September 2019 at the local clinical center.\n\nSubsequent first re-resection in 10/2019.\n\n**Presenting Complaint:**\n\nMr. Miller presented to the neurosurgical outpatient department\naccompanied by his wife. Recent imaging indicated a potential recurrence\nof the glioblastoma. The neuro-oncological board on 04/12/2020\nrecommended a re-resection.\n\n**Physical eon Admission:**\n\nAlert, oriented x4, cooperative.\n\nNon-fluent aphasia.\n\nCranial nerves intact.\n\nNo sensory or motor deficits in the extremities.\n\nSurgical scar clean and dry.\n\nNo signs of neurogenic bladder or rectal dysfunction.\n\nKPSS 70%.\n\n**Medications on Admission:**\n\n-Lisinopril 10mg daily\n\n-Bisoprolol 2.5mg nightly\n\n-Januvia 50mg twice daily\n\n-Allopurinol 100mg daily\n\n-Atorvastatin 40mg nightly\n\n-Ezetimibe 10mg nightly\n\n-Levetiracetam 1000mg twice daily\n\n-Actraphane insulin as prescribed\n\n**Surgical Intervention (04/12/2020):**\n\nNavigated microsurgical resection of tumor spots assisted with 5-ALA.\nStable MEPs were maintained. An intraoperative MRI (iMRI) was utilized.\nPost-resection, the surgical area was managed using Tabotamp, Duragen,\nTachoSil, and dog-bone plates, concluding with layered wound closure.\n\n**Postoperative Course:**\n\nUncomplicated recovery.\n\nPost-op MRI showed no residual tumor.\n\nSurgical site remained clean, dry, and showed no signs of infection or\nirritation.\n\n**Discharge Diagnosis:**\n\nRecurrence of known glioblastoma, WHO CNS grade 4.\n\n**Interdisciplinary Neuro-oncological Tumor Board Recommendation\n(04/20/2020):**\n\nMolecular tumor board review.\n\nOffer reinitiation of Temozolomide chemotherapy.\n\n**Physical Examination on Discharge:**\n\nSimilar to admission, with suture in place and wound site in good\ncondition.\n\nKPSS 70%.\n\n**Medications on Discharge:**\n\n-Allopurinol 100mg daily (morning)\n\n-Atorvastatin 40mg nightly (evening)\n\n-Bisoprolol 2.5mg nightly (evening)\n\n-Ezetimibe 10mg nightly (evening)\n\n-Sitagliptin (Januvia) 50mg twice daily (morning and evening)\n\n-Levetiracetam (Keppra) 1000mg twice daily (morning and evening)\n\n-Lisinopril 10mg daily (morning)\n\n-Acetaminophen 500mg as needed for pain or fever\n\n-Actraphane insulin as prescribed\n\n**Surgery Report **\n\n**Diagnosis**:\n\nTumor recurrence in the right hippocampal region and along the resection\ncavity post glioblastoma resection on 8/11/2019.\n\nPrevious treatments include radiochemotherapy at our clinic. Local\ntherapy center (from August to September 2019) and re-resection on\n10/12/2019.\n\n**Surgery Type**:\n\nRe-opening of the temporal region with navigation, microsurgery using\n5-ALA assistance, iMRI, and re-resection, among other procedures.\n\n**Procedure Details**:\n\nStart: 11:50 pm on 04/12/2020\n\nEnd: 4:00 pm on 04/12/2020\n\nDuration: 4 hours 10 minutes.\n\n**Assessment**:\n\nEvidence of recurrent glioblastoma areas warranted another biopsy and\nresection. After informing Mr. Miller about the procedure\\'s risks and\nbenefits, he provided written consent.\n\n**Operation**:\n\nDetails on the positioning, pre-operative preparations, resection, and\npost-operative procedures are provided.\n\nBest regards,\n\nMEDICAL HISTORY:\n\nMr. Miller underwent surgery because of tumor recurrence in the right\nhemisphere last November to treat a right temporal glioblastoma. He\npresented to our private outpatient clinic due to a wound complication,\nspecifically a wound dehiscence measuring about 1 cm. On closer\nexamination, pus was noted. Despite being symptom-free otherwise, a\nconsultation with Dr. Doe was scheduled. After discussion, it was\ndecided to clean the wound, trim the deteriorated wound edges, and clean\nthe bone flap with an antibiotic solution before reinserting it. The\npatient was thoroughly educated about the nature and risks of the\nprocedure and gave consent.\n\nOPERATION:\n\nThe patient was placed in a supine position. The hair surrounding the\nsurgical site was trimmed, followed by skin disinfection and sterile\ndraping. The bicoronal skin incision was reopened. Deteriorated wound\nedges were excised and the wound was extensively cleaned with\nirrigation. The bone flap was removed and immersed in a Refobacin\nsolution. The epidural pannus tissue was removed. The dura was\ncompletely sutured. Multiple samples were collected both subgaleally and\nepidurally. A sponge was applied, followed by the reinsertion of the\nbone flap using a dog bone miniplate fixation and local application of\nvancomycin powder. A subgaleal drain was placed, and the skin was closed\nusing Donati continuous sutures. A sterile staple dressing was applied,\nand the patient was transferred to recovery.\n\nCLINICAL NOTES:\n\nEpidural pannus suggestive of infection. Past surgical history includes\nglioblastoma removal in 8/11/2019 and subsequent surgeries because of\nrecurrence, the last of these in 04/12/2020. Nature and type of growth?\n\nMACROSCOPIC EXAMINATION:\n\nFixed tissue samples measuring 1.2 x 1.0 x 0.4 cm were entirely\nembedded.\n\nSTAINING: 1 block, Hematoxylin & Eosin (HE), Periodic Acid Schiff (PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology shows entirely necrotic tissue and some bony fragments. No\nmicroorganisms were detected in the PAS stain.\n\nFINDINGS:\n\nFully necrotic tissue. No signs of inflammation or malignancy in the\navailable samples.\n\nOPERATIVE REPORT:\n\nDiagnosis: Wound healing disruption high on the forehead, following a\nresection of recurrent gioblastoma in the right hemisphere in\n04/12/2020.\n\nProcedure: Wound revision, thorough wound cleaning, reinsertion of the\nautologous bone flap.\n\nTime of incision: 3:30 PM, 06/01/2020\n\nTime of suture completion: 4:35, 06/01/2020\n\nDuration: 65 minutes\n\nPATIENT HISTORY:\n\nThe patient had two prior surgeries with our team. The most recent was a\nrevision due to a wound healing complication. The patient was informed\nabout the procedure\\'s nature, extent, risks, and potential outcomes,\nand was given ample opportunity to ask questions. After thoughtful\nconsideration, written consent was obtained.\n\nOPERATION:\n\nThe patient was positioned supine with the head in a neutral position.\nThe surgical area was sterilized and draped. Antibiotic prophylaxis was\nadministered, and a timeout procedure was conducted. The old wound was\nreopened and slightly extended by about 1 cm in both directions. The\nbone flap was removed, inspected, and cleaned. It was then reinserted\nafter refreshing the bone edges. The wound edges were refreshed, and the\nwound was irrigated again before closure.\n\nSUMMARY:\n\nSuccessful wound revision without complications for a wound healing\ncomplication post-glioblastoma surgery.\n\nCLINICAL NOTES:\n\nComplication in wound healing after glioblastoma removal and radiation\ntherapy. Possible inflammation? Evaluate for pus. Nature and type of\ngrowth?\n\nMACROSCOPIC EXAMINATION:\n\nSubcutaneous tissue samples, 1.2 x 1.0 x 0.4 cm, were completely\nembedded after being cut into two.\n\nEpidural tissue samples, 5.6 x 5.3 x 1.0 cm, were partially embedded.\n\nSTAINING: 2 blocks, Hematoxylin & Eosin (HE), Periodic Acid Schiff\n(PAS).\n\nMICROSCOPIC EXAMINATION:\n\nHistology displays connective tissue surrounded by a pronounced\ninflammatory infiltrate, comprised of neutrophils, lymphocytes, and\nnumerous eosinophils. Additionally, budding capillaries were seen. No\nspecific findings in the PAS stain.\n\nHistologically, connective tissue infiltrated by predominantly\nlymphocytic inflammation was observed. Eosinophils and abundant necrotic\ntissue were also seen. Additionally, polarizable material was noted,\noccasionally engulfed by multinucleated giant cells. Hemorrhagic signs\nwere indicated by hemosiderin deposits. No specific findings in the PAS\nstain.\n\nFINDINGS:\n\n1 & 2. Soft tissue displays acute phlegmonous inflammation and chronic\ngranulating inflammation.\n\n**Brief report (07/15/2020): **\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 06/01/2020.\n\nWound healing disorder right parietal at the site of previous right-side\nglioblastoma, last revision 04/12/2020.\n\n-Single right body focal seizure 04/20/2020, single generalized seizure\n05/12/2020\n\n-Previous resection on 10/12/2019\n\n-Wound healing disorder with subsequent wound revision (06/2020)\n\n-Last cMRI on 05/03/2020: no recurrence observed.\n\nSecondary diagnoses:\n\nHypothyroidism\n\nSurgery type: injection of Ropivacaine, smear for microbiology,\nreadaptation of three small wound dehiscence, tobacco bag suture,\noverlay polyhexanide gel, plaster application\n\nInstructions: Return next Tuesday for wound check. Sutures to remain in\nplace for 10 days. Check microbiology results on Thursday. Clinically,\nno signs of infection observed.\n\nSurgical report:\n\nDiagnosis: superficial wound healing disorder and symptomatic, simple\nfocal epileptic seizure dated 04/20/2020.\n\nASSESSMENT:\n\nThe patient was presented at the emergency unit after observing a small\nwound dehiscence after the aforementioned surgery for a wound healing\ndisorder. The treating surgeon recommended a second local wound revision\nattempting to readapt the wound with a minor surgery. The patient\nprovided written consent for the procedure. The intervention was\nconducted with standard coagulation parameters.\n\nSURGERY:\n\nSterile preparation and draping of the surgical area. Initial injection\nof Ropivacaine. This was followed by swab collection for microbiology.\nThe wound edges were excised and the wound dehiscence was readapted\nusing a tobacco bag suture. Afterward, polyhexanide gel was applied,\nfollowed by a sterile plaster dressing.\n\nSurgery report:\n\nDiagnosis: significant scalp wound healing disorder in the prior\nsurgical access area post-resection and irradiation of a glioblastoma\nmultiforme.\n\nOperating time: 49 minutes\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nwe report on Mr. Miller, John, born 04/07/1961, who was in our inpatient\ntreatment from 09/12/2020 to 10/07/2020.\n\nDischarge diagnosis: Recurrence of the pre-described glioblastoma right\ninsular, WHO CNS grade 4 (IDH wild type, MGMT methylated).\n\nPhysical examination on admission:\n\nPatient awake, fully oriented, cooperative. Non-fluent aphasia. Speech\nclear and fluent. Latent left hemisymptomatic with strength grades 4+/5,\nstance and gait unsteady. Cranial nerve status regular. Scar conditions\nnon-irritant except for frontal superficial erosion at frontal wound\npole of pterional approach. Karnofsky 70%.\n\nMedication on Admission:\n\nLevothyroxine sodium 50 μg/1 pc (Synthroid® 50 micrograms, tablets)\n1-0-0-0\n\nLorazepam 0.5 mg/1 pc (Ativan® 0.5 mg, tablets) 1-1-1-1\n\nLacosamide 100 mg/1 pc (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\n**Imaging: **\n\ncMRI +/- contrast agent dated 09/15/2020: There is a contrast enhancing\nformation on the right temporo-mesial with approach to the insular\ncistern with suspected tumor recurrence.\n\nPET dated 09/10/2020 (external): Significant tracer multinodulation with\nactive areas in the islet region is seen.\n\n**Surgery of 09/18/2020: **\n\nReopening of existing skin incision and extension of craniotomy\ncranially, microsurgical navigated tumor resection right insular (IONM:\nMEP waste lower extremity with incomplete recovery) CUSA; extensive\nhemostasis, intraoperative MRI, sutures, reimplantation of bone flap\nwith multilayer wound closure. Skin suture.\n\nHistopathological report:\n\nRecurrence of pre-described glioblastoma, WHO CNS grade 4 (IDH wild\ntype, MGMT methylated).\n\nCourse:\n\nThe patient initially presented postoperatively with left hemiplegia in\nthe sense of SMA. This regressed significantly during the inpatient\nstay. Postoperative imaging revealed a regular resection finding. In\ncase of a possible adjustment disorder, the patient was treated with\nsertraline and lorazepam. The wound was dry and non-irritant during the\ninpatient stay. The patient received regular physiotherapeutic exercise.\nThe patient\\'s case was discussed in our neuro-oncological tumor board\non 09/29/2020, where the decision was made for adjuvant definitive\nradiochemotherapy. An inpatient transfer was offered by the colleagues\nof radiotherapy.\n\nProcedure:\n\nWe transfer Mr. Miller today in good clinical general condition to your\nfurther treatment and thank you for the kind takeover. We ask for\nregular wound controls as well as regular ECG controls to exclude a\nQTc-time prolongation under sertraline. Furthermore, the medication with\nlorazepam should be further phased out in the course of time. In case of\nacute neurological deterioration, a re-presentation in our neurosurgical\noutpatient clinic or surgical emergency room is possible at any time.\n\nClinical examination findings at discharge:\n\nPatient awake, fully oriented, cooperative. Speech clear and fluent.\nCranial nerve status without pathological findings. Hemiparesis\nleft-sided strength grade 4/5, right-sided no sensorimotor deficit.\nStance and gait unsteady. Non-fluent aphasia. Wound dry, without\nirritation. Karnofsky 70%.\n\n**Medication at Discharge:**\n\nLevothyroxine sodium 50 μg (Synthroid® 50 micrograms, tablets) 1-0-0-0\n\nLorazepam 0.5 mg (Ativan® 0.5 mg, tablets) as needed\n\nLacosamide 100 mg (Vimpat® 100 mg film-coated tablets) 1-0-1-0\n\nAcetaminophen 500 mg (Tylenol® 500 mg tablets) 1-1-1-1\n\nSertraline 50 mg (Zoloft® 50 mg film-coated tablets) by regimen\n\n**Magnetic Resonance Imaging (MRI) Report**\n\nDate of Examination: 02/02/2021\n\nClinical Indication: Multifocal glioblastoma WHO grade IV, IDH wild\ntype, MGMT methylated.\n\nClinical Query: Hemiparesis on the right side. Is there a structural\ncorrelate? Tumor progression?\n\n**Previous Imaging**: Multiple prior studies. The most recent contrasted\nMRI was on 09/15/2020.\n\n**Findings**:\n\n**Imaging Device**: GE 3T; Protocol: 3D FLAIR, 3D T1 Mprage with and\nwithout contrast, SWI, DWI, 3D T2, axial T2\\*, perfusion, DTI.\n\n1. **Report: **\n\n Known multimodal pretreated GBM since 2019, recently post-surgical\n resection for tumor progression in the frontotemporal region on\n 09/18/2020. Also noted is a post-surgical resection of additional\n foci in the right insular region. The resection cavity in the right\n frontal, insular, and temporal regions appears unchanged in size and\n configuration. Residual blood products are noted within.\n\n There are increased areas of contrast enhancement compared to the\n immediate post-operative images. There is a minor growth in a\n nodular enhancement posterior to the right middle cerebral artery.\n Adjacent to this, there\\'s a new nodular enhancement, which could be\n a postoperative reactive change or a new tumor lesion.\n\n Ongoing diffusion abnormalities are observed in the right caput\n nuclei caudatus, putamen, and globus pallidus, especially pronounced\n in posterior sections.\n\n Persistent FLAIR-hyperintense peritumoral edema in the right\n hemisphere remains unchanged. The midline shift is approximately 9mm\n to the left, which remains unchanged.\n\n Post-operative swelling and fluid accumulation are noted at the\n surgical entry point. The bone flap is in place. The width of both\n the internal and external CSF spaces remains constant, with no\n evidence of obstruction.\n\n The orbital contents are symmetrical. Paranasal sinuses and mastoid\n air cells are aerated appropriately.\n\n**Impression**:\n\nResidual tumor segments along the right middle cerebral artery showing\ngrowth. Adjacent to it, a new nodular area of contrast enhancement\nsuggests either a postoperative change or a new tumor lesion.\n\nPreviously identified ischemic changes in the right caput nuclei\ncaudatus, putamen, and globus pallidus. Persistent brain edema with a\nleftward midline shift of approximately 9mm remains unchanged.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nHerewith we report on our common patient Mr. John Miller, born\n04/07/1961, who was at our clinic between 02/04/2021 to 04/22/2021.\n\n-Recurrent manifestation of a glioblastoma\n\n-Stage: WHO CNS grade 4\n\n**Histology:**\n\nRecurrence of the pre-described glioblastoma, WHO CNS grade 4.\n\nMolecular pathological findings:\n\nIDH status: no p.R132H mutation (immunohistochemical).\n\nATRX: preservation of nuclear expression (immunohistochemical).\n\np53: technically not evaluable (immunohistochemical).\n\n1p/19q status: no combined loss (850k methylation analysis).\n\nCDKN2A/B: Deleted (850k methylation analysis).\n\nMGMT promoter: Methylated (850k methylation analysis).\n\nTumor localization: Islet/frontal right\n\nSecondary diagnoses:\n\nSymptomatic epilepsy\n\nHypothyroidism\n\nNausea\n\nLeukopenia I° (CTCAE)\n\nAnemia II° (CTCAE)\n\nPrevious course / therapies:\n\n08/2019: PET brain MRI indicated a suspected malignant mass in the right\nhemisphere\n\n08/11/2019: Glioblastoma resection performed in our neurosurgery\ndepartment.\n\n08-09/2019: He underwent adjuvant radiochemotherapy (43.4 at 2.7 Gy with\na boost of 52.4 Gy at 3 Gy) and Temodal treatment at the local clinical\ncenter.\n\n10/12/2019: A recurrent resection was performed at our facility.\n\n11/02/2019: Postoperative brain MRI showed no suspected tumor remnants.\n\n03/2020: Suspected recurrence\n\n04/2020: Revision surgery\n\n06-07/2020 Wound revisions and flap plasty for atrophic wound healing\ndisorder\n\n02/2021: Suspected recurrence with new FLAIR-positive tumor\nmanifestation insular on the right side. Stereotactic biopsy with\nevidence of glioblastoma.\n\nPathology: Renewed manifestation of a glioblastoma.\n\nRecommended radiochemotherapy.\n\nAccording to the interdisciplinary neuro-oncology board of 01/26/2021,\nwe gave the indication for adjuvant radiochemotherapy for the recurrence\nof glioblastoma.\n\n**Radiochemotherapy: **\n\nTechnique:\n\n1\\) Percutaneous intensity-modulated radiotherapy was administered to the\nformer recurrence tumor region in the frontal/insular right after CT-\nand MRI-guided radiation planning with 6 MV-photons in helical\ntomotherapy technique with a single dose of 2 Gy up to a total dose of\n60 Gy with 5 fractions per week. Daily position controls by CT.\n\n2\\) Subsequently, local dose saturation of the macroscopic tumor remnant\nwas performed.\n\nInsular right stereotactic ablative radiosurgery at the gamma knee to\nsaturate the macroscopic GammaKnife (Cobalt-60: 1.17 MeV and 1.33 MeV\nphotons) in mask fixation after CT- and MRI-guided radiotherapy planning\nunder image-guided setting (ConeBeam-CT) with a dose of 6 Gy in 2 Gy\nsingle dose to the 68% isodose up to a total cumulative dose of 66 Gy.\n\nChemotherapy:\n\nConcurrent chemotherapy with 75mg/m²KOF temozolomide daily (120 mg\ndaily).\n\nAbsolute dose: 5000 mg.\n\nTreatment Period:\n\nRadiotherapy 03/09/2021 -- 04/21/2021\n\nChemotherapy 03/09/2021 -- 04/21/2021\n\n**Course under therapy:**\n\nWe took over Mr. Miller on 03/06/2021 in reduced general and slightly\nreduced nutritional condition (Kanofsky index: 70 %, BMI: 18.5 kg/m²)\nfrom the Clinic for Neurosurgery for adjuvant re-radiochemotherapy on\nour radiooncology ward. At the time of admission, the patient had arm\n\nright hemiparesis (strength grades arm: 2/5, leg: 3/5). The patient was\nambulatory with assistance. Cranial nerve status was unremarkable.\nHeadache, nausea or dizziness were denied.\n\nOn 09/03/2021, combined re-radiochemotherapy was initiated.\n\nDuring the course of therapy with temozolomide, mild nausea occurred,\nwhich was treated with ondansetron 4mg as needed and dimenhydrinate\nSustained-release tablets 150 mg as needed. Under this treatment the\nsymptoms clearly regressed. Mild constipation was treated. Laboratory\ntests revealed mild leukopenia I° and anemia II° (CTCAE).\n\nOtherwise, the re-radiochemotherapy was very well tolerated overall.\n\nMr. Miller received physiotherapeutic exercise and psychotherapy during\nthe entire physiotherapeutic training and psycho-oncological support.\nUnder the physiotherapeutic treatment, his motor skills improved\nsignificantly. At the end of the therapy, the patient was also mobile\noutside the\n\nhouse without any aids.\n\nOn 04/22/2021 we discharged Mr. Miller to the outpatient care by his\nfamily doctor.\n\n04/11/2021: MR brain post contrast\n\nAfter renewed radiochemotherapy for a glioblastoma recurrence, a\nresidual suspicious barrier disturbance adjacent to the adjacent to the\nright cerebral artery. Stable nodular contrast enhancement\n\nPostoperative/reactive changes as described above. MR perfusion\nsequences show residual, contrast-absorbing tumor portions along the\nright A. cerebri media. Lateral to this, new nodular contrast-absorbing\nlesion, possibly postoperative reactive change. Previously known\nischemia at the right caput nuclei caudatii, putamen, and globus\npallidus. Unchanged medullary edema with midline shift to the left by\napproximately 9mm.\n\nLast lab:\n\nMCHC 29.4 g/dL (32 - 36) 04/20/2021\n\nMCH 25 pg (27 - 32) 04/20/2021\n\nLeukocytes 3.32 G/l (4.0 - 9.0) 04/20/2021\n\nHematocrit 31.6 % (37 - 43) 04/20/2021\n\nHemoglobin 9.3 g/dL (12 - 16) 04/20/2021\n\nErythrocytes 3.7 T/l (4.1 - 5.4) 04/20/2021\n\nUric acid 2.2 mg/dl (2.5 - 5.5) 04/20/2021\n\n**Further Procedure:**\n\nFurther skin care and behavior regarding side effects were explained to\nthe patient in detail.\n\nA first radiooncological control appointment was scheduled for\n06/05/2021 at 12:00 AM in our outpatient clinic. Prior to this, on\n06/02/2021 at 10:30 AM, an imaging exam (brain MRI) is scheduled.\n\nA further neuro-oncological connection is planned close to home via the\ntreating oncologist.\n\nAfter radiation therapy, we recommend annual ophthalmological check-ups\nand annual endocrinologic.\n\nwith testing of the hypothalamic-pituitary hormone axes.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nThis is a report on our mutual patient, Mr. John Miller, born\n04/07/1961:\n\nDiagnosis:\n\nRecurrent manifestation of glioblastoma\n\nWHO CNS grade 4\n\nTumor localization: Right isle/frontal\n\nSecondary diagnoses: Symptomatic epilepsy\n\nHypothyroidism Previous\n\nTreatments / Therapies\n\nResection and revisions\n\nAdjuvant radiochemotherapy\n\nTwo wound revisions and flap plasty for atrophic wound healing disorder\n\nNew FLAIR-positive tumor manifestation insular on the right side\n(02/2021)\n\nStereotactic biopsy with histopathology with evidence of glioblastoma\n\nTumor Board: Recommended new radiochemotherapy up to a total dose of 60\nGy à 2 Gy single dose. Subsequent local dose saturation of the\nmacroscopic tumor remnant as radiosurgery on GammaKnife with a dose of 6\nGy à 2 Gy single dose (\\@68% isodose).\n\n03-4/2021 Repeat stereotactic RTx in the area of the basal ganglia and\nthe resection cavity right frontal on the Gamma Knife with 46 Gy à 2 Gy;\n3 doses of Bevacizumab 7.5 mg/kg i.v.\n\n**Summary:**\n\nOn 07/03/2023, we conducted an initial telephone follow-up with the\npatient, Mr. Miller, for a radio-oncology consultation. Presently, Mr.\nMiller is undergoing rehabilitation, from which he feels he is deriving\nsubstantial benefits. His recent radiotherapy was well-received without\nany complications. Since the onset of his symptoms, there have been no\nnew developments. Symptoms related to intracranial pressure or new\nneurological deficits were denied. Fortunately, while on anticonvulsant\ntherapy with Lacosamide, Mr. Miller experienced no epileptic seizures.\nHis skin condition is normal. However, Mr. Miller did mention some\ncognitive challenges that minimally impact his daily activities,\nalongside feelings of fatigue and grade I CTCAE symptoms. The cMRI scan\nfrom 06/02/2021 revealed a notable reduction in the barrier disturbance\nof the right-sided basal ganglia. This was accompanied by small, mildly\nhyperperfused residual findings near the third ventricle. Moreover, the\npinpoint contrast enhancement in the left parietal lobe appeared\nunchanged, suggesting it is a scarring reaction. In collaboration with\nthe neurooncology team, Mr. Miller has discussed starting chemotherapy.\nThe next imaging assessment is scheduled for mid-September. We have also\nscheduled another radio-oncologic follow-up with Mr. Miller for\nSeptember 28th, per his preference, via telephone. For patient safety,\nMr. Miller is prohibited from operating private or commercial vehicles\nfor 3 months post-intracerebral radiotherapy. This duration may extend\nif there are existing or progressing brain conditions. Following\nradiotherapy, we are mandated by the Radiation Protection Act to\nfacilitate regular checks. Hence, we encourage enrollment in the\naftercare calendar, prompt reporting of any significant findings, and\nattendance of scheduled follow-ups. Alongside these, regular oncological\ncheck-ups by specialist practitioners are mandatory. Mr. Miller has been\nduly informed of all these requirements.\n", "title": "text_6" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n\n\n### text_5\n**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n\n\n\n\nHere is the query:\nRegarding the therapeutic approach to Mr. Wells' HCC, what was the primary reason for the intermittent pause and resumption of Atezolizumab/Bevacizumab therapy?\n\nChoose the correct answer from the following options:\nA. Progression of HCC as noted in follow-up imaging studies\nB. Development of pulmonary complications requiring steroid therapy\nC. Detection of Streptococcus pneumoniae in sputum cultures\nD. Fluctuations in liver function tests indicating possible drug-induced hepatitis\nE. The patient's personal preference after experiencing side effects\n\n\nYour response:\n", "role": "user" }, { "content": "Fluctuations in liver function tests indicating possible drug-induced hepatitis", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. Brian Carter, born on\n04/24/1956, who was under our inpatient care from 09/28/2021 to\n09/30/2021.\n\n**Diagnosis**: ARDS in the context of a COVID-19 infection\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Mr. Carter presented to our facility on foot\non 09/28/2021 with a five-day history of slowly progressive dyspnea, dry\ncough, and non-apoplectic, holocentral headache. His initial room air\nsaturation was 78%, which improved to 86% with 10 liters of oxygen.\nArterial blood gas analysis revealed an oxygenation disorder with a paO2\nof 50 mmHg, prompting the initiation of NIV therapy, under which Mr.\nCarter remained hemodynamically stable. CT imaging showed bilateral\ninterstitial pneumonia with COVID-typical infiltrates. Both a rapid test\nin the initial care unit and one from his primary care physician were\nnegative for COVID-19. Therefore, we admitted Mr. Carter to our\nintensive care unit for further evaluation.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Alert and cooperative\n\n[Cardiovascular/Abdominal Examination]{.underline}: Severely impaired\noxygenation improved with NIV; Sinus rhythm at 80 beats per minute\n\n[Abdomen]{.underline}: Surgical abdomen\n\n[Renal System:]{.underline} Urination initially scant, then polyuria\nOthers.\n\n**Therapy and Progression:** Upon admission, Mr. Carter was alert,\ncooperative, and hemodynamically stable despite significant oxygenation\nimpairment. Temporary improvement was achieved with differentiated NIV\nmask ventilation. On 09/30, there was a further deterioration in\noxygenation with an increase in respiratory rate and escalation of\nventilator settings, leading to the decision to intubate. A tolerable\nventilation situation was achieved with an oxygenation index of 125. Due\nto radiological suspicion of atypical pneumonia, we initiated empirical\nanti-infective therapy with Piperacillin/Tazobactam, Clarithromycin, and\nCotrimoxazole. Microbiological test results were pending at the time of\ntransfer. We also initiated mucolytic therapy with Ambroxol. The\npre-existing immunosuppressive therapy with Prednisolone was\ndiscontinued and switched to Dexamethasone 10 mg. At the time of\ntransfer, Mr. Carter was hemodynamically stable with low catecholamine\ndoses (0.07 µg/kg/min). A central venous catheter was placed, and\nenteral or parenteral nutrition had not yet been initiated. Diuresis was\nsufficient after a single dose of 20 mg furosemide, with retention\nparameters within the normal range. Prophylactic anticoagulation with\nheparin 500 U/h was initiated.\n\n**Status at Transfer**:\n\n[Neurology]{.underline}: RASS -5 under Propofol and Sufentanil sedation\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline (NA)\n0.07; Hemoglobin 12.8 g/dL\n\n[Lungs]{.underline}: Adequate decarboxylation with borderline\noxygenation: paO2 87.6 under FiO2 0.7; PEEP 16; PEAK 27\n\n[Abdomen]{.underline}: Soft abdomen, no nutrition initiated\n\n[Renal System]{.underline}: Normal urine output without stimulation.\nRetention values within normal range. Clear urine.\n\n[Access]{.underline}: CVC placed on 09/30, left radial artery catheter\nplaced on 09/30.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under our inpatient care from 09/30/2021 to 10/13/2021.\n\n**Diagnosis:** ARDS due to COVID-19 pneumonia with superinfection by\nAspergillus fumigatus\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The patient was admitted from the emergency\ndepartment, presenting with dyspnea and confirmed SARS-CoV-2 infection.\nAfter initial management in the intensive care unit, a non-invasive\nventilation (NIV) trial was attempted, followed by successful\nintubation. The patient was then transferred to the Intensive Care Unit.\n\n**Therapy and Progression:** Upon admission, the patient was sedated,\nintubated, and controlled on mechanical ventilation with mild\ncatecholamine support. Due to oxygenation impairment despite\nlung-protective ventilation and inhaled supportive NO therapy,\nconservative ARDS therapy was initiated, including positioning therapy\n(a total of 9 prone positions). After stabilization of gas exchange with\npositioning therapy, sedation and ventilation weaning were performed.\nGas exchange and oxygenation are currently stable under BIPAP\nventilation (PiP 25 mbar, PEEP 13 mbar, breathing rate 18/min). The\npatient, under reduced analgosedation with Sufentanil and Clonidine,\nexhibits a sufficient awakening response, is adequately responsive, and\nfollows commands with reduced muscle strength.\n\nThe home medication of Methotrexate and Prednisolone for uveitis was\ndiscontinued upon admission. The patient received Dexamethasone for 10\ndays initially and, starting from 11/10, prednisolone with prophylactic\nCotrimoxazole therapy.\n\nUpon detection of Aspergillus in tracheobronchial secretions, antifungal\ntherapy with Voriconazole and Caspofungin (until target Voriconazole\nlevels were achieved) was initiated. The initially started antimicrobial\ntherapy with Piperacillin + Tazobactam was escalated to Meropenem on\n10/05/2021 due to worsening infection parameters and progression of\ninfiltrates on X-ray. Infection parameters have been fluctuating, and\nfever is not currently observed. Diuresis is qualitatively and\nquantitatively within normal limits, and retention parameters are within\nthe normal range.\n\nAnticoagulation was administered in therapeutic doses using\nlow-molecular-weight heparin.\n\nEnteral nutrition is provided through a nasogastric tube, and the\npatient has regular bowel movements.\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Analgosedated, GCS 10, pupils equal and\nreactive, limb movement prompt, follows commands with reduced strength\n\n[Lungs]{.underline}: Intubated with BIPAP 25/13, FiO2 0.4\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline 0.05\n\n[Abdomen]{.underline}: Obese, no tenderness, abdomen soft, oral intake\nvia a nasogastric tube, regular bowel movements\n\n[Diuresis]{.underline}: Normal urine output, retention parameters within\nnormal limits\n\nSkin/Wounds: Some pressure sores from positioning (see nursing handover\nsheet)\n\n[Mobilization]{.underline}: Not conducted\n\n**Imaging:**\n\n**Bedside Chest X-ray from 10/11/2021:**\n\n[Clinical information, question, justifying indication:]{.underline}\nCOVID pneumonia, insertion of a central venous catheter (CVC)\n\n**Assessment**: Comparison with 10/05/21: Endotracheal tube identical,\ngastric tube seen extending well into the abdomen, left CVC currently\npositioned in the brachiocephalic vein region, right CVC via internal\njugular vein with tip in superior vena cava. No pneumothorax, no\neffusions, increasing consolidation of infiltrates in the right lower\nlobe and retrocardially on the left without significant cavitation as\nfar as can be assessed. Left heart without significant central\ncongestion.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under intensive care treatment from 09/28/2021 to 10/12/2021 and\nin our intensive care unit from 10/13/2021 to 10/21/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The initial hospital admission of the patient was\nthrough our emergency department due to severe respiratory insufficiency\nin the context of COVID-19 pneumonia.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Skin/Mucous Membranes]{.underline}: Warm, Skin Perfusion: Good\nperfusion, Edema: Lower legs\n\n[Head]{.underline}: Mobility: Active and passive free movement, Tongue:\nMoist\n\n[Thorax]{.underline}: Auscultation: Clear bilaterally\n\n[Abdomen]{.underline}: Soft, no guarding, Bowel Sounds: Sparse\nperistalsis, Tenderness: None\n\n[Neurology]{.underline}: Pupil Shape: Round, Pupil Size: Moderate, Light\nReaction: Both sides +++\n\nAlertness: Awake\n\n**ECG on admission:** Tachycardic sinus rhythm with 107/min, Left type,\nP-wave normally configured, normal PQ interval, no pathological Q as in\nPardee-Q, narrow QRS, regular R progression, R/S transition in V3/4, no\nS persistence, no ST segment changes, no discordant T-negatives.\n\n**Therapy and Progression:** Despite intensified oxygen therapy with\nnasal high-flow and mask CPAP, adequate oxygenation could not be\nachieved, and the patient was intubated on 09/29/21. Leading oxygenation\nimpairment led to lung-protective ventilation with inhaled supportive NO\ntherapy and conservative ARDS therapy, including positioning therapy (a\ntotal of 9 prone positions, 16 hours each, from 09/29/21 to 10/8/21).\n\nDue to elevated procalcitonin, the patient received empirical antibiotic\ntreatment with Piperacillin/Tazobactam starting from 10/2/21, which was\nescalated to Meropenem on 10/5/21 and continued until 10/14/21.\n\nAfter the detection of Aspergillus in tracheobronchial secretions and\nBAL, the patient received Voriconazole since 10/7/2021 (treatment\nduration formally 4-6 weeks). Most recently, the level was\nsubtherapeutic, so the dose was adjusted to 2 x 400 mg daily.\n\nThe immunosuppressive therapy with Methotrexate and Prednisolone for\nrheumatoid arthritis was switched to Dexamethasone (09/29 to 10/8) and,\nsince 10/09, Prednisolone monotherapy. After controlling the fungal\ninfection, a rheumatology re-consultation was planned. Furthermore,\nsubtherapeutic anticoagulation with Fraxiparine was initiated for the\nprevention of thrombotic complications in the context of COVID-19.\n\nUnder this treatment regimen, gas exchange continuously improved, and on\n10/12/21, the patient was transferred with low catecholamine\nrequirements for ventilation and sedation weaning. Mr. Carter was\nextubated on 12/13/21 and now maintains good oxygenation with less than\n3L oxygen via nasal cannula. Delirium symptoms after extubation\ncompletely regressed within a few days.\n\nSevere dysphagia was observed after invasive ventilation, leading to a\nspeech therapy consultation. Oral feeding is currently not possible, so\nMr. Carter is receiving parenteral nutrition. As a result, there was a\nparavasate in the upper right extremity with painful erythema. Adequate\npain control was achieved with local cooling and Piritramide as needed.\nDue to continued dietary restrictions, a central venous catheter was\nplaced on 10/20/2021 for parenteral nutrition.\n\nWe request continued speech therapy treatment.\n\nOn 10/21/21, Staphylococcus aureus was detected in blood culture, so we\ninitiated the administration of Flucloxacillin. The MRSA rapid test was\nnegative.\n\nWe are transferring Mr. Carter on 10/21/21 in stable condition, awake,\nand appropriately responsive for further treatment. We appreciate the\ntransfer of our patient and are available for any further questions.\n\n**Current Recommendations:**\n\n- Continuation of antifungal therapy for a total of at least 4-6 weeks\n\n- Voriconazole level measurement\n\n- Speech therapy consultation\n\n- Rheumatology re-consultation\n\n- Follow-up blood cultures upon detection of Staph. aureus\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Mr. Brian Carter, born on 04/24/1956, who was under\nour inpatient care from 10/21/2021 to 11/08/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Transfer for continuation of antimicrobial\ntherapy for MSSA bacteremia. Transesophageal echocardiogram planned for\ntomorrow. Cleared for full diet by speech therapy today. Patient\nmobilized to standing position for the first time today. Overall,\nmobility is significantly limited, but the patient can mobilize to the\nedge of the bed independently. No pain, no fever, mild cough without\nsputum. No shortness of breath. Mood is significantly depressed, but\nthis is a known issue. Before COVID-19, he was heavily affected by\nrheumatoid arthritis.\n\n**Medical History:** The patient was transferred to our COVID ward after\na positive SARS-CoV-2 RNA PCR test in the naso-oropharyngeal swab and\nrespiratory failure. On physical examination, he had a reduced general\ncondition. Respiratory rate was 24/min, and oxygen saturation was 97% on\n4 L/min of O2 via nasal cannula. Oxygen supply of 4 L via nasal cannula\ncould not be reduced during the course. A chest X-ray performed on 11/21\nshowed increasingly loosened infiltrates in the left basal region and a\nminimal effusion at the base.\n\nA SARS-CoV-2 RNA PCR test from 11/10/2020 was negative, so Mr. Carter\nwas no longer in isolation.\n\nDue to the detection of Aspergillus fumigatus in bronchoalveolar lavage,\nintravenous Voriconazole therapy initiated on 10/07/2021 was continued\nand was planned to be adjusted according to drug level monitoring.\nAdditionally, Staph. aureus was identified in a blood culture, and\nStaph. epidermidis. Antibiotic therapy with Cefazolin was started on\n10/22 and was to be continued for a total of 14 days after the first\nnegative blood culture. The central venous catheter, likely the source\nof infection, was removed on 10/22, and microbiological examination of\nthe catheter tip indicated suspicion of Staphylococci. To rule out\nendocarditis, a transesophageal echocardiogram was scheduled for 10/24.\nMr. Carter has already been informed about this intervention, and\nFraxiparine was to be paused on the evening of 10/24 and the morning of\n10/27, with the patient kept fasting.\n\nThere is also a known history of rheumatoid arthritis, which was treated\non an outpatient basis with Methotrexate and Prednisolone. Due to the\ncurrent infection, Methotrexate was paused, and after consultation with\nthe rheumatologists, it was decided to continue with prednisolone 5mg.\nAfter complete pulmonary recovery, a rheumatology re-consultation was\nplanned, and the resumption of methotrexate was considered.\n\nUpon admission, the patient had significant dysphagia, which improved\nduring the course. A flexible endoscopic swallowing examination\nperformed on 10/24/2021 by speech therapists and phoniatrics revealed a\nnormal swallow reflex. Mr. Carter can now resume a regular diet.\n\n**Physical Examination:** Weight: 83 kg, Height: 182 cm. Temperature:\n36.5°C, Heart rate: 80/min, Respiratory rate: 25/min, Blood pressure:\n130/80 mmHg, Oxygen saturation: 98% with 2 L/min O2\n\n[Skin/mucous membranes:]{.underline} No edema, no skin abnormalities.\nCentral venous catheter exit site on the neck is unremarkable.\n\n[Head/neck:]{.underline} Own teeth, intact mucous membranes\n\n[Heart]{.underline}: Rhythmic, tachycardic up to 100/min, clear heart\nsounds, no murmurs\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no adventitious\nsounds\n\n[Abdomen]{.underline}: Soft, active bowel sounds, no tenderness, no\nresistance\n\n[Lymph nodes:]{.underline} Cervical, axillary nodes not palpable\n\n[Vessels]{.underline}: Foot pulses palpable\n\n[Musculoskeletal:]{.underline} Muscle strength reduced due to CIP/CIM.\nCan mobilize to the bedside independently\n\n[Basic neurological examination:]{.underline} Alert, oriented, friendly\n\n[Psychological state]{.underline}: Depressed mood\n\n**Therapy and Progression:** The emergency presentation of Mr. Carter\nwas on 09/28/2021 due to severe dyspnea and respiratory insufficiency.\nAfter direct transfer to Intensive Care Unit, despite intensified oxygen\ntherapy with nasal high flow and mask CPAP, adequate oxygenation could\nnot be achieved, leading to intubation on 10/29/21.\n\nLung-protective ventilation was initiated due to leading oxygenation\nimpairment, with inhalational supportive NO therapy and conservative\nARDS therapy, including positional changes (a total of 9 sessions of 16\nhours each from 09/29/21 to 10/08/21). Due to elevated PCT levels, the\npatient received empiric antibiotic therapy with\nPiperacillin/Tazobactam, escalated to Meropenem. Voriconazole was\ninitiated on 10/07/2021 after the detection of Aspergillus in\ntracheobronchial secretions and BAL (intended treatment duration 4-6\nweeks).\n\nSubtherapeutic anticoagulation with Fraxiparine was administered for the\nprevention of thrombotic complications in the context of COVID-19. Under\nthis treatment regimen, gas exchange steadily improved, and on 10/12/21,\nthe patient was transferred with low catecholamine requirements for\nweaning from mechanical ventilation and sedation. There, he was\nextubated on 10/13/21.\n\nAfter extubation, severe dysphagia was observed, and speech therapy was\nconsulted. Oral diet is currently not possible, so Mr. Carter is on\nparenteral nutrition. This led to a paravasate in the right upper\nextremity with painful erythema. Adequate pain control was achieved with\nlocal cooling and subcutaneous Piritramide, as needed.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- ------------ ---------------------\n Absolute Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.3 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.61 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\>90 \\>90\n BUN 23 mg/dL 17-48 mg/dL\n Total Bilirubin 0.18 mg/dL \\< 1.20 mg/dL\n C-Reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 6.1 ng/L \\< 14 ng/L\n ALT 50 U/L \\< 41 U/L\n AST 40 U/L \\< 50 U/L\n Alkaline Phosphatase 111 U/L 40-130 U/L\n Gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cells 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.56 K/µL 3.90-10.50 K/µL\n Platelets 280 K/µL 150-370 K/µL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Prothrombin Time 89% 78-123%\n INR 1.09 0.90-1.25\n Activated Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n**Imaging:**\n\n**Chest X-ray bedside on 09/29/2021:** CT scan of the chest from\n9/28/2021 is available for comparison. Tracheal tube tip supracarinal.\nCentral venous catheter (CVC) via right internal jugular vein, tip in\nthe confluence of veins. Gastric tube tip infradiaphragmatic. Patchy\nconfluent bilateral lung infiltrates, mainly perihilar, left and right\nupper and lower fields. No significant changes compared to the previous\nday. Small bilateral pleural effusions. No pneumothorax in the lying\nposition. Left-sided heart prominence with mild stasis/capillary leak.\n\n**Chest X-ray bedside on 10/3/2021:**\n\n[Findings]{.underline}: Compared to 09/29/2021. Tracheal tube with tip\napproximately 4 cm above the carina. Gastric tube slightly retracted,\ntip located just below the diaphragm. Central venous catheter via the\nright internal jugular vein, currently with the tip in the superior vena\ncava. Regression and loosening of infiltrates (mainly in the lower\nfields on both sides). No significant effusion or pneumothorax. No\nsubstantial volume overload.\n\n**Chest X-ray bedside on 10/6/2021:**\n\n[Findings]{.underline}: Compared to the previous examination on\n11/4/2020. New central venous catheter (CVC) from the left internal\njugular vein with tip in the confluence. No pneumothorax in the lying\nposition, no large pleural effusions. Progressive infiltrates in the\nright lower field, perihilar regions on both sides. No significant\ncentral stasis. Heart not enlarged, mediastinum slim.\n\n**Chest X-ray bedside on 10/11/2021:**\n\n[Findings]{.underline}: Compared to 10/5/2021. Tracheal tube and gastric\ntube as before. Left CVC with the tip currently in the region of the\nbrachiocephalic vein, right CVC via the internal jugular vein with the\ntip in the superior vena cava. No pneumothorax, no effusions, increasing\nconsolidation of infiltrates in the right lower field and retrocardial\nleft with no significant cavitation. Left-biased heart without\nsignificant central congestion.\n\n**Chest X-ray bedside on 10/16/2021:**\n\n[Findings]{.underline}: Compared to previous examinations on 10/11/2021.\nHeart borderline enlarged. Mediastinum, as far as can be assessed from\nslightly rotated images, appears central and slim. Increasing\nconsolidation in the right lower lobe and left lower lobe, which is well\ncompatible with pneumonic infiltrates. At most, a small pleural effusion\non the left. No pneumothorax in the lying position. No signs of\nsignificant congestion. Right jugular catheter projecting into the\nsuperior vena cava. Tracheal tube and left jugular catheter have been\nremoved since the last examination.\n\n**Chest X-ray bedside on 10/20/2021:**\n\n[Findings]{.underline}: Compared to the examination on 10/16/2021. In\nthe course of known COVID pneumonia, there is an increasingly loosened\nappearance of infiltrates in the left basal region. A small effusion\ncontinues to drain basally. Otherwise, no significant changes in the\nshort-term follow-up. Right jugular catheter projecting into the\nsuperior vena cava, as before.\n\n**EKG on 10/27/2021:** Normal sinus rhythm, 86/min. Indeterminate axis.\nPQ interval: 108ms QRS duration: 108ms. QTc interval: 484ms. Peripheral\nlow voltage. Delayed R progression up to and including V3. RS transition\nin V4. No significant ST-T wave changes.\n\n**Ultrasound Abdomen on 11/01/2021:**\n\n[Reason for referral:]{.underline} History of COVID, Aspergillosis\n\n[Liver]{.underline}: Vertical diameter in the midclavicular line on the\nright is 120 mm.\n\n[Biliary tract]{.underline}: Well visualized. No abnormalities in the\nintrahepatic and extrahepatic bile ducts. Maximum width of the common\nbile duct is 3 mm.\n\n[Gallbladder]{.underline}: Well visualized. Normal findings.\n\n[Pancreas]{.underline}: Maximum diameters - Head: 17 mm, Body: 12 mm,\nTail: 15 mm. Well visualized. Normal findings.\n\n[Spleen]{.underline}: Normal size, normal homogeneous internal echo\npattern, no focal changes, hilum is free. Organ size: 120 mm x 38 mm.\n\n[Right kidney:]{.underline} Partially assessable, as far as\nrecognizable, parenchymal edge is age-appropriate, smooth organ contour,\nno urinary obstruction, no stones. Size: 120 mm x 45 mm, parenchymal\nthickness 21 mm.\n\n[Left kidney:]{.underline} Partially assessable, as far as recognizable,\nparenchymal edge is age-appropriate, smooth organ contour, no urinary\nobstruction, no stones. Size: 115 mm x 61 mm, parenchymal thickness 19\nmm.\n\n[Bladder:]{.underline} Well visualized, orthotopically located, normal\nwall proportions, no pathological echo structures in the lumen, normal\norgan size.\n\n[Abdominal vessels:]{.underline} Normal findings.\n\n[Abdominal lymph nodes:]{.underline} No evidence of enlarged lymph nodes\nin the subphrenic region.\n\n[Peritoneum]{.underline}: No free fluid.\n\n[Color duplex sonography of the portal vein:]{.underline} Orthograde\nflow, no evidence of thrombosis.\n\n[Assessment]{.underline}: In the right lower lobe cranial-lateral\n(segment VII), there is an entirely echo-free cystic structure with a\nslightly lobulated contour. There is no \\\"double wall,\\\" and there are\nno features suggestive of Echinococcus. This is most likely a congenital\ncyst. The overall structure, architecture, and texture of the liver are\nnormal, with no other focal abnormalities. In the rest of the abdomen,\nthere are no other pathological findings.\n\n**Cardiology Consultation on 10/29/2021:**\n\n**Medical History:** The patient reports thoracic complaints following\nthe intensive care unit stay post-COVID. These pains have been noticed\nwith mild exertion and are described as retrosternal with radiation to\nthe left chest. This last occurred on Sunday afternoon, lasting for\napproximately 1 hour and then spontaneously resolving at rest. This pain\ncannot be induced by a change in position, coughing, or deep\ninspiration. Dyspnea is continuously present, and the patient still\nrequires oxygen. Dyspnea worsens when lying down.\n\n**Cardiovascular risk factors**: Mildly elevated blood pressure\n(hypertension) since May of this year, managed with half a tablet\naccording to self-measurements (averaging 120/80 mmHg, rarely in the\n130s). Lipid profile checked by the general practitioner earlier this\nyear, presumably with good results. No known diabetes. Former smoker\nuntil 2007, but it is difficult to estimate the pack-years, as smoking\noccurred on occasions and during stressful times, less than 15\npack-years. No family history of cardiovascular diseases.\nUveitis/scleritis/episcleritis managed with 10mg MTX per week and 5 mg p\n\nPrednisolone orally daily, well-controlled without recurrence.\n\n**Physical Examination**: Lungs with moist rales bilaterally. Cardiac\nexamination with faint heart sounds. Regular heart rate of 80/min. No\npericardial rub. Pale-gray skin color. Respiratory rate of 15/min while\nsitting. Radial pulses palpable bilaterally. Groin pulses not examined.\nAllen\\'s test operable on the right, borderline on the left.\n\n**ECG**: tachycardic sinus rhythm with a heart rate of 109/min, left\naxis deviation, regular R-wave progression in chest leads, mild\nS-persistence in V6, no significant ST-T wave changes.\n\n**Transthoracic and transesophageal echocardiography on 11/27/2020**:\n\n[Kinetics]{.underline}: Hypokinesia of the lateral and anterior walls,\notherwise normokinetic and synergistic. Systolic function (right\nventricle): TAPSE 18 mm (\\> 16 mm), RV-S\\' 17.6 cm/s (\\> 10 cm/s).\n\n[Valves]{.underline}: Mitral valve - Delicate leaflets, good opening\nmotion, no significant insufficiency. Lambl\\'s excrescences on the\natrial side. Small fluttering structure at the subvalvular apparatus,\ncompatible with chordae tendineae. Aortic valve - Tricuspid, delicate\nvalve. Functionally intact (AV Vmax 1.0 m/s). Tricuspid valve -\nMorphologically normal. Mild insufficiency. TR Vmax 1.9 m/s, sPAP 15\nmmHg + CVP. Pulmonic valve - Morphologically and functionally normal.\n\n[Other Findings:]{.underline} No pericardial effusion. Small Persistent\nForamen Ovale. Left atrial appendage free of intracavitary thrombi at\n60°/90°/150°. Thoracic aorta with smooth-walled plaques, no dissections\nor thrombi.\n\n[Assessment]{.underline}: No structures suggestive of endocarditis. No\nrelevant valvular abnormalities. Incidentally, there is a moderately\nreduced LVEF with wall motion abnormalities in the RIVA (right\nventricular anterior) region. We request a cardiology consultation and\nfurther diagnostics.\n\n**Phoniatric Consultation on 10/24/2021:**\n\n[Medical History:]{.underline} Patient with a history of COVID\npneumonia, twice tested negative. Currently, the patient has Aspergillus\nand pneumonia. Previously, the patient was in the ICU and intubated for\ntwo weeks due to COVID. Following speech therapy for dysphagia, a\nflexible endoscopic evaluation of swallowing (FEES) is requested.\n\n[Findings]{.underline}: FEES reveals a normal configuration of the\nlarynx with good mobility of the tongue and lips. Normal gross mobility\nof the vocal cords during phonation and respiration transitions. Full\nglottic closure appears complete. Flexible transnasal swallow evaluation\n(FEES) with blue dye: Sufficient oral bolus control for liquids, purees,\nand solids. No drooling or leakage. Swallow reflex present. Voluntary\ninitiation of the swallow act is possible. Side-by-side swallowing of\ntest substances over the valleculae without evidence of\npre-/intra-/post-deglutitive penetration or aspiration for all test\nconsistencies. Rosenbeck\\'s Penetration-Aspiration Scale score: 1\n(Minimal retention in the valleculae with puree, which can be completely\ncleared by swallowing). Normal sensitivity, strong cough reflex. No\nnasal regurgitation.\n\n[Assessment]{.underline}: Normal swallowing function.\n\n[Current Recommendations:]{.underline} Able to consume regular diet and\nthin liquids, as well as medications with water.\n\n**Therapy and Progression:** The patient was admitted for further\ntreatment. Upon admission, the patient was in a reduced general\ncondition with significant mobility limitations.\n\nStaphylococcus aureus was detected in a blood culture, leading to a\ntransesophageal echocardiogram (TEE) on 11/26/2020. No vegetations were\nfound, but a moderate hypokinesia of the left ventricle in the RIVA area\nwas observed. Cardiac enzymes were within normal limits. This was\ninterpreted as post-COVID myocarditis, differential diagnosis myocardial\ninjury in severe ARDS, coronary artery disease, or mixed picture.\n\nIn consultation with the cardiology colleagues, a cautious heart failure\nmedication regimen with beta-blockers and ACE inhibitors was initiated.\nWe recommend an elective coronary angiography in the future. Currently,\nthe patient was symptom-free with low cardiac markers and a normal ECG,\nso acute diagnostic procedures were not indicated.\n\nThe antibiotic therapy with Cefazolin was continued until 11/05/2021\n(last sterile blood cultures from 10/24/2021). Staphylococcus\nepidermidis detected in the blood culture on 10/20/21 and at the tip of\nthe central venous catheter on 10/22/21 were considered\ncatheter-associated. The catheter was immediately removed. The patient\ndid not develop a fever during the hospital stay. Inflammatory markers\nimproved over time.\n\nAn abdominal ultrasound was performed due to an unclear liver lesion,\nwhich was found to be a congenital cyst. Echinococcus serology was\nnegative.\n\nIn consultation with the psychiatric colleagues, Quetiapine medication\nwas cautiously resumed for known depression, but it had to be\ndiscontinued later due to significant QTc prolongation. Long-term oxygen\ntherapy of 2 liters was indicated.\n\nOur ophthalmology colleagues recommended the resumption of MTX therapy\ngiven the patient\\'s stable vision. We request this therapy be initiated\nand an outpatient follow-up appointment in ophthalmology arranged after\nthe patient completes rehabilitation.\n\nWith physiotherapy, the patient achieved mobilization up to walking.\nSwallowing and articulation difficulties also significantly improved.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency** **Route**\n ---------------------------------- --------------- ------------------------------ ------------\n Metoprolol Succinate (Toprol XL) 23.8 mg 1-0-1-0 Oral\n Dicloxacillin Sodium (Dynapen) 2176 mg 1-1-1-0 Oral\n Voriconazole (Vfend) 200 mg 2-0-2-0 Oral\n Acetaminophen (Tylenol) 500 mg As needed Oral\n Ipratropium Bromide (Atrovent) 0.26 mg/2 ml 6-0-0-0 Inhalation\n Albuterol Sulfate (ProAir) 1.5 mg/2.5 ml 6-0-0-0 Inhalation\n Amitriptyline (Elavil) 28.3 mg 0-0-1-0 Oral\n Citalopram (Celexa) 50 mg 1-0-0-0 Oral\n Melatonin 2 mg 0-0-2-0 Oral\n Montelukast (Singulair) 10 mg 1-0-0-0 Oral\n Pantoprazole (Protonix) 45 mg 0-0-1-0 Oral\n Eplerenone (Inspra) 25 mg 1-0-0-0 Oral\n Ramipril (Altace) 2.5 mg 0-0-1-0 Oral\n Folic Acid 5 mg 0-0-1-0 48h after MTX intake Oral\n Methotrexate (Trexall) 15 mg 1-0-0-0 Once a Week Oral\n\n\n\n### text_4\n**Dear colleague, **\n\nWe thank you for referring your patient, Mr. Brian Carter, born on\n04/24/1956 to our outpatient care on 02/03/2022.\n\n**Diagnoses**: Suspected Post-Intensive-Care Syndrome with:\n\n- Dysphagia\n\n- ICU-acquired weakness\n\n- Depressive mood, anxiety\n\n**Other Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n<!-- -->\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** Mr. Carter was treated in the intensive care unit\nfor a total of 24 days in September and October 2021 due to COVID-19.\nFollowing intensive care treatment, he underwent neurological\nrehabilitation from 11/08/2021 to 01/18/2022, with the following\nrehabilitation results: \\\"Mr. I. benefited well from the therapies.\nParticularly, physiotherapy helped regain confidence in walking. During\ntreatment, breathing difficulties improved, and oxygen supplementation\nwas no longer necessary.\\\" An antidepressant therapy with Mirtazapine\nwas initiated for sleep disorders and mood swings, resulting in a\nreduction in sleep disturbances.\n\n**Assessment**: Since the illness, Mr. Carter reports general fatigue,\nquick fatigue, and weakness, especially in the lower extremities. He is\ncurrently not undergoing physiotherapy or any other treatments.\nRegarding psychopharmacological therapy, the patient has been seeing a\npsychiatrist once a month based on anamnesis. After a short exertion, he\nexperiences dyspnea and regularly needs to take breaks. Room air\nsaturation was at 94%. Physical examination revealed significant\nexpiratory wheezing and prolonged expiration bilaterally. Furthermore,\nthe patient reports cognitive impairments with marked forgetfulness and\ndifficulty concentrating. This is evident in the reduced results of the\nMiniCog (2/3 words, normal clock, 4 points) and animal naming tests\n(correct single naming of 10 animals, 3 points). Additionally, the\npatient reports an exacerbation of symptoms of depression known since\n2011, including sadness, fatigue, sleep disturbances, and anxiety. These\nworsened during the ICU stay. The current medication includes Citalopram\n40 mg and Mirtazapine 7.5 mg, which have somewhat improved previously\nworsened sleep disturbances. Psychotherapy is not currently taking place\nbut is strongly recommended.\n\nDysphagia diagnosed during the intensive care unit stay has slightly\nimproved, allowing Mr. Carter to consume regular food again. However, he\nstill experiences dysphagia and coughing during each meal. An\nappointment at the swallowing clinic has been scheduled by us (see\nbelow).\n\n**Current Recommendations:**\n\nAs swallowing difficulties persist, an appointment has been scheduled at\nour local swallowing clinic. We also recommend a pulmonary evaluation.\nContact has already been made, and the colleagues from Pulmonology will\nget in touch with Mr. Carter. Furthermore, due to a previously existing\ndepressive mood with currently exacerbated symptoms, we recommend\nconnecting the patient with an outpatient psychotherapist. Some\ntherapists have already been suggested by the patient\\'s general\npractitioner, and we strongly recommend further contact. A prescription\nfor physiotherapy has been issued for pronounced muscle weakness and\nsuspected ICU-acquired weakness. Further physiotherapeutic engagement\nwith the general practitioner\\'s assistance is urgently required.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------- ------------- ---------------------\n Neutrophils 49.0 % 42.0-77.0 %\n Lymphocytes 31.9 % 20.0-44.0 %\n Monocytes 7.2 % 2.0-9.5 %\n Basophils 0.7 % 0.0-1.8 %\n Eosinophils 10.8 % 0.5-5.5 %\n Immature Granulocytes 0.4 % 0.0-1.0 %\n Sodium 139 mEq/L 136-145 mEq/L\n Potassium 3.5 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.99 mg/dL 0.70-1.20 mg/dL\n BUN 25 mg/dL 17-48 mg/dL\n Total Bilirubin 0.45 mg/dL \\< 1.20 mg/dL\n CRP 3.9 mg/dL \\< 5.0 mg/dL\n ALT 21 U/L \\< 41 U/L\n AST 20 U/L \\< 50 U/L\n Alkaline Phosphatase 65 U/L 40-130 U/L\n Gamma-GT 38 U/L 8-61 U/L\n LDH 160 U/L 135-250 U/L\n Lipase 20 U/L 13-60 U/L\n Procalcitonin 0.03 µg/L \\< 0.50 µg/L\n Hemoglobin 13.2 g/dL 13.5-17.0 g/dL\n Hematocrit 44.2 % 39.5-50.5 %\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 7.62 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n\n\n\n\nHere is the query:\nWhat therapy was initiated in Mr. Carter on 09/30/2021 due to radiological suspicion of atypical pneumonia?\n\nChoose the correct answer from the following options:\nA. Methotrexate\nB. Dexamethasone\nC. Piperacillin/Tazobactam, Clarithromycin, and Cotrimoxazole\nD. Meropenem\nE. Voriconazole\n\n\nYour response:\n", "role": "user" }, { "content": "Piperacillin/Tazobactam, Clarithromycin, and Cotrimoxazole", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on our mutual patient, Mr. Brian Carter, born on\n04/24/1956, who was under our inpatient care from 09/28/2021 to\n09/30/2021.\n\n**Diagnosis**: ARDS in the context of a COVID-19 infection\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Mr. Carter presented to our facility on foot\non 09/28/2021 with a five-day history of slowly progressive dyspnea, dry\ncough, and non-apoplectic, holocentral headache. His initial room air\nsaturation was 78%, which improved to 86% with 10 liters of oxygen.\nArterial blood gas analysis revealed an oxygenation disorder with a paO2\nof 50 mmHg, prompting the initiation of NIV therapy, under which Mr.\nCarter remained hemodynamically stable. CT imaging showed bilateral\ninterstitial pneumonia with COVID-typical infiltrates. Both a rapid test\nin the initial care unit and one from his primary care physician were\nnegative for COVID-19. Therefore, we admitted Mr. Carter to our\nintensive care unit for further evaluation.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Alert and cooperative\n\n[Cardiovascular/Abdominal Examination]{.underline}: Severely impaired\noxygenation improved with NIV; Sinus rhythm at 80 beats per minute\n\n[Abdomen]{.underline}: Surgical abdomen\n\n[Renal System:]{.underline} Urination initially scant, then polyuria\nOthers.\n\n**Therapy and Progression:** Upon admission, Mr. Carter was alert,\ncooperative, and hemodynamically stable despite significant oxygenation\nimpairment. Temporary improvement was achieved with differentiated NIV\nmask ventilation. On 09/30, there was a further deterioration in\noxygenation with an increase in respiratory rate and escalation of\nventilator settings, leading to the decision to intubate. A tolerable\nventilation situation was achieved with an oxygenation index of 125. Due\nto radiological suspicion of atypical pneumonia, we initiated empirical\nanti-infective therapy with Piperacillin/Tazobactam, Clarithromycin, and\nCotrimoxazole. Microbiological test results were pending at the time of\ntransfer. We also initiated mucolytic therapy with Ambroxol. The\npre-existing immunosuppressive therapy with Prednisolone was\ndiscontinued and switched to Dexamethasone 10 mg. At the time of\ntransfer, Mr. Carter was hemodynamically stable with low catecholamine\ndoses (0.07 µg/kg/min). A central venous catheter was placed, and\nenteral or parenteral nutrition had not yet been initiated. Diuresis was\nsufficient after a single dose of 20 mg furosemide, with retention\nparameters within the normal range. Prophylactic anticoagulation with\nheparin 500 U/h was initiated.\n\n**Status at Transfer**:\n\n[Neurology]{.underline}: RASS -5 under Propofol and Sufentanil sedation\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline (NA)\n0.07; Hemoglobin 12.8 g/dL\n\n[Lungs]{.underline}: Adequate decarboxylation with borderline\noxygenation: paO2 87.6 under FiO2 0.7; PEEP 16; PEAK 27\n\n[Abdomen]{.underline}: Soft abdomen, no nutrition initiated\n\n[Renal System]{.underline}: Normal urine output without stimulation.\nRetention values within normal range. Clear urine.\n\n[Access]{.underline}: CVC placed on 09/30, left radial artery catheter\nplaced on 09/30.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under our inpatient care from 09/30/2021 to 10/13/2021.\n\n**Diagnosis:** ARDS due to COVID-19 pneumonia with superinfection by\nAspergillus fumigatus\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The patient was admitted from the emergency\ndepartment, presenting with dyspnea and confirmed SARS-CoV-2 infection.\nAfter initial management in the intensive care unit, a non-invasive\nventilation (NIV) trial was attempted, followed by successful\nintubation. The patient was then transferred to the Intensive Care Unit.\n\n**Therapy and Progression:** Upon admission, the patient was sedated,\nintubated, and controlled on mechanical ventilation with mild\ncatecholamine support. Due to oxygenation impairment despite\nlung-protective ventilation and inhaled supportive NO therapy,\nconservative ARDS therapy was initiated, including positioning therapy\n(a total of 9 prone positions). After stabilization of gas exchange with\npositioning therapy, sedation and ventilation weaning were performed.\nGas exchange and oxygenation are currently stable under BIPAP\nventilation (PiP 25 mbar, PEEP 13 mbar, breathing rate 18/min). The\npatient, under reduced analgosedation with Sufentanil and Clonidine,\nexhibits a sufficient awakening response, is adequately responsive, and\nfollows commands with reduced muscle strength.\n\nThe home medication of Methotrexate and Prednisolone for uveitis was\ndiscontinued upon admission. The patient received Dexamethasone for 10\ndays initially and, starting from 11/10, prednisolone with prophylactic\nCotrimoxazole therapy.\n\nUpon detection of Aspergillus in tracheobronchial secretions, antifungal\ntherapy with Voriconazole and Caspofungin (until target Voriconazole\nlevels were achieved) was initiated. The initially started antimicrobial\ntherapy with Piperacillin + Tazobactam was escalated to Meropenem on\n10/05/2021 due to worsening infection parameters and progression of\ninfiltrates on X-ray. Infection parameters have been fluctuating, and\nfever is not currently observed. Diuresis is qualitatively and\nquantitatively within normal limits, and retention parameters are within\nthe normal range.\n\nAnticoagulation was administered in therapeutic doses using\nlow-molecular-weight heparin.\n\nEnteral nutrition is provided through a nasogastric tube, and the\npatient has regular bowel movements.\n\n**Physical Examination:**\n\n[Neurology]{.underline}: Analgosedated, GCS 10, pupils equal and\nreactive, limb movement prompt, follows commands with reduced strength\n\n[Lungs]{.underline}: Intubated with BIPAP 25/13, FiO2 0.4\n\n[Cardiovascular]{.underline}: Normal sinus rhythm, noradrenaline 0.05\n\n[Abdomen]{.underline}: Obese, no tenderness, abdomen soft, oral intake\nvia a nasogastric tube, regular bowel movements\n\n[Diuresis]{.underline}: Normal urine output, retention parameters within\nnormal limits\n\nSkin/Wounds: Some pressure sores from positioning (see nursing handover\nsheet)\n\n[Mobilization]{.underline}: Not conducted\n\n**Imaging:**\n\n**Bedside Chest X-ray from 10/11/2021:**\n\n[Clinical information, question, justifying indication:]{.underline}\nCOVID pneumonia, insertion of a central venous catheter (CVC)\n\n**Assessment**: Comparison with 10/05/21: Endotracheal tube identical,\ngastric tube seen extending well into the abdomen, left CVC currently\npositioned in the brachiocephalic vein region, right CVC via internal\njugular vein with tip in superior vena cava. No pneumothorax, no\neffusions, increasing consolidation of infiltrates in the right lower\nlobe and retrocardially on the left without significant cavitation as\nfar as can be assessed. Left heart without significant central\ncongestion.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Brian Carter, born on 04/24/1956,\nwho was under intensive care treatment from 09/28/2021 to 10/12/2021 and\nin our intensive care unit from 10/13/2021 to 10/21/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** The initial hospital admission of the patient was\nthrough our emergency department due to severe respiratory insufficiency\nin the context of COVID-19 pneumonia.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n -------------------------- ------------ ---------------\n Prednisone (Deltasone) 5 mg 1-0-0\n Methotrexate (Trexall) 25 mg 1-0-0\n Candesartan (Atacand) 4 mg 1-0-0\n Quetiapine (Seroquel) 300 mg 0-0-1\n Amitriptyline (Elavil) 25 mg 0-0-1\n Citalopram (Celexa) 40 mg 1-0-0\n Montelukast (Singulair) 10 mg 1-0-0\n Desloratadine (Clarinex) 5 mg 1-0-0\n\n**Physical Examination:**\n\n[Skin/Mucous Membranes]{.underline}: Warm, Skin Perfusion: Good\nperfusion, Edema: Lower legs\n\n[Head]{.underline}: Mobility: Active and passive free movement, Tongue:\nMoist\n\n[Thorax]{.underline}: Auscultation: Clear bilaterally\n\n[Abdomen]{.underline}: Soft, no guarding, Bowel Sounds: Sparse\nperistalsis, Tenderness: None\n\n[Neurology]{.underline}: Pupil Shape: Round, Pupil Size: Moderate, Light\nReaction: Both sides +++\n\nAlertness: Awake\n\n**ECG on admission:** Tachycardic sinus rhythm with 107/min, Left type,\nP-wave normally configured, normal PQ interval, no pathological Q as in\nPardee-Q, narrow QRS, regular R progression, R/S transition in V3/4, no\nS persistence, no ST segment changes, no discordant T-negatives.\n\n**Therapy and Progression:** Despite intensified oxygen therapy with\nnasal high-flow and mask CPAP, adequate oxygenation could not be\nachieved, and the patient was intubated on 09/29/21. Leading oxygenation\nimpairment led to lung-protective ventilation with inhaled supportive NO\ntherapy and conservative ARDS therapy, including positioning therapy (a\ntotal of 9 prone positions, 16 hours each, from 09/29/21 to 10/8/21).\n\nDue to elevated procalcitonin, the patient received empirical antibiotic\ntreatment with Piperacillin/Tazobactam starting from 10/2/21, which was\nescalated to Meropenem on 10/5/21 and continued until 10/14/21.\n\nAfter the detection of Aspergillus in tracheobronchial secretions and\nBAL, the patient received Voriconazole since 10/7/2021 (treatment\nduration formally 4-6 weeks). Most recently, the level was\nsubtherapeutic, so the dose was adjusted to 2 x 400 mg daily.\n\nThe immunosuppressive therapy with Methotrexate and Prednisolone for\nrheumatoid arthritis was switched to Dexamethasone (09/29 to 10/8) and,\nsince 10/09, Prednisolone monotherapy. After controlling the fungal\ninfection, a rheumatology re-consultation was planned. Furthermore,\nsubtherapeutic anticoagulation with Fraxiparine was initiated for the\nprevention of thrombotic complications in the context of COVID-19.\n\nUnder this treatment regimen, gas exchange continuously improved, and on\n10/12/21, the patient was transferred with low catecholamine\nrequirements for ventilation and sedation weaning. Mr. Carter was\nextubated on 12/13/21 and now maintains good oxygenation with less than\n3L oxygen via nasal cannula. Delirium symptoms after extubation\ncompletely regressed within a few days.\n\nSevere dysphagia was observed after invasive ventilation, leading to a\nspeech therapy consultation. Oral feeding is currently not possible, so\nMr. Carter is receiving parenteral nutrition. As a result, there was a\nparavasate in the upper right extremity with painful erythema. Adequate\npain control was achieved with local cooling and Piritramide as needed.\nDue to continued dietary restrictions, a central venous catheter was\nplaced on 10/20/2021 for parenteral nutrition.\n\nWe request continued speech therapy treatment.\n\nOn 10/21/21, Staphylococcus aureus was detected in blood culture, so we\ninitiated the administration of Flucloxacillin. The MRSA rapid test was\nnegative.\n\nWe are transferring Mr. Carter on 10/21/21 in stable condition, awake,\nand appropriately responsive for further treatment. We appreciate the\ntransfer of our patient and are available for any further questions.\n\n**Current Recommendations:**\n\n- Continuation of antifungal therapy for a total of at least 4-6 weeks\n\n- Voriconazole level measurement\n\n- Speech therapy consultation\n\n- Rheumatology re-consultation\n\n- Follow-up blood cultures upon detection of Staph. aureus\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Brian Carter, born on 04/24/1956, who was under\nour inpatient care from 10/21/2021 to 11/08/2021.\n\n**Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n**Other Diagnoses:**\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Current Presentation:** Transfer for continuation of antimicrobial\ntherapy for MSSA bacteremia. Transesophageal echocardiogram planned for\ntomorrow. Cleared for full diet by speech therapy today. Patient\nmobilized to standing position for the first time today. Overall,\nmobility is significantly limited, but the patient can mobilize to the\nedge of the bed independently. No pain, no fever, mild cough without\nsputum. No shortness of breath. Mood is significantly depressed, but\nthis is a known issue. Before COVID-19, he was heavily affected by\nrheumatoid arthritis.\n\n**Medical History:** The patient was transferred to our COVID ward after\na positive SARS-CoV-2 RNA PCR test in the naso-oropharyngeal swab and\nrespiratory failure. On physical examination, he had a reduced general\ncondition. Respiratory rate was 24/min, and oxygen saturation was 97% on\n4 L/min of O2 via nasal cannula. Oxygen supply of 4 L via nasal cannula\ncould not be reduced during the course. A chest X-ray performed on 11/21\nshowed increasingly loosened infiltrates in the left basal region and a\nminimal effusion at the base.\n\nA SARS-CoV-2 RNA PCR test from 11/10/2020 was negative, so Mr. Carter\nwas no longer in isolation.\n\nDue to the detection of Aspergillus fumigatus in bronchoalveolar lavage,\nintravenous Voriconazole therapy initiated on 10/07/2021 was continued\nand was planned to be adjusted according to drug level monitoring.\nAdditionally, Staph. aureus was identified in a blood culture, and\nStaph. epidermidis. Antibiotic therapy with Cefazolin was started on\n10/22 and was to be continued for a total of 14 days after the first\nnegative blood culture. The central venous catheter, likely the source\nof infection, was removed on 10/22, and microbiological examination of\nthe catheter tip indicated suspicion of Staphylococci. To rule out\nendocarditis, a transesophageal echocardiogram was scheduled for 10/24.\nMr. Carter has already been informed about this intervention, and\nFraxiparine was to be paused on the evening of 10/24 and the morning of\n10/27, with the patient kept fasting.\n\nThere is also a known history of rheumatoid arthritis, which was treated\non an outpatient basis with Methotrexate and Prednisolone. Due to the\ncurrent infection, Methotrexate was paused, and after consultation with\nthe rheumatologists, it was decided to continue with prednisolone 5mg.\nAfter complete pulmonary recovery, a rheumatology re-consultation was\nplanned, and the resumption of methotrexate was considered.\n\nUpon admission, the patient had significant dysphagia, which improved\nduring the course. A flexible endoscopic swallowing examination\nperformed on 10/24/2021 by speech therapists and phoniatrics revealed a\nnormal swallow reflex. Mr. Carter can now resume a regular diet.\n\n**Physical Examination:** Weight: 83 kg, Height: 182 cm. Temperature:\n36.5°C, Heart rate: 80/min, Respiratory rate: 25/min, Blood pressure:\n130/80 mmHg, Oxygen saturation: 98% with 2 L/min O2\n\n[Skin/mucous membranes:]{.underline} No edema, no skin abnormalities.\nCentral venous catheter exit site on the neck is unremarkable.\n\n[Head/neck:]{.underline} Own teeth, intact mucous membranes\n\n[Heart]{.underline}: Rhythmic, tachycardic up to 100/min, clear heart\nsounds, no murmurs\n\n[Lungs]{.underline}: Bilateral vesicular breath sounds, no adventitious\nsounds\n\n[Abdomen]{.underline}: Soft, active bowel sounds, no tenderness, no\nresistance\n\n[Lymph nodes:]{.underline} Cervical, axillary nodes not palpable\n\n[Vessels]{.underline}: Foot pulses palpable\n\n[Musculoskeletal:]{.underline} Muscle strength reduced due to CIP/CIM.\nCan mobilize to the bedside independently\n\n[Basic neurological examination:]{.underline} Alert, oriented, friendly\n\n[Psychological state]{.underline}: Depressed mood\n\n**Therapy and Progression:** The emergency presentation of Mr. Carter\nwas on 09/28/2021 due to severe dyspnea and respiratory insufficiency.\nAfter direct transfer to Intensive Care Unit, despite intensified oxygen\ntherapy with nasal high flow and mask CPAP, adequate oxygenation could\nnot be achieved, leading to intubation on 10/29/21.\n\nLung-protective ventilation was initiated due to leading oxygenation\nimpairment, with inhalational supportive NO therapy and conservative\nARDS therapy, including positional changes (a total of 9 sessions of 16\nhours each from 09/29/21 to 10/08/21). Due to elevated PCT levels, the\npatient received empiric antibiotic therapy with\nPiperacillin/Tazobactam, escalated to Meropenem. Voriconazole was\ninitiated on 10/07/2021 after the detection of Aspergillus in\ntracheobronchial secretions and BAL (intended treatment duration 4-6\nweeks).\n\nSubtherapeutic anticoagulation with Fraxiparine was administered for the\nprevention of thrombotic complications in the context of COVID-19. Under\nthis treatment regimen, gas exchange steadily improved, and on 10/12/21,\nthe patient was transferred with low catecholamine requirements for\nweaning from mechanical ventilation and sedation. There, he was\nextubated on 10/13/21.\n\nAfter extubation, severe dysphagia was observed, and speech therapy was\nconsulted. Oral diet is currently not possible, so Mr. Carter is on\nparenteral nutrition. This led to a paravasate in the right upper\nextremity with painful erythema. Adequate pain control was achieved with\nlocal cooling and subcutaneous Piritramide, as needed.\n\n**Lab results:**\n\n **Parameter** **Result** **Reference Range**\n --------------------------------------- ------------ ---------------------\n Absolute Reticulocytes 0.01/nL \\< 0.01/nL\n Sodium 138 mEq/L 136-145 mEq/L\n Potassium 4.3 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.61 mg/dL 0.70-1.20 mg/dL\n Estimated GFR \\>90 \\>90\n BUN 23 mg/dL 17-48 mg/dL\n Total Bilirubin 0.18 mg/dL \\< 1.20 mg/dL\n C-Reactive Protein 4.1 mg/L \\< 5.0 mg/L\n Troponin-T 6.1 ng/L \\< 14 ng/L\n ALT 50 U/L \\< 41 U/L\n AST 40 U/L \\< 50 U/L\n Alkaline Phosphatase 111 U/L 40-130 U/L\n Gamma-GT 200 U/L 8-61 U/L\n Free Triiodothyronine (T3) 2.3 ng/L 2.00-4.40 ng/L\n Free Thyroxine (T4) 14.2 ng/L 9.30-17.00 ng/L\n Thyroid Stimulating Hormone (TSH) 4.1 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 11.6 g/dL 13.5-17.0 g/dL\n Hematocrit 34.5% 39.5-50.5%\n Red Blood Cells 3.7 M/µL 4.3-5.8 M/µL\n White Blood Cells 9.56 K/µL 3.90-10.50 K/µL\n Platelets 280 K/µL 150-370 K/µL\n MCV 92.5 fL 80.0-99.0 fL\n MCH 31.1 pg 27.0-33.5 pg\n MCHC 33.6 g/dL 31.5-36.0 g/dL\n MPV 8.9 fL 7.0-12.0 fL\n RDW-CV 14.0% 11.5-15.0%\n Prothrombin Time 89% 78-123%\n INR 1.09 0.90-1.25\n Activated Partial Thromboplastin Time 25.3 sec. 22.0-29.0 sec.\n\n**Imaging:**\n\n**Chest X-ray bedside on 09/29/2021:** CT scan of the chest from\n9/28/2021 is available for comparison. Tracheal tube tip supracarinal.\nCentral venous catheter (CVC) via right internal jugular vein, tip in\nthe confluence of veins. Gastric tube tip infradiaphragmatic. Patchy\nconfluent bilateral lung infiltrates, mainly perihilar, left and right\nupper and lower fields. No significant changes compared to the previous\nday. Small bilateral pleural effusions. No pneumothorax in the lying\nposition. Left-sided heart prominence with mild stasis/capillary leak.\n\n**Chest X-ray bedside on 10/3/2021:**\n\n[Findings]{.underline}: Compared to 09/29/2021. Tracheal tube with tip\napproximately 4 cm above the carina. Gastric tube slightly retracted,\ntip located just below the diaphragm. Central venous catheter via the\nright internal jugular vein, currently with the tip in the superior vena\ncava. Regression and loosening of infiltrates (mainly in the lower\nfields on both sides). No significant effusion or pneumothorax. No\nsubstantial volume overload.\n\n**Chest X-ray bedside on 10/6/2021:**\n\n[Findings]{.underline}: Compared to the previous examination on\n11/4/2020. New central venous catheter (CVC) from the left internal\njugular vein with tip in the confluence. No pneumothorax in the lying\nposition, no large pleural effusions. Progressive infiltrates in the\nright lower field, perihilar regions on both sides. No significant\ncentral stasis. Heart not enlarged, mediastinum slim.\n\n**Chest X-ray bedside on 10/11/2021:**\n\n[Findings]{.underline}: Compared to 10/5/2021. Tracheal tube and gastric\ntube as before. Left CVC with the tip currently in the region of the\nbrachiocephalic vein, right CVC via the internal jugular vein with the\ntip in the superior vena cava. No pneumothorax, no effusions, increasing\nconsolidation of infiltrates in the right lower field and retrocardial\nleft with no significant cavitation. Left-biased heart without\nsignificant central congestion.\n\n**Chest X-ray bedside on 10/16/2021:**\n\n[Findings]{.underline}: Compared to previous examinations on 10/11/2021.\nHeart borderline enlarged. Mediastinum, as far as can be assessed from\nslightly rotated images, appears central and slim. Increasing\nconsolidation in the right lower lobe and left lower lobe, which is well\ncompatible with pneumonic infiltrates. At most, a small pleural effusion\non the left. No pneumothorax in the lying position. No signs of\nsignificant congestion. Right jugular catheter projecting into the\nsuperior vena cava. Tracheal tube and left jugular catheter have been\nremoved since the last examination.\n\n**Chest X-ray bedside on 10/20/2021:**\n\n[Findings]{.underline}: Compared to the examination on 10/16/2021. In\nthe course of known COVID pneumonia, there is an increasingly loosened\nappearance of infiltrates in the left basal region. A small effusion\ncontinues to drain basally. Otherwise, no significant changes in the\nshort-term follow-up. Right jugular catheter projecting into the\nsuperior vena cava, as before.\n\n**EKG on 10/27/2021:** Normal sinus rhythm, 86/min. Indeterminate axis.\nPQ interval: 108ms QRS duration: 108ms. QTc interval: 484ms. Peripheral\nlow voltage. Delayed R progression up to and including V3. RS transition\nin V4. No significant ST-T wave changes.\n\n**Ultrasound Abdomen on 11/01/2021:**\n\n[Reason for referral:]{.underline} History of COVID, Aspergillosis\n\n[Liver]{.underline}: Vertical diameter in the midclavicular line on the\nright is 120 mm.\n\n[Biliary tract]{.underline}: Well visualized. No abnormalities in the\nintrahepatic and extrahepatic bile ducts. Maximum width of the common\nbile duct is 3 mm.\n\n[Gallbladder]{.underline}: Well visualized. Normal findings.\n\n[Pancreas]{.underline}: Maximum diameters - Head: 17 mm, Body: 12 mm,\nTail: 15 mm. Well visualized. Normal findings.\n\n[Spleen]{.underline}: Normal size, normal homogeneous internal echo\npattern, no focal changes, hilum is free. Organ size: 120 mm x 38 mm.\n\n[Right kidney:]{.underline} Partially assessable, as far as\nrecognizable, parenchymal edge is age-appropriate, smooth organ contour,\nno urinary obstruction, no stones. Size: 120 mm x 45 mm, parenchymal\nthickness 21 mm.\n\n[Left kidney:]{.underline} Partially assessable, as far as recognizable,\nparenchymal edge is age-appropriate, smooth organ contour, no urinary\nobstruction, no stones. Size: 115 mm x 61 mm, parenchymal thickness 19\nmm.\n\n[Bladder:]{.underline} Well visualized, orthotopically located, normal\nwall proportions, no pathological echo structures in the lumen, normal\norgan size.\n\n[Abdominal vessels:]{.underline} Normal findings.\n\n[Abdominal lymph nodes:]{.underline} No evidence of enlarged lymph nodes\nin the subphrenic region.\n\n[Peritoneum]{.underline}: No free fluid.\n\n[Color duplex sonography of the portal vein:]{.underline} Orthograde\nflow, no evidence of thrombosis.\n\n[Assessment]{.underline}: In the right lower lobe cranial-lateral\n(segment VII), there is an entirely echo-free cystic structure with a\nslightly lobulated contour. There is no \\\"double wall,\\\" and there are\nno features suggestive of Echinococcus. This is most likely a congenital\ncyst. The overall structure, architecture, and texture of the liver are\nnormal, with no other focal abnormalities. In the rest of the abdomen,\nthere are no other pathological findings.\n\n**Cardiology Consultation on 10/29/2021:**\n\n**Medical History:** The patient reports thoracic complaints following\nthe intensive care unit stay post-COVID. These pains have been noticed\nwith mild exertion and are described as retrosternal with radiation to\nthe left chest. This last occurred on Sunday afternoon, lasting for\napproximately 1 hour and then spontaneously resolving at rest. This pain\ncannot be induced by a change in position, coughing, or deep\ninspiration. Dyspnea is continuously present, and the patient still\nrequires oxygen. Dyspnea worsens when lying down.\n\n**Cardiovascular risk factors**: Mildly elevated blood pressure\n(hypertension) since May of this year, managed with half a tablet\naccording to self-measurements (averaging 120/80 mmHg, rarely in the\n130s). Lipid profile checked by the general practitioner earlier this\nyear, presumably with good results. No known diabetes. Former smoker\nuntil 2007, but it is difficult to estimate the pack-years, as smoking\noccurred on occasions and during stressful times, less than 15\npack-years. No family history of cardiovascular diseases.\nUveitis/scleritis/episcleritis managed with 10mg MTX per week and 5 mg p\n\nPrednisolone orally daily, well-controlled without recurrence.\n\n**Physical Examination**: Lungs with moist rales bilaterally. Cardiac\nexamination with faint heart sounds. Regular heart rate of 80/min. No\npericardial rub. Pale-gray skin color. Respiratory rate of 15/min while\nsitting. Radial pulses palpable bilaterally. Groin pulses not examined.\nAllen\\'s test operable on the right, borderline on the left.\n\n**ECG**: tachycardic sinus rhythm with a heart rate of 109/min, left\naxis deviation, regular R-wave progression in chest leads, mild\nS-persistence in V6, no significant ST-T wave changes.\n\n**Transthoracic and transesophageal echocardiography on 11/27/2020**:\n\n[Kinetics]{.underline}: Hypokinesia of the lateral and anterior walls,\notherwise normokinetic and synergistic. Systolic function (right\nventricle): TAPSE 18 mm (\\> 16 mm), RV-S\\' 17.6 cm/s (\\> 10 cm/s).\n\n[Valves]{.underline}: Mitral valve - Delicate leaflets, good opening\nmotion, no significant insufficiency. Lambl\\'s excrescences on the\natrial side. Small fluttering structure at the subvalvular apparatus,\ncompatible with chordae tendineae. Aortic valve - Tricuspid, delicate\nvalve. Functionally intact (AV Vmax 1.0 m/s). Tricuspid valve -\nMorphologically normal. Mild insufficiency. TR Vmax 1.9 m/s, sPAP 15\nmmHg + CVP. Pulmonic valve - Morphologically and functionally normal.\n\n[Other Findings:]{.underline} No pericardial effusion. Small Persistent\nForamen Ovale. Left atrial appendage free of intracavitary thrombi at\n60°/90°/150°. Thoracic aorta with smooth-walled plaques, no dissections\nor thrombi.\n\n[Assessment]{.underline}: No structures suggestive of endocarditis. No\nrelevant valvular abnormalities. Incidentally, there is a moderately\nreduced LVEF with wall motion abnormalities in the RIVA (right\nventricular anterior) region. We request a cardiology consultation and\nfurther diagnostics.\n\n**Phoniatric Consultation on 10/24/2021:**\n\n[Medical History:]{.underline} Patient with a history of COVID\npneumonia, twice tested negative. Currently, the patient has Aspergillus\nand pneumonia. Previously, the patient was in the ICU and intubated for\ntwo weeks due to COVID. Following speech therapy for dysphagia, a\nflexible endoscopic evaluation of swallowing (FEES) is requested.\n\n[Findings]{.underline}: FEES reveals a normal configuration of the\nlarynx with good mobility of the tongue and lips. Normal gross mobility\nof the vocal cords during phonation and respiration transitions. Full\nglottic closure appears complete. Flexible transnasal swallow evaluation\n(FEES) with blue dye: Sufficient oral bolus control for liquids, purees,\nand solids. No drooling or leakage. Swallow reflex present. Voluntary\ninitiation of the swallow act is possible. Side-by-side swallowing of\ntest substances over the valleculae without evidence of\npre-/intra-/post-deglutitive penetration or aspiration for all test\nconsistencies. Rosenbeck\\'s Penetration-Aspiration Scale score: 1\n(Minimal retention in the valleculae with puree, which can be completely\ncleared by swallowing). Normal sensitivity, strong cough reflex. No\nnasal regurgitation.\n\n[Assessment]{.underline}: Normal swallowing function.\n\n[Current Recommendations:]{.underline} Able to consume regular diet and\nthin liquids, as well as medications with water.\n\n**Therapy and Progression:** The patient was admitted for further\ntreatment. Upon admission, the patient was in a reduced general\ncondition with significant mobility limitations.\n\nStaphylococcus aureus was detected in a blood culture, leading to a\ntransesophageal echocardiogram (TEE) on 11/26/2020. No vegetations were\nfound, but a moderate hypokinesia of the left ventricle in the RIVA area\nwas observed. Cardiac enzymes were within normal limits. This was\ninterpreted as post-COVID myocarditis, differential diagnosis myocardial\ninjury in severe ARDS, coronary artery disease, or mixed picture.\n\nIn consultation with the cardiology colleagues, a cautious heart failure\nmedication regimen with beta-blockers and ACE inhibitors was initiated.\nWe recommend an elective coronary angiography in the future. Currently,\nthe patient was symptom-free with low cardiac markers and a normal ECG,\nso acute diagnostic procedures were not indicated.\n\nThe antibiotic therapy with Cefazolin was continued until 11/05/2021\n(last sterile blood cultures from 10/24/2021). Staphylococcus\nepidermidis detected in the blood culture on 10/20/21 and at the tip of\nthe central venous catheter on 10/22/21 were considered\ncatheter-associated. The catheter was immediately removed. The patient\ndid not develop a fever during the hospital stay. Inflammatory markers\nimproved over time.\n\nAn abdominal ultrasound was performed due to an unclear liver lesion,\nwhich was found to be a congenital cyst. Echinococcus serology was\nnegative.\n\nIn consultation with the psychiatric colleagues, Quetiapine medication\nwas cautiously resumed for known depression, but it had to be\ndiscontinued later due to significant QTc prolongation. Long-term oxygen\ntherapy of 2 liters was indicated.\n\nOur ophthalmology colleagues recommended the resumption of MTX therapy\ngiven the patient\\'s stable vision. We request this therapy be initiated\nand an outpatient follow-up appointment in ophthalmology arranged after\nthe patient completes rehabilitation.\n\nWith physiotherapy, the patient achieved mobilization up to walking.\nSwallowing and articulation difficulties also significantly improved.\n\n**Medication upon Discharge:**\n\n **Medication** **Dosage** **Frequency** **Route**\n ---------------------------------- --------------- ------------------------------ ------------\n Metoprolol Succinate (Toprol XL) 23.8 mg 1-0-1-0 Oral\n Dicloxacillin Sodium (Dynapen) 2176 mg 1-1-1-0 Oral\n Voriconazole (Vfend) 200 mg 2-0-2-0 Oral\n Acetaminophen (Tylenol) 500 mg As needed Oral\n Ipratropium Bromide (Atrovent) 0.26 mg/2 ml 6-0-0-0 Inhalation\n Albuterol Sulfate (ProAir) 1.5 mg/2.5 ml 6-0-0-0 Inhalation\n Amitriptyline (Elavil) 28.3 mg 0-0-1-0 Oral\n Citalopram (Celexa) 50 mg 1-0-0-0 Oral\n Melatonin 2 mg 0-0-2-0 Oral\n Montelukast (Singulair) 10 mg 1-0-0-0 Oral\n Pantoprazole (Protonix) 45 mg 0-0-1-0 Oral\n Eplerenone (Inspra) 25 mg 1-0-0-0 Oral\n Ramipril (Altace) 2.5 mg 0-0-1-0 Oral\n Folic Acid 5 mg 0-0-1-0 48h after MTX intake Oral\n Methotrexate (Trexall) 15 mg 1-0-0-0 Once a Week Oral\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe thank you for referring your patient, Mr. Brian Carter, born on\n04/24/1956 to our outpatient care on 02/03/2022.\n\n**Diagnoses**: Suspected Post-Intensive-Care Syndrome with:\n\n- Dysphagia\n\n- ICU-acquired weakness\n\n- Depressive mood, anxiety\n\n**Other Diagnoses:**\n\n- COVID-19 with severe ARDS\n\n- Symptoms began on 09/24/2021 with progressive dyspnea, cough, and\n headache\n\n- Initial detection of SARS-CoV-2 on 09/28/2021 in nasopharyngeal swab\n\n- Dexamethasone from 09/29 to 10/8/2021\n\n- Prone positioning from 09/18 to 10/8 and NO therapy\n\n- Intubation on 09/30, initial extubation on 10/13\n\n- Reporting to the health department by the referring physician\n\n- Pulmonary superinfection with detection of Aspergillus fumigatus\n\n- Voriconazole therapy since 10/7/2021\n\n- Bacteremia with detection of Staphylococcus aureus in blood culture\n on 10/19/21\n\n- Flucloxacillin since 10/21/2021\n\n- Thrombophlebitis of the right forearm\n\n- Left eye pigment epithelium clumping, suggestive of a history of\n retinal central serous chorioretinopathy\n\n<!-- -->\n\n- Rheumatoid arthritis\n\n- Uveitis\n\n- Bronchial asthma\n\n- Arterial hypertension\n\n- Depression\n\n**Medical History:** Mr. Carter was treated in the intensive care unit\nfor a total of 24 days in September and October 2021 due to COVID-19.\nFollowing intensive care treatment, he underwent neurological\nrehabilitation from 11/08/2021 to 01/18/2022, with the following\nrehabilitation results: \\\"Mr. I. benefited well from the therapies.\nParticularly, physiotherapy helped regain confidence in walking. During\ntreatment, breathing difficulties improved, and oxygen supplementation\nwas no longer necessary.\\\" An antidepressant therapy with Mirtazapine\nwas initiated for sleep disorders and mood swings, resulting in a\nreduction in sleep disturbances.\n\n**Assessment**: Since the illness, Mr. Carter reports general fatigue,\nquick fatigue, and weakness, especially in the lower extremities. He is\ncurrently not undergoing physiotherapy or any other treatments.\nRegarding psychopharmacological therapy, the patient has been seeing a\npsychiatrist once a month based on anamnesis. After a short exertion, he\nexperiences dyspnea and regularly needs to take breaks. Room air\nsaturation was at 94%. Physical examination revealed significant\nexpiratory wheezing and prolonged expiration bilaterally. Furthermore,\nthe patient reports cognitive impairments with marked forgetfulness and\ndifficulty concentrating. This is evident in the reduced results of the\nMiniCog (2/3 words, normal clock, 4 points) and animal naming tests\n(correct single naming of 10 animals, 3 points). Additionally, the\npatient reports an exacerbation of symptoms of depression known since\n2011, including sadness, fatigue, sleep disturbances, and anxiety. These\nworsened during the ICU stay. The current medication includes Citalopram\n40 mg and Mirtazapine 7.5 mg, which have somewhat improved previously\nworsened sleep disturbances. Psychotherapy is not currently taking place\nbut is strongly recommended.\n\nDysphagia diagnosed during the intensive care unit stay has slightly\nimproved, allowing Mr. Carter to consume regular food again. However, he\nstill experiences dysphagia and coughing during each meal. An\nappointment at the swallowing clinic has been scheduled by us (see\nbelow).\n\n**Current Recommendations:**\n\nAs swallowing difficulties persist, an appointment has been scheduled at\nour local swallowing clinic. We also recommend a pulmonary evaluation.\nContact has already been made, and the colleagues from Pulmonology will\nget in touch with Mr. Carter. Furthermore, due to a previously existing\ndepressive mood with currently exacerbated symptoms, we recommend\nconnecting the patient with an outpatient psychotherapist. Some\ntherapists have already been suggested by the patient\\'s general\npractitioner, and we strongly recommend further contact. A prescription\nfor physiotherapy has been issued for pronounced muscle weakness and\nsuspected ICU-acquired weakness. Further physiotherapeutic engagement\nwith the general practitioner\\'s assistance is urgently required.\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n ----------------------- ------------- ---------------------\n Neutrophils 49.0 % 42.0-77.0 %\n Lymphocytes 31.9 % 20.0-44.0 %\n Monocytes 7.2 % 2.0-9.5 %\n Basophils 0.7 % 0.0-1.8 %\n Eosinophils 10.8 % 0.5-5.5 %\n Immature Granulocytes 0.4 % 0.0-1.0 %\n Sodium 139 mEq/L 136-145 mEq/L\n Potassium 3.5 mEq/L 3.5-4.5 mEq/L\n Creatinine 0.99 mg/dL 0.70-1.20 mg/dL\n BUN 25 mg/dL 17-48 mg/dL\n Total Bilirubin 0.45 mg/dL \\< 1.20 mg/dL\n CRP 3.9 mg/dL \\< 5.0 mg/dL\n ALT 21 U/L \\< 41 U/L\n AST 20 U/L \\< 50 U/L\n Alkaline Phosphatase 65 U/L 40-130 U/L\n Gamma-GT 38 U/L 8-61 U/L\n LDH 160 U/L 135-250 U/L\n Lipase 20 U/L 13-60 U/L\n Procalcitonin 0.03 µg/L \\< 0.50 µg/L\n Hemoglobin 13.2 g/dL 13.5-17.0 g/dL\n Hematocrit 44.2 % 39.5-50.5 %\n Red Blood Cells 5.2 M/µL 4.3-5.8 M/µL\n White Blood Cells 7.62 K/µL 3.90-10.50 K/µL\n Platelets 281 K/µL 150-370 K/µL\n", "title": "text_4" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n\n\n\n\nHere is the query:\nWhich medication is NOT part of Mr. Hurley's post-transplantation regimen?\n\nChoose the correct answer from the following options:\nA. Acyclovir\nB. Entecavir\nC. Mycophenolate Mofetil\nD. Cyclosporine\nE. Methotrexate\n\n\nYour response:\n", "role": "user" }, { "content": "Methotrexate", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who has been\nunder our outpatient treatment since 02/11/2020.\n\n**Diagnoses:**\n\n- Refractory tuberculosis\n\n- Manifestations: Open pulmonary tuberculosis, lymph node tuberculosis\n (cervical, hilar, mediastinal), liver tuberculosis\n\n**Imaging:**\n\n- 11/01/19 Chest CT: Mediastinal lymph node conglomerate centrally\n with poststenotic infiltrates on both sides. Splenomegaly.\n\n- 11/04/19 Bronchoscopy: Large mediastinal and right hilar lymphomas.\n Subcritical constriction of right segmental bronchi. EBUS-TBNA LK4R\n and 10/11R.\n\n**Microbiology:**\n\n- 11/04/19 Tracheobronchial Secretions: Microscopic detection of\n acid-fast rods, cultural detection of Mycobacterium tuberculosis,\n phenotypically no evidence of resistance.\n\n**Therapy:**\n\n- Initial omission of pyrazinamide due to pancytopenia.\n\n- Moxifloxacin: 11/10/19-11/20/19\n\n- Pyrazinamide: 11/20/19-02/11/20\n\n- Ethambutol: 11/08/19-02/11/20\n\n- Rifampicin since: 11/08/19\n\n- Isoniazid since: 11/08/19\n\n- Levofloxacin since: 02/11/20\n\n- Immunomodulatory therapy for low basal interferon / interferon\n levels (ACTIMMUNE®)\n\n**Microbiology:**\n\n- 01/20/20 Sputum: Cultural detection of Mycobacterium tuberculosis:\n Phenotypically no evidence of resistance.\n\n- 01/02/20 Sputum: Last cultural detection of Mycobacterium\n tuberculosis.\n\n- 06/15/20 BAL: Occasional acid-fast rods, 16S-rRNA-PCR: M.\n tuberculosis complex, no cultural evidence of Mycobacteria.\n\n- 06/15/20 Lung biopsy: Occasional acid-fast rods, no cultural\n evidence of Mycobacteria.\n\n- 03/12/21 Sputum: first sputum without acid-fast rods, consistently\n microscopically negative sputum samples since then.\n\n**Histology:**\n\n- 07/16/21: Mediastinal lymph node biopsy: Histologically no evidence\n of malignancy/lymphoma.\n\n**Other Diagnoses: **\n\n- Secondary Acute Myeloid Leukemia with Myelodysplastic Syndrome\n\n- Blood count at initial diagnosis: 15% blasts, erythrocyte\n substitution required.\n\n**Therapy:**\n\n- 12/20-03/21 TB therapy\n\n- 02/20-01/21 TB therapy: RMP + INH + FQ\n\n- 01/21-04/21 RMP + INH + FQ + Actimmune® 04/22 CT: Regressive\n findings of pulmonary TB changes, regressive cervical lymph nodes,\n mediastinal LAP, and liver lesions size-stable; Sputum: No acid-fast\n rods detected for the first time since 03/21.\n\n- BM aspiration: Secondary AML.\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation\n\nPathogen Location / Material of Detection or Infection Month/Year or\nLast Detection\n\n- HIV Serology: Negative - 11/19\n\n- Mycobacterium tuberculosis Complex: Bronchoalveolar Lavage,\n Tracheobronchial Secretion, Sputum - 11/19\n\n**Medical History:** We took over Mr. Hurley for the continuation of TB\ntherapy on 11/02/20. His hospital admission took place at the end of\nOctober 2019 due to neutropenic fever. The patient reported temperatures\nup to 39°C for the past 3 days. Since 08/19, the patient has been\nreceiving hematological-oncological treatment for MDS. The colleagues\nfrom hematology performed a repeat bone marrow aspiration before\ntransferring to Station 12. The blast percentage was significantly\nreduced. HLA typing of the brother for allogeneic stem cell\ntransplantation planning had already been done in the summer of 2019.\nAfter a chest CT revealed extensive mediastinal lymphomas with\ncompression of the bronchial tree bilaterally and post-stenotic\ninfiltrates, a bronchoscopy was performed. M. tuberculosis was cultured\nfrom sputum and TBS. An EBUS-guided lymph node biopsy was histologically\nprocessed, revealing granulomatous inflammation and molecular evidence\nof the M. tuberculosis complex. On 11/08/19, a four-drug\nanti-tuberculosis therapy was initiated, initially with Moxifloxacin\ninstead of Pyrazinamide due to pancytopenia. Moxifloxacin was replaced\nby Pyrazinamide on 11/20/19. The four-drug therapy was continued for a\ntotal of 3 months due to prolonged microscopic evidence of acid-fast\nrods in follow-up sputum samples. Isoniazid dosage was adjusted after\npeak level control (450 mg q24h), as was Rifampicin dose (900 mg q24h).\nOn 01/02/20, Mycobacterium tuberculosis was last cultured in a sputum\nsample. Nevertheless, acid-fast rods continued to be detected in the\nsputum. Due to the lack of culturability of mycobacteria, Mr. Hurley was\ndischarged to home care after consultation with the Tuberculosis Welfare\nOffice.\n\n**Allergies**: None known. Toxic Substances: Smoking: Non-smoker;\nAlcohol: No; Drugs: No\n\n**Social History:** Originally from Brazil, has been living in the US\nfor 8 years. Lives with his partner.\n\n**Current lab results:**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------------- -------------- ---------------------\n ConA-Induced Cytokines (Th1/Th2) \n Interleukin 10 10 pg/mL \\< 364 pg/mL\n Interferon Gamma 265-6781 pg/mL\n Interleukin 2 74 pg/mL 43-374 pg/mL\n Interleukin 4 13 pg/mL \\< 34 pg/mL\n Interleukin 5 3 pg/mL \\< 55 pg/mL\n Naive CD45RA+CCR7+ (% of CD8+) 6.35 % 8.22-59.58 %\n TEMRA CD45RA+CCR7- (% of CD8+) 50.44 % 7.32-55.99 %\n Central Memory CD45RA-CCR7+ (% of CD) 2.60 % 1.67-5.84 %\n Effector Memory CD45RA-CCR7- (% of CD) 40.60 % 22.52-62.25 %\n Naive CD45RA+ (% of CD4+) 26.26 % 17.46-60.24 %\n TEMRA CD45RA+ CCR7- (% of CD4+) 1.26 % 2.74-15.54 %\n Central Memory CD45RA-CCR7+ (% of CD) 34.21 % 16.40-33.41 %\n Effector Memory CD45RA-CCR7- (% of CD) 38.28 % 17.38-40.38 %\n Granulocytes 0.60 abs./nL 3.00-6.50 abs./nL\n Granulocytes (relative) 45 % 50-80 %\n Lymphocytes 0.57 abs./nL 1.50-3.00 abs./nL\n Lymphocytes (relative) 43 % 20-40 %\n Monocytes 0.13 abs./nL \\<0.50 abs./nL\n Monocytes (relative) 10 % 2-10 %\n NK Cells 0.16 abs./nL 0.10-0.40 abs./nL\n NK Cells (% of Lymphocytes) 29 5-25\n γ/δ TCR+ T-Cells (relative) 2 % \\< 10 %\n α/β TCR+ T-Cells (relative) 98 % \\>90 %\n CD19+ B-Cells (% of Lymphocytes) 3 % 5-25 %\n CD4/CD8 Ratio 0.9 % 1.1-3.0 %\n CD8-CD4-T-Cells (% of T-Cells) 5.86 % \\< 15.00 %\n CD8+CD4+-T-Cells (% of T-Cells) 0.74 % \\< 10.00 %\n CD3+ T-Cells 0.38 abs./nL 0.90-2.20 abs./nL\n\n **Parameter** **Results** **Reference Range**\n -------------------------------------------------- ---------------- ---------------------\n Complete Blood Count (EDTA) \n Hemoglobin 6.6 g/dL 13.5-17.0 g/dL\n Hematocrit 19.0 % 39.5-50.5 %\n Erythrocytes 2.3 x 10\\^6/uL 4.3-5.8 x 10\\^6/uL\n Platelets 61 x 10\\^3/uL 150-370 x 10\\^3/uL\n MCV (Mean Corpuscular Volume) 81.5 fL 80.0-99.0 fL\n MCH (Mean Corpuscular Hemoglobin) 28.3 pg 27.0-33.5 pg\n MCHC (Mean Corpuscular Hemoglobin Concentration) 34.7 g/dL 31.5-36.0 g/dL\n MPV (Mean Platelet Volume) 10.4 fL 7.0-12.0 fL\n RDW-CV (Red Cell Distribution Width-CV) 12.7 % 11.5-15.0 %\n\n **Parameter** **Results** **Reference Range**\n -------------------------- ------------- ---------------------\n Other Investigations \n QFT-TB Gold plus TB1 0.11 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus TB2 0.07 IU/mL \\<0.35 IU/mL\n QFT-TB Gold plus Mitogen 3.38 IU/mL \\>0.50 IU/mL\n QFT-TB Gold plus Result Negative \n\n**Lung Aspiration from 06/15/20:** Examination Request: Acid-fast rods\n(Microscopy + Culture) **Microscopic Findings:**\n\n- Auramine stain: Occasionally, acid-fast rods Result: No growth of\n Mycobacterium sp. after 12 weeks of incubation.\n\n2. Forceps Biopsy Exophytic Trachea: One piece of tissue. Microscopy:\n HE, PAS, Giemsa, Diagnosis:\n\n3. Predominantly blood clot and necrotic material alongside sparsely\n altered lymphatic tissue due to sampling (EBUS-TBNA LK 7 as\n indicated).\n\n4. Components of a granulation tissue polyp (Forceps Biopsy Exophytic\n Trachea as indicated). Comment: The finding in 1. continues to be\n suspicious of a mycobacterial infection. We are conducting molecular\n pathological examinations in this regard and will report again.\n\n> [Comment]{.underline}: Detection of mycobacterial DNA of the M.\n> tuberculosis complex type. No evidence of atypical mycobacteria. No\n> evidence of malignancy.\n\n**Current Medication:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**\\\n**\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our patient Mr. Bruno Hurley, born on 12/24/1965.\n\nWho has received inpatient treatment from 07/17/2021 to 09/03/2021.\n\n**Diagnoses**:\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n<!-- -->\n\n- Myelodysplastic Syndrome EB-2, diagnosed in July 2010. Blood count\n at initial diagnosis: 15% blasts, erythrocyte transfusion-dependent.\n Cytogenetics: 46,XY \\[1\\]; 47,XY,+Y,i(21)(q10)\\[15\\];\n 47,XY,+Y,trp(21)(q11q22)\\[4\\]. Molecular genetics: Mutations in\n RUNX1, SF3B1. IPSS-R: 7 (very high risk).\n\n- In 08/2020, diagnosed with Myelodysplastic Syndrome with ring\n sideroblasts.\n\n- Received transfusions of 2 units of red blood cells every 3-4 weeks\n to maintain hemoglobin between 4-6 g/dL.\n\n- Bone marrow biopsy showed MDS-EB2 with 14.5% blasts.\n\n- Initiated Azacitidine treatment (2x 75 mg subcutaneously, days 1-5 +\n 8-9 every 4 weeks) as an outpatient.\n\n- 10/23/2019: Hospitalized for fever during neutropenia.\n\n- 12/06/2019: Diagnosed with tuberculosis - positive Tbc-PCR in\n tracheobronchial secretions, acid-fast bacilli in tracheobronchial\n secretions, histological confirmation from EBUS biopsy of a\n conglomerate of melted lymph nodes from 11/03/2019.\n\n- 01/2021: Bone marrow biopsy showed secondary AML with 26% blasts.\n\n- 03/2021: Started Venetoclax/Vidaza.\n\n- 05/2021: Bone marrow biopsy showed 0.8% myeloid blasts coexpressing\n CD117 and CD7. Cytology showed 6% blasts.\n\n- 05/2021: Started the 4th cycle of Vidaza/Venetoclax.\n\n- 06/17/2022: Started the 5th cycle of Vidaza/Venetoclax.\n\n- 07/29/2021: Underwent allogeneic stem cell transplantation from a\n HLA-identical unrelated donor (10/10 antigen match) for AML-MRC in\n first complete remission (CR). Conditioning regimen included\n Treosulfan 12g/m2, Fludarabin 5x 30 mg/m2, ATG 3x 10 mg/kg.\n\n**Other Diagnoses:**\n\n- Persistent tuberculosis with lymph node swelling since June 2020.\n\n- Open lung tuberculosis diagnosed in November 2019.\n\n - Location: CT of the chest showed central mediastinal lymph node\n conglomerate with post-stenotic infiltrates bilaterally,\n splenomegaly.\n\n - Bronchoscopy on December 5, 2020, showed large mediastinal and\n right hilar lymph nodes, subcritical narrowing of right\n segmental bronchi. EBUS-TBNA\n\n - CT Chest/Neck on 02/05/2020: Regression of pulmonary\n infiltrates, enlargement of necrotic lymph nodes in the upper\n mediastinum and infraclavicular on the right (compressing the\n internal jugular vein/esophagus).\n\n - Culture confirmation of Mycobacterium tuberculosis,\n pansensitive: Tracheobronchial secretion\n\n - Initiated antituberculous combination therapy\n\n**Current Presentation:** Admission for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor (10/10 antigen\nmatch) for AML-MRC in first complete remission.\n\n**Medical History:** In 2019, Mr. Hurley was diagnosed with\nMyelodysplastic Syndrome EB-2. Starting from September 2019, he received\nAzacitidine therapy. In December 2020, he was diagnosed with open lung\ntuberculosis, which was challenging to treat due to his dysfunctional\nimmune system. In January 2021, his MDS progressed to AML-MRC with 26%\nblasts. After treatment with Venetoclax/Vidaza, he achieved remission in\nMay 2021. Tuberculosis remained largely under control.\n\nDue to AML-MRC, he was recommended for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor. At the time of\nadmission for transplantation, he was largely asymptomatic. He\noccasionally experienced mild dry cough but denied fever, night sweats,\nor weight loss. The admission and counseling were conducted with\ntranslation assistance from his life partner due to limited proficiency\nin English.\n\n**Allergies**: None\n\n**Transfusion History**: Currently requires transfusions every 14 days.\nBoth red blood cell and platelet transfusions have been tolerated\nwithout problems.\n\n**Abdominal CT from 01/20/2021:**\n\n**Findings**: Significant peripancreatic fluid accumulation in the upper\nabdominal area with a somewhat indistinct border between the pancreatic\ntissue, particularly in the pancreatic head region. Evidence of\ninflammation affecting the stomach and duodenum. No presence of free air\nor indications of hollow organ perforation. No conclusive signs of a\nwell-defined abscess. Moreover, the other parenchymal abdominal organs,\nespecially those lacking focal abnormalities suggestive of neoplastic or\ninflammatory conditions, displayed normal appearances. The gallbladder\nshowed no notable issues, and there were no radiopaque concretions\nobserved. Both the intra- and extrahepatic bile ducts appeared\nadequately dilated. Abdominal hollow organs exhibited unremarkable and\nnormal appearances without corresponding contrast and dilation. The\nappendix appeared within normal parameters. Abdominal lymph nodes showed\nno unusual findings. Some degree of aortic vasosclerosis was noted. The\ndepiction of the included lung portions revealed no abnormalities.\n\n**Results**: Findings indicative of acute pancreatitis, most likely of\nan exudative nature. No signs of hollow organ perforation were detected,\nand there was no definitive evidence of an abscess (as far as could be\ndetermined from native imaging).\n\n**Summary**: The patient was admitted to our hospital through the\nemergency department with the symptoms described above. With typical\nupper abdominal pain and significantly elevated serum lipase levels, we\ndiagnosed acute pancreatitis. This diagnosis was corroborated by\nperipancreatic fluid and ill-defined organ involvement in the abdominal\nCT scan. There were no laboratory or anamnestic indications of a biliary\norigin. The patient denied excessive alcohol consumption.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------ ---------------\n Rifampin (Rifadin) 600 mg 1-0-0\n Isoniazid (Nydrazid) 500 mg 1-0-0\n Levofloxacin (Levaquin) 450 mg 1-0-1\n\n**Physical Examination:** General: Oriented in all qualities, in good\ngeneral condition with normal body weight (75 kg, 187 cm) Vital signs at\nadmission: Heart rate 63/min, Blood pressure 110/78 mmHg. Temperature at\nadmission 36.8 °C, Oxygen saturation 100% on room air. Skin and mucous\nmembranes: Dry skin, normal skin color, normal skin turgor. No scleral\nicterus, non-irritated conjunctiva. Normal oral mucosa, moist tongue\nwithout coating, no ulcers or thrush. Heart: Normal heart sounds,\nrhythmic, regular rate, no pathological heart murmurs heard on\nauscultation. Lungs: Resonant percussion sound, clear breath sounds\nbilaterally, no wheezing, no prolonged expiration. Abdomen: Unremarkable\nscar tissue, normal bowel sounds in all quadrants, soft, non-tender, no\nguarding, liver and spleen not enlarged. Vascular: Central and\nperipheral pulses palpable, no jugular vein distention, no peripheral\nedema, extremities warm with no significant difference in size. Lymph\nnodes: Palpable cervical swelling, inguinal and axillary lymph nodes\nunremarkable. Neurology: Grossly neurologically unremarkable.\n\nOn 08/22/2021, a four-lumen central venous catheter was placed in the\nright internal jugular vein without complications. During the\nconditioning regimen, the patient received the following:\n\n **Medication** **Dosage** **Frequency**\n ---------------------------------------------- ---------------------- -------------------------\n Fludarabine (Fludara) 30 mg/m² (5x 57 mg) 07/23/2023 - 07/27/2023\n Treosulfan (Ovastat) 12 g/m² (3x 22.9 g) 07/23/2023 - 07/25/2023\n Anti-Thymocyte Globulin (ATG, Thymoglobulin) 10 mg/kg (3x 700 mg) 07/23/2023 - 07/28/2023\n\n**Antiemetic Therapy:**\n\nThe antiemetic therapy included Ondansetron, Aprepitant, and\nDexamethasone, and the conditioning regimen was well tolerated.\n\n**Prophylaxis of Graft-Versus-Host Disease (GvHD):**\n\n **Substances** **Start Date** **Day -2** **Day 1**\n ---------------- ---------------- ------------ -----------\n Cyclosporine 08/28/2022 \n Mycophenolate 07/30/2021 \n\n **Stem Cell Source** **Date** **CD34/kg KG** **CD45/kg KG** **CD3/kg KG** **Volume**\n ---------------------- ------------ ---------------- ---------------- --------------- ------------\n PBSCT 07/29/2021 7.39 x10\\^6 8.56 x10\\^8 260.7 x10\\^6 194 ml\n\n**Summary:** Mr. Hurley was admitted for allogeneic stem cell\ntransplantation from a HLA-identical unrelated donor for AML-MRC. The\nconditioning regimen with Treosulfan, Fludarabin, and ATG was well\ntolerated, and the transplantation proceeded without complications.\n\n**Toxicities:** There was an adverse event-related increase in bilirubin\nlevels, reaching a maximum of 2.68 mg/dL. Elevated ALT levels, up to a\nmaximum of 53 U/L, were observed.\n\n**Acute Graft-Versus-Host Disease (GvHD):** Signs of GvHD were not\nobserved until the time of discharge.\n\n**Medication upon Discharge:**Formularbeginn\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------------- ------------ ------------------------------------------------\n Acyclovir (Zovirax) 500 mg 1-0-1-0\n Entecavir (Baraclude) 0.5 mg 1-0-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 2-0-0-0\n Levofloxacin (Levaquin) 500 mg 1-0-1-0\n Mycophenolate Mofetil (CellCept) 500 mg 2-0-2-0\n Folic Acid 5 mg 1-0-0-0\n Magnesium \\-- 3-3-3-0\n Pantoprazole (Protonix) 40 mg 1-0-0-0 (before a meal)\n Ursodeoxycholic Acid (Actigall) 250 mg 1-1-1-0\n Cyclosporine (Sandimmune) 100 mg 100 mg 4-0-4-0\n Cyclosporine (Sandimmune) 50 mg 50 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n Cyclosporine (Sandimmune) 10 mg 10 mg 4-0-4-0 (based on TDM, last dose 400 mg 1-0-1)\n\n**Current Recommendations: **\n\n1. Bone marrow puncture on Day +60, +120, and +360 post-transplantation\n (including MRD and chimerism) and Day +180 depending on MRD and\n chimerism progression.\n\n2. Continuation of immunosuppressive therapy with ciclosporin adjusted\n to achieve target levels of around 150 ng/ml, for a minimum of 3\n months post-transplantation. Immunosuppression with mycophenolate\n mofetil will be continued until Day +40.\n\n3. Prophylaxis with Aciclovir must continue for 6 weeks after\n discontinuation of immunosuppression at a dosage of 15-20 mg/kg/day\n (divided into 2 doses). Dose adjustment based on renal function may\n be necessary.\n\n4. Pneumocystis pneumonia prophylaxis through monthly Pentamidine\n inhalation or administration of Cotrim forte 960mg must continue at\n least until immunosuppression is discontinued or until an absolute\n CD4+ T-cell count exceeds \\>200/µL in peripheral blood. Cotrim forte\n 960mg has not been started when leukocytes are \\<2/nL.\n\n5. Weekly monitoring of CMV and EBV viral loads through quantitative\n PCR from EDTA blood.\n\n6. Timing of antituberculous medication intake:\n\n- Take Rifampicin and Isoniazid in the morning on an empty stomach, 30\n minutes before breakfast.\n\n- Take levofloxacin with a 2-hour gap from divalent cations (Mg2+,\n strongly calcium-rich foods).\n\n**Lab results upon Discharge:**\n\n **Parameter** **Result** **Reference Range**\n ------------------------------ -------------------- ---------------------\n Cyclosporine 127.00 ng/mL \\--\n Sodium 141 mEq/L 136-145 mEq/L\n Potassium 4.1 mEq/L 3.5-4.5 mEq/L\n Glucose 108 mg/dL 60-110 mg/dL\n Creatinine 0.65 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR CKD-EPI) 111 mL/min/1.73 m² \\--\n Urea 26 mg/dL 17-48 mg/dL\n Total Bilirubin 0.35 mg/dL \\<1.20 mg/dL\n\n**Complete Blood Count **\n\n **Parameter** **Results** **Reference Range**\n --------------- ----------------- -----------------------\n Hemoglobin 9.5 g/dL 13.5-17.0 g/dL\n Hematocrit 28.2% 39.5-50.5%\n Erythrocytes 3.2 x 10\\^6/µL 4.3-5.8 x 10\\^6/µL\n Leukocytes 1.47 x 10\\^3/µL 3.90-10.50 x 10\\^3/µL\n Platelets 193 x 10\\^3/µL 150-370 x 10\\^3/µL\n MCV 88.7 fL 80.0-99.0 fL\n MCH 29.9 pg 27.0-33.5 pg\n MCHC 33.7 g/dL 31.5-36.0 g/dL\n MPV 9.8 fL 7.0-12.0 fL\n RDW-CV 18.9% 11.5-15.0%\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report on Mr. Bruno Hurley, born on 12/24/1965, who was under our\ninpatient care from 2/20/2022, to 02/24/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Medical History:** The patient presented via ambulance from his\nworkplace. The patient reported sudden onset upper abdominal pain,\nmainly in the epigastric region, accompanied by nausea and vomiting. He\nalso experienced watery diarrhea once today. He had lunch around noon,\nconsisting noodles. There was no fever, cough, sputum production,\ndyspnea, or urinary abnormalities. He has been taking daily\nantitubercular combination therapy, including Rifampicin, for open\ntuberculosis. The patient denied alcohol consumption and weight loss.\n\n **Medication** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg 1-0-0\n Rifampin (Rifadin) 600 mg 1.5-0-0\n Isoniazid/Pyridoxine (Nydrazid) 300 mg 1-0-1\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed\n Prednisolone 4 mg As needed\n\n**Allergies:** None\n\n**Physical Exam:**\n\nVital Signs: Blood Pressure 178/90 mmHg, Pulse 85/min, SpO2 89%,\nTemperature 36.7°C, Respiratory Rate 20/min.\n\nClinical Status: Upon initial examination, a reduced general condition.\n\nCardiovascular: Heart sounds were normal, rhythm was regular, and no\nmurmurs were heard.\n\nRespiratory: Vesicular breath sounds, sonorous percussion.\n\nAbdominal: Sluggish peristalsis, soft abdominal walls, guarding and\ntenderness in the epigastrium, liver and spleen not palpable, no free\nfluid.\n\nExtremities: Minimal edema.\n\n**ECG Findings:** ECG on admission showed normal sinus rhythm (69/min),\nnormal ST intervals, R/S transition in V3/V4, and no significant\nabnormalities.\n\n´\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n ----------------------------------------- ------------ ----------------------------\n Acyclovir (Zovirax) 400 mg 1-0-1\n Entecavir (Baraclude) 0.5 mg PAUSED\n Rifampin (Rifadin) 600 mg PAUSED\n Isoniazid/Pyridoxine (Nydrazid) 300 mg PAUSED\n Pantoprazole (Protonix) 40 mg 1-0-0\n Trimethoprim/Sulfamethoxazole (Bactrim) 960 mg 1 tablet, on Mon, Wed, Fri\n Methylprednisolone (Medrol) 0.79 mg As needed (as needed)\n Prednisolone 4 mg As needed (as needed)\n Tramadol (Ultram) 50 mg 1 tablet, every 6 hours\n\n **Parameter** **Results** **Reference Range**\n ------------------------- ----------------- -----------------------\n White Blood Cells (WBC) 5.0 x 10\\^9/L 3.7 - 9.9 x 10\\^9/L\n Hemoglobin 14.0 g/dL 13.6 - 17.5 g/dL\n Hematocrit 40% 40 - 53%\n Red Blood Cells (RBC) 4.00 x 10\\^12/L 4.4 - 5.9 x 10\\^12/L\n MCV 99 fL 80 - 96 fL\n MCH 32.8 pg 28.3 - 33.5 pg\n MCHC 33.1 g/dL 31.5 - 34.5 g/dL\n Platelets 161 x 10\\^9/L 146 - 328 x 10\\^9/L\n Absolute Neutrophils 3.7 x 10\\^9/L 1.8 - 6.2 x 10\\^9/L\n Absolute Monocytes 0.31 x 10\\^9/L 0.25 - 0.85 x 10\\^9/L\n Absolute Eosinophils 0.03 x 10\\^9/L 0.03 - 0.44 x 10\\^9/L\n Absolute Basophils 0.01 x 10\\^9/L 0.01 - 0.08 x 10\\^9/L\n Absolute Lymphocytes 0.9 x 10\\^9/L 1.1 - 3.2 x 10\\^9/L\n Immature Granulocytes 0.0 x 10\\^9/L 0.0 x 10\\^9/L\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you on our patient, Mr. Hurley, who presented\nto our outpatient clinic on 07/12/2022.\n\n**Diagnoses:**\n\n- Acute Pancreatitis, possibly medication-related under antitubercular\n therapy.\n\n- Current medications include Entecavir, Rifampicin, and\n Isoniazid/Pyridoxin, which have been paused after consultation with\n the infectious disease team.\n\n**Other Diagnoses:**\n\n- Acute Myeloid Leukemia with Myelodysplasia-Related Changes (AML-MRC)\n\n- Myelodysplastic Syndrome EB-2\n\n- Allogeneic stem cell transplantation\n\n- EBV Reactivation (Treated with immunoglobulins for 3 days)\n\n- Persistent Tuberculosis with lymph node swelling\n\n- Open Lung Tuberculosis - Initial Diagnosis\n\n- Antitubercular combination therapy since (Moxifloxacin, Pyrazinamid,\n Ethambutol, Rifampicin, Isoniazid).\n\n- Rectal colonization with 4-MRGN.\n\n**Current Presentation:** Presented with a referral from outpatient\noncologist for suspected recurrent AML, with DD GvHD ITP in the setting\nof progressive pancytopenia, primarily thrombocytopenia. The patient is\nin good general condition, denying acute symptoms, particularly no rash,\ndiarrhea, dyspnea, or fever.\n\n**Physical Examination:** Alert, oriented, no signs of respiratory\ndistress, heart sounds regular, abdomen soft, no tenderness, no skin\nrashes, especially no signs of GvHD, no edema.\n\n- Heart Rate (HR): 130/85\n\n- Temperature (Temp): 36.7°C\n\n- Oxygen Saturation (SpO2): 97\n\n- Respiratory Rate (AF): 12\n\n- Pupillary Response: 15\n\n**Imaging (CT):**\n\n- [11/04/19 CT Chest/Abdomen/Pelvis ]{.underline}\n\n- [01/04/20 Chest CT:]{.underline} Marked necrotic lymph nodes hilar\n right with bronchus and vascular stenosis. Significant increasing\n pneumonic infiltrates predominantly on the right.\n\n- [02/05/20 Neck/Chest CT]{.underline}: Regression of pulmonary\n infiltrates, but increased size of necrotic lymph nodes, especially\n in the upper mediastinum and right infraclavicular with slit-like\n compression of the right internal jugular vein and the esophagus.\n\n- [06/07/20 Neck/Chest CT]{.underline}: Size-stable necrotic lymph\n node conglomerate infraclavicular right, dimensioned axially up to\n about 6 x 2 cm, with ongoing slit-shaped compression of the right\n internal jugular vein. Hypoplastic mastoid cells left, idem.\n Progressive, partly new and large-volume consolidations with\n adjacent ground glass infiltrates on the right in the anterior, less\n posterior upper lobe and perihilar. Inhomogeneous, partially reduced\n contrast of consolidated lung parenchyma, broncho pneumogram\n preserved dorsally only.\n\n- [10/02/20 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Size-regressive\n consolidating infiltrate in the right upper lobe and adjacent\n central lower lobe with increasing signs of liquefaction.\n Progressive right pleural effusion and progressive signs of\n pulmonary volume load. Regressive cervical, mediastinal, and right\n hilar lymphadenopathy. Ongoing central hilar conglomerates that\n compress the central hilar structures. Partly constant, partly\n regressive presentation of known tuberculosis-suspected liver\n lesions.\n\n- [12/02/20 CT Chest/Abdomen/Pelvis]{.underline}.\n\n- [01/20/2021 Abdominal CT.]{.underline}\n\n- [02/23/21 Neck/Chest CT:]{.underline} Slightly regressive/nodular\n fibrosing infiltrate in the right upper lobe and adjacent central\n lower lobe with continuing significant residual findings. Within the\n infiltrate, larger poorly perfused areas with cavitations and\n scarred bronchiectasis. Increasing, partly patchy densities on the\n left basal region, differential diagnoses include infiltrates and\n ventilation disorders. Essentially constant cervical, mediastinal,\n and hilar lymphadenopathy. Constant liver lesions in the upper\n abdomen, differential diagnoses include TB manifestations and cystic\n changes.\n\n- [06/12/21 Neck/Chest/Abdomen/Pelvis CT:]{.underline} Improved\n ventilation with regressive necrotic TB manifestations perihilar,\n now only subtotal lobar atelectasis. Essentially constant necrotic\n lymph node manifestations cervical, mediastinal, and right hilar,\n exemplarily suprasternal right or right paratracheal. Narrow right\n pleural effusion. Medium-term constant hypodense liver lesions\n (regressive).\n\n**Patient History:** Known to have AML with myelodysplastic changes,\nfirst diagnosed 01/2021, myelodysplastic syndrome EB-2, fist diagnoses\n07/2019, and history of allogeneic stem cell transplantation.\n\n**Treatment and Progression:** Patient is hemodynamically stable, vital\nsigns within normal limits, afebrile. In good general condition,\nclinical examination unremarkable, especially no skin GvHD signs. Venous\nblood gas: Acid-base status balanced, electrolytes within normal range.\nLaboratory findings show pancytopenia, Hb 11.3 g/dL, thrombocytopenia\n29/nL, leukopenia 1.8/nL, atypical lymphocytes described as \\\"resembling\nCLL,\\\" no blasts noted. Consultation with Hemato/Oncology confirmed no\nacute need for hospitalization. Follow-up in the Hemato-Oncological\nClinic in September.\n\n**Imaging:**\n\n**CT Chest/Abdomen/Pelvis on 11/04/19:**\n\n**Assessment:** In comparison with 10/23/19: In today\\'s\ncontrast-enhanced examination, a newly unmasked large tumor is noted in\nthe right pulmonary hilum with encasement of the conduits of the right\nlung lobe. Differential diagnosis includes a lymph node conglomerate,\ncentral bronchial carcinoma, or, less likely, an inflammatory lesion.\nMultiple suspicious malignant enlarged mediastinal lymph nodes,\nparticularly on the right paratracheal and infracarinal regions.\n\nShort-term progression of peribronchovascular consolidation in the right\nupper lobe and multiple new subsolid micronodules bilaterally.\nDifferential diagnosis includes inflammatory lesions, especially in the\npresence of known neutropenia, which could raise suspicion of fungal\ninfection.\n\nIntraabdominally, there is an image suggestive of small bowel subileus\nwithout a clearly defined mechanical obstruction.\n\nDensity-elevated and ill-defined cystic lesion in the left upper pole of\nthe kidney. Primary consideration is a hemorrhaged or thickened cyst,\nbut ultimately, the nature of the lesion remains uncertain.\n\n**CT Chest on 01/04/20:** Significant necrotic hilar lymph nodes on the\nright with bronchial and vascular stenosis. Marked progression of\npulmonary infiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known active tuberculosis\n\n**CT Chest from 02/05/20**: Marked necrotic lymph nodes hilar right with\nbronchial and vascular stenosis. Significantly increasing pneumonia-like\ninfiltrates, particularly on the right, still compatible with\nsuperinfection in the context of known open tuberculosis.\n\n**Neck/Chest CT from 06/07/20:** Size-stable necrotic lymph node\nconglomerate infraclavicular right, dimensioned axially up to about 6 x\n2 cm, with ongoing slit-shaped compression of the right internal jugular\nvein. Hypoplastic mastoid cells left, idem. Progressive, partly new and\nlarge-volume consolidations with adjacent ground glass infiltrates on\nthe right in the anterior, less posterior upper lobe and perihilar.\nInhomogeneous, partially reduced contrast of consolidated lung\nparenchyma, broncho pneumogram preserved dorsally only.\n\n**Neck Ultrasound from 08/14/2020:** Clinical History, Question,\nJustifying Indication: Follow-up of cervical lymph nodes in\ntuberculosis.\n\n**Findings/Assessment:** Neck Lymph Node Ultrasound from 05/20/2020 for\ncomparison. As in the previous examination, evidence of two\nsignificantly enlarged supraclavicular lymph nodes on the right, both\nshowing a decrease in size compared to the previous examination: The\nmore medial node measures 2.9 x 1.6 cm compared to the previous 3.7 x\n1.7 cm, while the more laterally located lymph node measures 3.3 x 1.4\ncm compared to the previous 4.2 x 1.5 cm. The more medial lymph node\nappears centrally hypoechoic, indicative of partial liquefaction, while\nthe more lateral lymph node has a rather solid appearance. No other\npathologically enlarged lymph nodes detected in the cervical region.\n\n**CT Neck/Chest/Abdomen/Pelvis from 10/02/2020:** Assessment: Compared\nto the previous examination from 06/07/2020, there is evidence of\nregression in findings: Size regression of consolidating infiltrate in\nthe right upper lobe and the adjacent central lower lobe, albeit with\nincreasing signs of cavitation. Progressive right pleural effusion and\nprogressive signs of pulmonary volume overload. Regression of cervical,\nmediastinal, and right hilar lymphadenopathy. Persistent centrally\nliquefying lymph node conglomerates in the right hilar region,\ncompressing central hilar structures. Some findings remain stable, while\nothers have regressed. No evidence of new manifestations.\n\n**CT Chest/Abdomen/Pelvis from 12/02/20:** Assessment: Compared to\n10/02/20: In today\\'s contrast examination, a newly unmasked large tumor\nis located right pulmonary hilar, encasing the conduits of the right\nlung lobe; Differential diagnosis includes lymph node conglomerate,\ncentral bronchial carcinoma, and a distant possibility of inflammatory\nlesions. Multiple suspiciously enlarged mediastinal lymph nodes,\nespecially right paratracheal and infracarinal. In a short time,\nprogressive peribronchovascular consolidations in the right upper lobe\nand multiple new subsolid micronodules bilaterally; Differential\ndiagnosis includes inflammatory lesions, potentially fungal in the\ncontext of known neutropenia. Intra-abdominally, there is a picture of\nsmall bowel subileus without discernible mechanical obstruction.\nCorresponding symptoms? Densely elevated and ill-defined cystic lesion\nin the upper pole of the left kidney; Differential diagnosis primarily\nincludes a hemorrhaged/thickened cyst, ultimately with uncertain\nmalignancy.\n\n**Chest in two planes on 04/23/2021:** **Findings/Assessment:** In\ncomparison with the corresponding prior images, most recently on\n08/14/2020. Also refer to CT Neck and Chest on 01/23/2021. The heart is\nenlarged with a leftward emphasis, but there are no signs of acute\ncongestion. Extensive consolidation projecting onto the right mid-field,\nwith a long-term trend toward regression but still clearly demarcated.\nNo pneumothorax. No pleural effusion. Known lymph nodes in the\nmediastinum/hilum. Degenerative spinal changes.\n\n**Neck/Chest CT on 02/23/21:** Slightly regressive/nodular fibrosing\ninfiltrate in the right upper lobe and adjacent central lower lobe with\ncontinuing significant residual findings. Within the infiltrate, larger\npoorly perfused areas with cavitations and scarred bronchiectasis.\nIncreasing, partly patchy densities on the left basal region,\ndifferential diagnoses include infiltrates and ventilation disorders.\nEssentially constant cervical, mediastinal, and hilar lymphadenopathy.\nConstant liver lesions in the upper abdomen, differential diagnoses\ninclude TB manifestations and cystic changes.\n\n**CT Neck/Chest/Abdomen/Pelvis from 06/12/2021**: CT from 02/23/2021\navailable for comparison. Neck/Chest: Improved right upper lobe (ROL)\nventilation with regressive necrotic TB manifestations peri-hilar, now\nonly with subtotal lobar atelectasis. Essentially stable necrotic lymph\nnode manifestations in the cervical, mediastinal, and right hilar\nregions, for example, supraclavicular on the right (18 mm, previously\n30.1 Im 21.2) or right paratracheal (18 mm, previously 30.1 Im 33.8).\nNarrow right pleural effusion, same as before. No pneumothorax. Heart\nsize normal. No pericardial effusion. Abdomen: Mid-term stable hypodense\nliver lesions (regressing since 07/2021).\n\n**Treatment and Progression:** Due to the extensive findings and the\nuntreatable immunocompromising underlying condition, we decided to\nswitch from a four-drug TB therapy to a three-drug therapy after nearly\n3 months. In addition to rifampicin and isoniazid, levofloxacin was\ninitiated. Despite very good therapy adherence, acid-fast bacilli\ncontinued to be detected microscopically in sputum samples without\nculture confirmation of mycobacteria, even after discharge. Furthermore,\nthe radiological findings worsened. In April 2020, liver lesions were\nidentified in the CT that had not been described up to that point, and\npulmonary and mediastinal changes increased. Clinically, right cervical\nlymphadenopathy also progressed in size. Due to a possible immune\nreaction, a therapy with prednisolone was attempted for several weeks,\nwhich did not lead to improvement. In June 2020, Mr. Hurley was\nreadmitted for bronchoscopy with BAL and EBUS-guided biopsy to rule out\ndifferential diagnoses. An NTM-NGS-PCR was performed on the BAL, which\ndid not detect DNA from nontuberculous mycobacteria. Histologically,\npredominantly necrotic material was found in the lymph node tissue, and\nmolecular pathological analysis detected DNA from the M. tuberculosis\ncomplex. There were no indications of malignancy. In addition,\nwhole-genome sequencing of the most recently cultured mycobacteria was\nperformed, and latent resistance genes were also ruled out. Other\npathogens, including fungi, were likewise not detected. Aspergillus\nantigen in BAL and serum was also negative. We continued the three-drug\ntherapy with Rifampicin, Isoniazid, and Levofloxacin. Mr. Hurley\ndeveloped an increasing need for red blood cell transfusions due to\nmyelodysplastic syndrome and began receiving regular transfusions from\nhis outpatient hematologist-oncologist in the summer of 2020. In a\nrepeat CT control in October 2020, increasing necrotic breakdown of the\nright upper and middle lobes was observed, as well as progressive\nipsilateral pleural effusion and persistent mediastinal lymphadenopathy\nand liver lesions. Mr. Hurley was referred to the immunology colleagues\nto discuss additional immunological treatment options. After extensive\nimmune deficiency assessment, a low basal interferon-gamma level was\nnoted in the setting of lymphopenia due to MDS. In an immunological\nconference, the patient was thoroughly discussed, and a trial of\ninterferon-gamma therapy in addition to antituberculous therapy was\ndiscussed due to a low basal interferon-gamma level and a negative\nQuantiferon test. After approval of an off-label application, we began\nActimmune® injections in January 2021 after extensive patient education.\nMr. Hurley learned to self-administer the subcutaneous injections and\ninitially tolerated the treatment well. Due to continuous worsening of\nthe blood count, a bone marrow puncture was performed again on an\noutpatient basis by the attending hematologist-oncologist, and secondary\nAML was diagnosed. Since February 2021, Mr. Hurley has received\nAzacitidine and regular red blood cell and platelet concentrates. After\n3 months of Actimmune® therapy, sputum no longer showed acid-fast\nbacilli in March 2021, and radiologically, the left pleural effusion had\ncompletely regressed, and the infiltrates had decreased. Actimmune® was\ndiscontinued after 3 months. Towards the end of Actimmune® therapy, Mr.\nHurley developed pronounced shoulder arthralgia and pain in the upper\nthoracic spine. Fractures were ruled out. With pain therapy, the pain\nbecame tolerable and gradually improved. Arthralgia and myalgia are\ncommon side effects of interferon-gamma. Due to the demonstrable\ntherapeutic response, we presented Mr. Hurley, along with an\ninterpreter, at the Department of Hematology and Oncology to discuss\nfurther therapeutic options for AML in the context of the hematological\nand infectious disease situation. After extensive explanation of the\ndisease situation, the risks of aggressive AML therapy in the presence\nof unresolved tuberculosis, and the consequences of palliative AML\ntherapy. Mr. Hurley agreed to allogeneic stem cell transplantation after\nsome consideration. On an outpatient basis, the cytostatic therapy with\nAzacitidine was expanded to include Venetoclax. Antituberculous therapy\nwith rifampicin, isoniazid, and levofloxacin was continued. Regular\nsputum checks remained consistently microscopically negative until\ncomplete AML remission was achieved. Mr. will be admitted for allogeneic\nstem cell transplantation in July 2021. A repeat CT in June 2021\nconfirmed continued regression of the tuberculosis findings.\nAntituberculous therapy will be continued indefinitely.\n\n**CT Neck/Chest/Abdomen/Pelvis on 06/12/2022:** CT for comparison.\nNeck/Chest: Improved right lung upper lobe ventilation with regressing\nnecrotic tuberculosis manifestations, now with only subtotal lobar\natelectasis. Essentially constant necrotic lymph node manifestations in\nthe cervical, mediastinal, and right hilar regions, as exemplified by\nthe right supraclavicular (18 mm, SE 301 HU 212) or right paratracheal\n(18 mm, SE 301 HU 338) nodes. Narrow pleural effusion on the right,\nlikewise. No pneumothorax. The heart is not enlarged. No pericardial\neffusion. Abdomen: Medium-term constant hypodense liver lesions\n(regressing)\n\n**Current Recommendations:** Continue antituberculous therapy without a\ndefined endpoint. Sputum checks during allogeneic stem cell\ntransplantation every 1-2 weeks. In case of clinical signs of persistent\ninfection, perform early CT scans of the neck, chest, and abdomen.\nFollow-up appointment in our infectious diseases outpatient clinic after\nallogeneic stem cell transplantation.\n", "title": "text_3" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n\n\n### text_3\n**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n\n\n### text_7\n**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n\n\n### text_8\n**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n\n\n### text_9\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n\n\n### text_10\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n\n\n### text_11\n**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n\n\n### text_12\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n\n\n\n\nHere is the query:\nWhat was the histopathological finding related to the gallbladder during the exploratory laparotomy performed in Mrs. Anderson?\n\nChoose the correct answer from the following options:\nA. Acute cholecystitis.\nB. Cholelithiasis.\nC. Chronic cholecystitis.\nD. Gallbladder polyps.\nE. Gallbladder adenocarcinoma.\n\n\nYour response:\n", "role": "user" }, { "content": "Chronic cholecystitis.", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n", "title": "text_9" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n", "title": "text_10" }, { "content": "**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n", "title": "text_11" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n", "title": "text_12" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n\n\n### text_6\n**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n\n\n### text_7\n**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n\n\n\n\nHere is the query:\nWhich chemotherapy regimen was Mr. Rudolph initially treated with after his diagnosis?\n\nChoose the correct answer from the following options:\nA. Doxorubicin and Cyclophosphamide\nB. Fluorouracil and Leucovorin\nC. Methotrexate and Vinblastine\nD. Gemcitabine and Cisplatin\nE. Carboplatin and Paclitaxel\n\n\nYour response:\n", "role": "user" }, { "content": "Gemcitabine and Cisplatin", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolph, born\non 05/26/1954, who was under our care from 01/16/2019 to 01/17/2019.\n\n**Diagnosis**: Suspected malignant mass at pyeloureteral junction/left\nrenal pelvis and suspicious paraaortic lymph nodes.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: Post-ablation in 2013\n\n- pTCA stenting in 2010 for acute myocardial infarction\n\n- Suspected soft tissue rheumatism, currently no complaints\n\n- Laparoscopic cholecystectomy in 2012\n\n- Tonsillectomy\n\n- Obesity\n\n**Procedure:** Diagnostic ureterorenoscopy on the left with biopsy and\nleft DJ stent placement on 01/16/2019.\n\n**Current Presentation:** Elective presentation for further endoscopic\nevaluation of the unclear mass in the pyeloureteral junction area\ninvolving the proximal ureter and renal pelvis. Additionally, abnormal\nlymph nodes were observed in external imaging. The patient reports\noccasional mild discomfort in the left upper abdomen.\n\n**Physical Examination:** Soft abdomen, no pressure pain.\n\n**CT Thorax (Plain) from 01/16/2019:**\n\nPresence of axillary and mediastinal lymph nodes with borderline\nenlarged lymph nodes ventral to the tracheal bifurcation (approximately\n10 mm).\n\nCalcification of aortic valves. Aortic and coronary sclerosis.\n\nNo suspicious lesions detected within the lungs. No pleural effusions.\nNo infiltrates.\n\nHistory of cholecystectomy.\n\nKnown soft tissue density formation in the left renal hilum from the\nprevious examination.\n\nThe assessment of other upper abdominal organs that were visible and\ncould be evaluated natively was unremarkable.\n\nNo evidence of suspicious retrocrural lymph nodes. Vascular sclerosis.\n\n**Skeletal Assessment:** Degenerative changes in the spine. No evidence\nof suspicious lesions.\n\n**Assessment:** No definitive evidence of metastatic lesions in the\nlungs. Increased presence of mediastinal lymph nodes, some borderline\nenlarged, ventral to the tracheal bifurcation. Differential diagnosis\nincludes nonspecific findings or lymph node metastases, which cannot be\nexcluded based solely on CT morphology.\n\n**Main Diagnosis and Main Procedure from the Surgical Report:**\n\n- Surgical Diagnosis: Unclear proximal ureter tumor on the left\n\n- Unclear tumor in the left renal pelvis\n\n- Surgical Procedure: Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Procedure:**\n\nThe patient underwent a diagnostic ureterorenoscopy, which proceeded\nwithout complications. During the procedure, a total of eight biopsies\nwere successfully obtained from the ureter for histological evaluation.\nCytological samples were also collected from both the ureter and renal\npelvis. Although there was a stenosing tumor present, endoscopic passage\ninto the renal pelvis was successfully accomplished.\n\nFollowing the diagnostic procedure, a left-sided double-J catheter was\nplaced under radiographic control. Additionally, a urinary catheter was\ninserted. It was observed that the initial urine output appeared\nhemorrhagic, but it subsequently cleared to a normal coloration.\n\nFor post-procedural management, plans are in place for the DJ catheter\nto be removed, the timing of which will be guided by improvements in the\ncolor of the urine as well as the patient\\'s overall clinical status. A\nsonogram will be performed prior to discharge as part of routine\nfollow-up. Moreover, the patient has been scheduled for counseling to\naddress the significantly elevated PSA values noted in recent lab tests.\n\n**Diagnosis:** Unclear proximal ureter tumor on the left. Unclear tumor\nin the left renal pelvis\n\n**Type of Surgery:**\n\n- Diagnostic ureterorenoscopy on the left\n\n- Biopsy of the left ureter\n\n- Retrograde urography on the left\n\n- DJ catheter placement on the left\n\n- Diagnostic urethroscopy\n\n**Anesthesia Type:** Laryngeal mask\n\n**Report:** Indication: Unclear mass in the left renal pelvis. Elective\ndiagnostic ureterorenoscopy for further assessment. Written consent is\nobtained. The urine is sterile. The procedure is conducted under\nantibacterial prophylaxis with Ampicillin/Sulbactam 3g.\n\n1. Standard preparation, lithotomy position on the X-ray unit, sterile\n scrubbing/disinfection, and sterile draping by nursing staff.\n Verification and approval.\n\n2. Anesthesiology and urology discussion. Surgery clearance. Antibiotic\n administration.\n\n3. Initial urethroscopy was unremarkable, with no signs of tumors.\n\n4. Semi-rigid ureterorenoscopy with a 6.5/8.5 continuous-flow\n ureterorenoscopy. Unremarkable ureterorenoscopy of the entire ureter\n until just before the pyeloureteral junction, where a papillary\n stenotic constriction was encountered, impeding further passage with\n the endoscope. Cytology collection (20 mL) was performed. Retrograde\n urography was conducted to visualize the proximal collecting system,\n and biopsies were obtained from the accessible portions, with 8\n biopsies taken using an access sheath. Even with flexible\n Viperscope, further passage was not feasible.\n\n5. A DJ catheter was inserted under radiographic guidance over a\n guidewire. Collection of irrigation cytology (5 ml) from the renal\n pelvis.\n\n6. Insertion of a DJ catheter (7/28 Vortek) over the indwelling wire\n and endoscope under radiographic control. Documentation of images.\n\n7. Placement of a permanent catheter. Urine initially appeared bloody\n but cleared rapidly.\n\n**Conclusion:** Uncomplicated diagnostic ureterorenoscopy with biopsy of\nthe ureter (8 biopsies taken), cytology collection from the ureter and\nrenal pelvis, and endoscopic passage into the renal pelvis in the\npresence of a stenosing tumor. DJ catheter placement on the left.\nEndoscopic assessment of the urinary bladder and distal ureter revealed\nno abnormalities. Follow-up steps:\n\n- Removal of the urinary catheter based on urine appearance and\n patient vigilance.\n\n- Sonography before discharge.\n\n- Further steps determined by histology.\n\n- Recommend evaluation and clarification of the significantly elevated\n PSA value.\n\n**Internal Cytological Report Clinical Details: Sample Date: 01/16/2019\n**\n\n1. Left ureter (100 mL colorless, clear)\n\n2. Left renal pelvis (50 mL brown) (Papanicolaou staining)\n\nBoth materials contain increased urinary sediment, along with\ngranulocytes, erythrocytes, and urothelial cells from various layers\nwith multi-nuclear surface cells. Material 1 also shows papillary\narrangements of urothelial cells, some of which have peripheral\nhyperchromatic cell nuclei and altered nuclear-plasma ratios. Material 2\nshows individual papillary urothelial cell arrangements with similar\nnuclear quality, hyperchromasia, and eccentric placement within the\ncytoplasm, as well as nuclear rounding. Numerous individual urothelial\ncells are also present with significantly rounded and enlarged cell\nnuclei, frequently in a peripheral location with hyperchromasia.\n\n**Critical Findings Report:**\n\n1. Detection of a papillary-structured urothelial population with\n nuclear changes, which may be related to instrumentation. Malignant\n urothelial proliferation cannot be definitively ruled out.\n\n2. Abundant cell material with papillary and single atypical urothelia,\n highly suspicious for urothelial carcinoma cells.\n\n**Diagnostic Classification:** Suspicious\n\n**Internal Histopathological Report**\n\n**Clinical Details/Question:** Endoscopic suspicion of urothelial\ncarcinoma.\n\n**Macroscopy:**\n\n1. Left proximal ureter: Unfixed nephrectomy specimen measuring 9.2 x\n 6.5 x 5.2 cm with a maximum 4 cm wide perirenal fat tissue and\n maximum 1 cm wide perihilar fat tissue. Also, a 5 cm long ureter,\n max 1 cm hilar vessels, and a 2.1 x 1.3 x 0.8 cm adrenal gland at\n the upper pole of the kidney. On the sections at the renal hilum,\n there is a maximum 4.3 cm grayish induration. No clear infiltration\n of vessels by the induration is visible macroscopically. No\n connection between the induration and the adrenal gland. The minimal\n distance from the induration to the specimen edge at the renal hilum\n is focally \\< 0.1 cm. Furthermore, the renal pelvis system is\n dilated, and there is a maximum 0.4 cm grayish indurated nodule in\n the perirenal fat tissue.\n\n**Therapy and Progression:** After thorough preparation and patient\ncounseling, we successfully performed the above procedure on 01/16/2019\nwithout complications. Intraoperatively, a stenotic process reaching the\nproximal ureter was observed, preventing passage into the renal pelvis.\nCytology and biopsy were obtained, and a left DJ stent was placed. The\npostoperative course was uneventful. We were able to remove the\ntransurethral catheter upon clearing of urine and discharged the patient\nto your outpatient care.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological evaluations.\n\n- Given the histological findings and highly suspicious radiological\n findings for a malignant mass, we recommend performing an isotope\n renogram to assess separate kidney function. An appointment has been\n scheduled for 03/05/2019. We ask the patient to visit our\n preoperative outpatient clinic on the same day to prepare for left\n nephroureterectomy.\n\n- The surgical procedure is scheduled for 03/20/2019.\n\n- In case of acute urological symptoms, immediate reevaluation is\n welcome at any time.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report to you regarding our mutual patient Mr. Peter\nRudolph, born on 05/26/1954, who was under our care from 03/17/2019 to\n04/01/2019.\n\n**Diagnosis:** Urothelial carcinoma of the renal pelvis, high grade,\nmaximum size 4.3 cm. TNM Classification (8th edition, 2017): pT3, pN0\n(0/11), M1 (ADR), Pn1, L1, V1.\n\n**Other Diagnoses:**\n\n- Atrial fibrillation: History of ablation in 2013\n\n- History of pTCA stenting in 2010 due to acute myocardial infarction\n\n- Suspected soft tissue rheumatism\n\n- History of laparoscopic cholecystectomy in 2012\n\n- History of tonsillectomy\n\n- Obesity\n\n**Procedures:** Open left nephroureterectomy with lymphadenectomy on\n03/18/2019.\n\n**Histology: Critical Findings Report:**\n\n[Renal pelvis carcinoma (left kidney):]{.underline} Extensive\ninfiltration of a high-grade urothelial carcinoma in the renal pelvis\nwith infiltration of the renal parenchyma and perihilar adipose tissue,\nmaximum size 4.3 cm (1.). In the included adrenal tissue, central\nevidence of small carcinoma infiltrates, to be interpreted as distant\nmetastasis (M1) with no macroscopic evidence of direct infiltration and\ncentral localization.\n\n[Resection Status]{.underline}: Carcinoma-free resection margins of the\nproximal left ureter and ureter with mild florid urocystitis at the\nureteral orifice. Margin-forming carcinoma infiltrates at the main\npreparation hilar near the renal vein, with the cranial hilar resection\nmargins I and II being carcinoma-free.\n\n[Nodal Status:]{.underline} Eleven metastasis-free lymph nodes in the\nsubmissions as follows: 0/1 (2.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nFinal TNM Classification (8th edition, 2017): pT3, pN0(0/11), M1 (ADR),\nPn1, L1, V1.\n\n**Current Presentation:** The patient was electively scheduled for the\nabove-mentioned procedure. The patient does not report any complaints in\nthe urological field.\n\n**Physical Examination:** Abdomen is soft, no tenderness. Both renal\nbeds are free.\n\n**Fast Track Report on 03/18/2019: **\n\n**Microscopy:** Histologically, there are extensive infiltrations of a\ncarcinoma growing in large solid formations with focal necrosis and\nhighly pleomorphic cell nuclei. In block 1A, there is a section of a\nurothelium-lined duct structure with a transition from normal epithelium\nto highly atypical epithelium and invasive carcinoma infiltrates. Broad\ninfiltration into adjacent fat tissue and renal parenchyma is observed.\nFocal perineural sheath infiltration.\n\n**Critical Findings**: Left renal pelvis carcinoma: Extensive\ninfiltrates of high-grade urothelial carcinoma in the renal pelvis,\ninfiltrating the renal parenchyma and perihilar fat tissue, max 4.3 cm\n(1.). No direct infiltration of the accompanying adrenal gland is found.\nIsolated abnormal cells in the adrenal gland parenchyma, which will be\nfurther characterized to exclude the smallest carcinoma extensions. An\nupdate will be provided after the completion of investigations.\n\n**Resection Status:** Carcinoma-free resection margins of the proximal\nleft ureter with mild florid urocystitis near the ureteral orifice.\nCarcinoma-forming infiltrates on the main specimen hilus near the renal\nvein, but postresected cranial hili I and II were free of carcinoma.\n\n**Nodal status**: Eleven metastasis-free lymph nodes in the submissions\nas follows: 0/1 (2nd.), 0/3 (4.), 0/6 (5.), 0/1 (6.).\n\nTNM classification (8th edition 2017): pT3, pN0 (0/11), Pn1, L1, V1.\n\n**Urinanalysis from 03/20/2019**\n\n**Material: Urine, Midstream Collected on 10/13/2020 at 00:00**\n\n- Antimicrobial Agents: Negative. No evidence of growth-inhibiting\n substances in the sample material.\n\n- Bacterial Count per ml: 1,000 - 10,000\n\n- Assessment: Bacterial counts of 1000 CFU/mL or higher can be\n clinically relevant, especially with corresponding clinical\n symptoms, especially in pure cultures of uropathogenic\n microorganisms from midstream urine or single-catheter urine, along\n with concomitant leukocyturia.\n\n- Epithelial Cells (microscopic): \\<20 epithelial cells/μL\n\n- Leukocytes (microscopic): \\<20 leukocytes/μL\n\n- Microorganisms (microscopic): \\<20 microorganisms/μL\n\n**Pathogen:** Citrobacter koseri\n\n**Antibiogram:**\n\n- Cefalexin: Susceptible (S) with a minimum inhibitory concentration\n (MIC) of 8\n\n- Ampicillin/Amoxicillin: Resistant (R) with MIC \\>=32\n\n- Amoxicillin+Clavulanic Acid: Susceptible (S) with MIC of 8\n\n- Piperacillin+Tazobactam: Susceptible (S) with MIC \\<=4\n\n- Cefotaxime: Susceptible (S) with MIC \\<=1\n\n- Ceftazidime: Susceptible (S) with MIC of 0.25\n\n- Cefepime: Susceptible (S) with MIC \\<=0.12\n\n- Meropenem: Susceptible (S) with MIC \\<=0.25\n\n- Ertapenem: Susceptible (S) with MIC \\<=0.5\n\n- Cotrimoxazole: Susceptible (S) with MIC \\<=20\n\n- Gentamicin: Susceptible (S) with MIC \\<=1\n\n- Ciprofloxacin: Susceptible (S) with MIC \\<=0.25\n\n- Levofloxacin: Susceptible (S) with MIC \\<=0.12\n\n- Fosfomycin: Susceptible (S) with MIC \\<=16\n\n**Therapy and Progression:** After thorough preparation and patient\neducation, we performed the above-mentioned procedure on 03/18/2019,\nwithout complications. The postoperative course was uneventful except\nfor prolonged milky secretion from the indwelling wound drainage. Prior\nto catheter removal, a single instillation of Mitomycin was\nadministered. Regular examinations were unremarkable. We discharged Mr.\nRudolph on 04/01/2019, in good general condition after removal of the\ndrainage, following an unremarkable final examination, for your esteemed\noutpatient follow-up.\n\n**Current Recommendations:**\n\n- We request regular follow-up urological appointments. The first one\n should take place within one week after discharge.\n\n- Based on the histopathological findings with evidence of a\n metastasis in the adrenal tissue, we recommend the administration of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. The patient wishes\n for a local connection, which was initiated during the inpatient\n stay.\n\n- Anticoagulation: Following the recommendations of the current\n guideline for prophylaxis of venous thromboembolism, we advise\n continuing anticoagulation with low molecular weight heparins for a\n total of 4 - 5 weeks post-operation after urological procedures in\n the abdominal and pelvic area.\n\n- With the current single kidney situation, we recommend regular\n nephrological follow-up examinations.\n\n- In case of acute urological complaints, immediate re-presentation\n is, of course, welcome.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe are writing to inform you about our patient Mr. Peter Rudolph, born\non 05/26/1954, who was under treatment at our outpatient clinic on\n04/20/2020.\n\n**Diagnosis:** Newly hepatic and previously known adrenal metastasized,\nlocally advanced urothelial carcinoma of the left renal pelvis\n(diagnosed in 03/19).\n\n**Previous Diagnoses and Treatment:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis, pT3, pN0 (0/11), M1 (ADR), pn1, L1,\n V1, high-grade. 04 - 07/19: Four cycles of adjuvant chemotherapy\n with Gemcitabine/Cisplatin.\n\n- Newly emerged, progressively enlarging liver metastasis in Segment 6\n and Segment 7, in relation to the previously known adrenal\n metastasized and locally advanced urothelial carcinoma of the renal\n pelvis, following left nephroureterectomy and four cycles of\n adjuvant chemotherapy with Gemcitabine/Cisplatin. Suspected\n activation of a rheumatic disease.\n\n**Other Diagnoses:**\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presents electively with current\nimaging in our uro-oncological outpatient clinic for treatment and\ndiscussion of the further therapy plan.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated. In the summer, the\npatient presented with abdominal pain, and subsequently, an extensive\npsoas abscess was detected during our inpatient treatment. Planned\nfollow-up examinations have taken place since then, but the current\nimaging now suggests a newly emerged hepatic metastasis.\n\n**Therapy and Progression**: Mr. Rudolph is in a satisfactory general\ncondition. Bowel movements are unremarkable with 1-2 well-formed stools\nper day. Urinary frequency is up to 5-6 times a day with one episode of\nnocturia. There is no urinary hesitancy. Currently, the patient\ncomplains of an activation of his previously unclarified rheumatic\ndisease. He describes increasing pain with swelling in the left distal\nankle more than the right. Additionally, the patient complains of\npainful right knee, and a total endoprosthesis on this side was\napparently planned but postponed due to the current COVID-19 pandemic.\nFurthermore, the patient reports pain in the distal and proximal\ninterphalangeal joints of both hands. Externally, the general\npractitioner initiated a short-term cortisone pulse therapy with 3-day\nintervals (initial dose 100mg) due to suspicion of soft tissue\nrheumatism a week ago. Under this treatment, the pain has progressively\nimproved, and the patient is currently almost symptom-free. Otherwise,\nthere is a good social network, and no nursing care is required.\n\nThe urological findings indicate a newly emerged hepatic metastasis in\nrelation to the previously known adrenal metastasized, locally advanced\nurothelial carcinoma of the left renal pelvis, following\nnephroureterectomy and four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin. Due to the newly emerged metastasis within one\nyear after successful Cisplatin therapy, platinum resistance is\npresumed. Therefore, the indication for initiating a second-line therapy\nwith the immune checkpoint inhibitor Pembrolizumab, Atezolizumab, or\nNivolumab now exists. A comprehensive explanation was provided, with a\nparticular focus on risks and side effects. Special attention was given\nto the exacerbation of pre-existing rheumatic complaints, and it was\nstrongly advised that the patient consult a rheumatologist before\ninitiating systemic therapy with an immune checkpoint inhibitor. As the\npatient is already well-connected to the outpatient oncologist and has a\nlong commute, the initiation of local therapy was discussed with the\npatient. Telephonically, the patient has already been connected to the\nmentioned practice. Therapy initiation is planned for this week and will\nbe communicated to the patient separately.\n\n**Current Recommendations:**\n\n- We request the initiation of systemic therapy with an immune\n checkpoint inhibitor (Pembrolizumab, Atezolizumab, or Nivolumab).\n The first follow-up staging examination should take place after 4\n cycles of therapy using CT of the chest/abdomen/pelvis.\n\n- Prior to initiating systemic therapy, we recommend consultation with\n a local rheumatologist for further evaluation of rheumatic symptoms.\n\n- In particular, if systemic therapy with an immune checkpoint\n inhibitor is initiated despite existing rheumatic symptoms, regular\n follow-up and clinical monitoring should be closely observed.\n\n- Regarding the externally initiated high-dose Prednisolone course, we\n recommend a rapid tapering, so that after reaching a threshold dose\n of 10mg/day, immune checkpoint inhibitor therapy can be initiated.\n\n- In the event of acute complications or side effects, immediate\n medical evaluation may be necessary. In particular, the need for\n timely high-dose cortisone therapy with Prednisolone was emphasized\n if it is an immune-associated side effect.\n\n- If immune checkpoint inhibitor therapy is not feasible, the\n discussion of re-induction with Gemcitabine/Cisplatin or alternative\n therapy with Vinflunine as a second-line treatment should be\n considered.\n\n**Current Medication: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on our patient, Mr. Peter Rudolph, born on 05/26/1954,\nwho was under our inpatient care from 11/04/2020 to 11/05/2020.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD.\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy).\n\n- Unclear thyroid nodule.\n\n- 2012: Laparoscopic cholecystectomy.\n\n- Tonsillectomy (date unknown).\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus.\n\n**Intervention**: CT-guided liver biopsy on 11/04/2020.\n\n**Current Presentation:** Mr. Rudolph presents electively in our\nurological clinic for the aforementioned procedure. Under immunotherapy\nwith Nivolumab 240 mg q14d, there has been significant disease\nprogression. A CT-guided liver biopsy was initially discussed with Mr.\nRudolph for further therapy evaluation. At the time of admission, the\npatient is in good general condition.\n\n**Therapy and Progression:** Following appropriate patient information\nand preparation, we performed the above procedure without complications.\nPostoperatively, there were no complications. We were able to discharge\nMr. Rudolph in good general condition after unremarkable laboratory\nchecks on 11/05/2020.\n\n**Current Recommendations:**\n\n- We request a follow-up visit with the outpatient urologist within 1\n week of discharge for clinical monitoring.\n\n- We recommend switching the systemic therapy to Vinflunine. The\n patient can have this done locally through his outpatient urologist.\n\n- Further sequencing will be conducted through our interdisciplinary\n molecular tumor board, and the patient will be informed of this in\n due course.\n\n- In case of symptoms or complications (especially fever over 38.5°C,\n chills, or flank pain), an immediate return to our clinic is welcome\n at any time.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are providing you with an update on our patient, Mr. Peter Rudolph,\nborn on 05/26/1954, who presented himself at our outpatient clinic on\n06/29/2021.\n\n**Diagnosis**: Hepatic, lymphatic, and adrenal metastasized, locally\nadvanced urothelial carcinoma of the left renal pelvis (diagnosed in\n03/19).\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis (pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade)\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Initial diagnosis of liver metastases in Segment 6 and\n Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n- 10/20 - 06/21: Third-line chemotherapy with Vinflunin (external),\n resulting in hepatic progression\n\n- 01/21: Molecular tumor board: no evidence of a molecular target\n\n- 2013: Atrial fibrillation with ablation\n\n<!-- -->\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Soft tissue rheumatism\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy (date unknown)\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Current Presentation:** Mr. Rudolph presented to out outpatient clinic\non 06/29/2021, accompanied by his wife, in subjectively satisfactory\ncondition. Given the negative PDL1 status and FGFR mutation status\nobserved in our institution\\'s molecular tumor board, Mr. Rudolph was\nnow presented to us for reevaluation and discussion of further\nprocedures.\n\n**External CT Thorax dated 06/07/2021: **\n\n**Findings:** The last relevant preliminary examination was conducted on\n03/03/2021. Currently, well-ventilated lungs bilaterally without\ntumor-typical findings or infiltrates. The bronchial system is clear. No\npathologically enlarged lymph nodes in the mediastinum, hilar region, or\naxillae. Relatively pronounced atherosclerotic vascular calcifications,\notherwise unremarkable imaging of the major pulmonary and mediastinal\nvessels. Normal dimensions of the cardiac chambers. No pericardial\neffusion or pleural effusion. Thyroid and esophagus appear normal. No\nosteolysis or spinal canal stenosis.\n\n**Assessment**: Continued absence of thoracic metastases.\n\n**External CT Abdomen dated 06/07/2021: **\n\n**Findings:** Comparison with CT Abdomen dated 03/03/2021. Significant\nprogression of numerous, some large liver metastases in both liver\nlobes. For example, a formerly 4.2 x 2.5 cm measuring metastasis\nsubcapsular in liver segment 7 has now increased to 5.8 x 3.6 cm. A\nformerly 1.2 x 1.1 cm measuring metastasis in liver segment 4a has\nincreased to 3.3 x 2.4 cm. Portal vein and hepatic veins are properly\ncontrasted. Post-cholecystectomy status. Unremarkable adrenal glands.\nPost-left nephrectomy. The right kidney is unremarkable. The spleen is\nunremarkable. The pancreas appears normal. Diverticula of the sigmoid\nand colon. No suspicious inguinal, iliac, retroperitoneal, or mesenteric\nlymph nodes.\n\nAssessment: Significant progression of numerous, some large liver\nmetastases. Otherwise, no organ metastases. No lymph node metastases.\nPost-left nephrectomy.\n\n**Assessment**: The urological examination findings indicate progressive\nhepatic metastasized urothelial carcinoma originating from the left\nrenal pelvis, despite third-line chemotherapy with Vinflunin. The\nfindings were thoroughly discussed in the urological-interdisciplinary\nconference on 06/29/2021.\n\n[Recommendations for further procedures include:]{.underline}\n\n1. Chemotherapy with Gemcitabine and Paclitaxel.\n\n2. A best-supportive-care strategy with symptom-oriented approach and\n possible palliative medical support.\n\n3. After approval, a targeted therapy with Enfortumab Vedotin could be\n considered if further tumor-specific treatment is desired.\n\nThese recommendations were discussed with Mr. Rudolph and his wife\nduring an outpatient uro-oncology consultation. Mr. Rudolph demonstrated\nadequate orientation regarding his medical condition, given the overall\nlimited therapeutic options. A final decision on one of the proposed\nalternatives was not reached collectively, although Mr. Rudolph tended\ntowards a watchful waiting approach due to perceived significant side\neffects from the previous third-line chemotherapy with Vinflunin.\nTherefore, we left the final recommendation open with a tendency towards\nthe best-supportive-care strategy. A local palliative medicine\noutpatient connection was also recommended. According to the patient,\nthere is a living will and a power of attorney for healthcare decisions\nin place.\n\nWe have already provided feedback to the attending oncologist by phone.\n\n**Current Recommendations:**\n\n- In the presence of apparent treatment fatigue in the patient, a\n best-supportive-care strategy with a symptom-oriented approach and\n potential initiation of chemotherapy with Gemcitabine and Paclitaxel\n could be considered at the current time in an individualized\n setting.\n\n- We request the continuation of uro-oncological care by the attending\n oncologist.\n\n- After the medication Enfortumab-Vedotin is approved, a discussion of\n this therapy can take place, depending on the patient\\'s overall\n condition and the desire for further tumor-specific treatment.\n\n**Medication upon Discharge: **\n\n **Medication ** **Dosage** **Frequency**\n ------------------------- ------------ ---------------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n Pantoprazole (Protonix) 40 mg 1-0-0\n Prednisolone (Prelone) 80 mg According to scheme\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting on the examination conducted on Mr. Rudolph, born on\n05/26/1954 on 08/26/2021.\n\n**Diagnosis**: Stenosis of the left subclavian artery\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Clinical Findings:**\n\n[Fist Closure Test:]{.underline} Color Doppler sonography of the\nshoulder-arm arteries: Bilateral triphasic flow in the subclavian\narteries. Bilateral triphasic flow in the brachial arteries, even with\narm elevation. Left vertebral artery shows orthograde flow, no flow\nreversal during overhead work.\n\n[Conclusion]{.underline}: Clinically and duplex sonographically, no\nsubclavian stenosis can be demonstrated.\n\nBoth hands are warm and rosy and show intact sensory-motor function. No\nhand claudication or dizziness provoked during overhead work.\n\nPulse status: Bilateral palpable radial and ulnar arteries. Blood\npressure on the right 160 mmHg systolic, on the left 190 mmHg systolic.\n\nDuplex: Bilateral subclavian arteries show triphasic flow. Bilateral\nbrachial arteries show triphasic flow, even with arm elevation. Left\nvertebral artery demonstrates orthograde flow, with no flow reversal\nduring overhead work.\n\n**Current Recommenations: **\n\nThe evaluation is performed to assess a potential left subclavian\nstenosis with blood pressure side differences. Dizziness or arm\nclaudication, especially during overhead work, is denied.\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Peter Rudolph, born on 05/26/1954, who was in\nour inpatient treatment from 02/22/2022 to 02/29/2022.\n\n**Diagnosis**: Symptomatic incisional hernia in the area of the old\nlaparotomy scar (status post left nephroureterectomy in 03/19.\n\n**Other Diagnoses:**\n\n- 03/19: Left nephroureterectomy with the detection of urothelial\n carcinoma of the renal pelvis and adrenal metastasis, pT3, pN0,\n (0/11), M1 (ADR), pn1, L1, V1, high-grade\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg q14d\n\n<!-- -->\n\n- 2013: Atrial fibrillation with ablation\n\n- 2010: pTCA stenting for acute myocardial infarction/CHD\n\n- Suspected activated soft tissue rheumatism (currently under\n Prednisolone pulse therapy)\n\n- Unclear thyroid nodule\n\n- 2012: Laparoscopic cholecystectomy\n\n- Tonsillectomy\n\n- 01/2019: Left psoas abscess with detection of multisensitive\n Staphylococcus aureus\n\n**Operation:** Alloplastic Incisional Hernia Repair in intubation\nanesthesia on 02/23/2022.\n\n**Current Presentation:** The patient was admitted for elective surgery\nafter indications were assessed and preoperative preparation was\nconducted in our clinic for the above-mentioned diagnosis.\n\n**Therapy and Progression:** Following routine preoperative\npreparations, comprehensive informed consent, and premedication, we\nperformed the aforementioned procedure on 02/23/2022 in uncomplicated\nITN. There were no intraoperative complications.\n\nThe postoperative inpatient course progressed normally with dry and\nnon-irritated wound conditions. The drainage was timely removed as the\ndrainage volume decreased. Full mobilization and intensive respiratory\ntherapy exercises were initiated on the first postoperative day. Regular\nclinical and laboratory check-ups indicated a normal healing process.\nThe diet was well tolerated, and the wounds healed primarily. We\ndischarged Mr. Rudolph for further outpatient care on 02/29/2022.\n\n**Histology**: Skin/subcutaneous resection with scar fibrosis.\nFibrolipomatous hernial sac with obstructed vessels. No evidence of\nmalignancy.\n\n**Medication upon Admission:**\n\n **Medication ** **Dosage** **Frequency**\n --------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0\n Bisoprolol (Zebeta) 50 mg 1/2-0-0\n\n**Procedure:** From a surgical perspective, we request wound\ninspections. To prevent recurrence, avoid lifting heavy objects (\\>5 kg)\nfor the next 8-12 weeks. Please consistently wear the abdominal binder\nduring the wound healing period (14 days). Additionally, avoid excessive\nabdominal pressure, especially during bowel movements.\n\n**Surgical Report: **\n\n**Diagnoses:**\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Type of Surgery:** Incisional Hernia Repair with Optilene Mesh (30 x\n30 cm), Adhesiolysis of the intestine\n\n**Anesthesia Type:** Intubation anesthesia\n\n**Report**: **Indication**: Mr. Rudolph presents with an extensive\nincisional hernia following a history of nephrectomy and pancreatic\nresection for clear cell renal cell carcinoma. The indication for hernia\nrepair with mesh was made.\n\n**Operation**: The procedure was performed with the patient in a supine\nposition and in ITN. Sterile preparation, draping, and perioperative\nantibiotic prophylaxis with Ampicillin/Sulbactam 3g were administered.\nInitially, a skin incision was made to the left of the existing\ntransverse upper abdominal laparotomy scar, and a sparing spindly\nexcision of the scar was performed. Dissection into the depth revealed\nthe first hernia sac. This sac was dissected free and opened. Further\nlateral to the left, a very large additional hernia sac was found. This\none was also completely dissected free and opened. The two hernia\ndefects were connected only by a narrow isthmus of thinned abdominal\nwall fascia, which was cut, and the two hernia defects were united.\nFurthermore, another hernia sac was found laterally to the right in the\narea of the scar. Thus, the scar was opened across its entire width by\nextending the skin incision to the right. The right lateral hernia sac\nwas also dissected free and opened. Now, the hernia sacs were removed\none after the other (histology specimens). The epifascial adipose tissue\nwas then mobilized so that the abdominal wall fascia was exposed and\ncould serve as the base for the mesh to be placed. The three hernia\ndefects were then closed with a total of three continuous sutures using\nVicryl. This was done after the abdominal wall fascia was also dissected\nfree intra-abdominally, where the intestines or large mesh adhered to\nthe abdominal wall. After the hernia defects were now closed, the 30x30\ncm Optilene mesh was introduced after thorough irrigation and careful\nelectrocoagulation for hemostasis. It was fixed tightly but without\ntension at the edges with Ethibond sutures of size 0. Subsequently, a\nPalisade suture was placed around the closed hernia defects using\nProlene size 0 in a continuous technique. Final irrigation and\nhemostasis were performed. Four 12 Redon drains were placed in the\nwound, led out, and sutured. Subcutaneous sutures were made with Vicryl\n2-0. Skin sutures were placed with Nylon 3-0, followed by a sterile\nwound compression dressing.\n\n**Internal Histopathological Report**\n\n**Macroscopy:**\n\n- Skin spindle: Fixed. Skin spindle measuring 9 x 0.5 x 1.5 cm with a\n centrally located, slightly raised, and indurated scar.\n\n- Hernia sac I: Fixed. Cap-shaped serosal lamella measuring 8 x 7.5 x\n 2 cm with a bulging cord-like fibrosis. The serosa is smooth and\n shiny.\n\n- Hernia sac II: Fixed. A 15 x 3 x 0.5 cm large, reddish-livid serosal\n specimen with focal indurations, petechial hemorrhages, and adhesion\n strands. Multiple cross-sections embedded.\n\n- Hernia sac III: Fixed. A 3.5 x 1 x 0.3 cm serosal lamella with\n scarred fibrosis. Processing: Blocks: 4, H&E. Microscopy:\n\n- Skin/subcutaneous resection with scar fibrosis of the adjacent\n stroma. 2-4. Fibrolipomatous tissue, superficially peritonealized.\n Markedly congested blood vessels.\n\n**Critical Findings Report:** Skin/subcutaneous resection with scar\nfibrosis. 2-4. Fibrolipomatous hernia sac tissue with congested blood\nvessels. No evidence of malignancy.\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update regarding Mr. Peter Rudolph, born on\n05/26/1954, who presented to our surgical outpatient clinic on\n03/04/2022.\n\n**Diagnoses**: Status post umbilical hernia repair 10 days ago.\n\n- Extensive incisional hernia in the area of the transverse upper\n abdominal laparotomy scar, with a history of: Left\n nephroureterectomy with the detection of urothelial carcinoma of the\n renal pelvis and adrenal metastasis, pT3, pN0, (0/11), M1 (ADR),\n pn1, L1, V1, high-grade.\n\n- 04/19 - 07/19: Four cycles of adjuvant chemotherapy with\n Gemcitabine/Cisplatin.\n\n- 04/20: Newly emerged liver metastasis in Segment 6 and Segment 7.\n\n- 05/20 - 09/20: 10 cycles of immunotherapy with Nivolumab 240 mg\n q14d.\n\n**Medical History:** In March 2019, Mr. Rudolph underwent a\nnephroureterectomy with the detection of urothelial carcinoma of the\nrenal pelvis. Subsequently, four cycles of adjuvant chemotherapy with\nGemcitabine/Cisplatin were performed due to the detection of locally\nadvanced urothelial carcinoma with primary metastasis to the left\nadrenal gland. The chemotherapy was well-tolerated overall. On\n02/22/2022, Mr. Rudolph presented with an extensive incisional hernia\nfollowing a history of left nephroureterectomy. The indication for\nhernia repair with mesh was made.\n\n**Physical Examination**: Unremarkable scar, sutures in place.\n\n**Current Recommendation**: Follow-up appointment scheduled for Thursday\n(12th postoperative day) for suture removal and progress assessment.\n", "title": "text_7" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n\n\n### text_1\n**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n\n\n### text_2\n**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n\n\n### text_4\n**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n\n\n### text_5\n**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n\n\n\n\nHere is the query:\nAs of 11/20/2020, which COPD severity level was Mr. Wells classified under?\n\nChoose the correct answer from the following options:\nA. Gold I\nB. Gold II\nC. Gold III\nD. Gold IV\nE. Not classified\n\n\nYour response:\n", "role": "user" }, { "content": "Gold III", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report to you on Mr. Paul Wells, born on 04/02/1953, who was in our\ninpatient treatment from 07/26/2019 to 07/28/2019.\n\n**Diagnoses:** Suspected multifocal HCC segment IV, VII/VIII, first\ndiagnosed: 07/19.\n\n- COPD, current severity level Gold III.\n\n- Pulmonary emphysema, respiratory partial insufficiency with home\n oxygen.\n\n- Postnasal drip syndrome\n\n**Current Presentation:** The elective presentation of Mr. Wells was\nmade in accordance with the decision of the interdisciplinary liver\nboard of 07/20/2019 for further diagnostics in the case of multiple\nmalignoma-specific hepatic space demands.\n\n**Medical History: **In brief, Mr. Wells presented to the Medical Center\nSt. Luke's with persistent right-sided pain in the upper abdomen.\nComputer tomography showed multiple intrahepatic masses of the right\nliver lobe (SIV, SVII/VIII). For diagnostic clarification of the\nmalignoma-specific findings, the patient was presented to our liver\noutpatient clinic. The tumor marker diagnostics have not been\nconclusive. Analogous to the recommendation of the liver board, a liver\npuncture, staging, and endoscopic exclusion of a primary in the\ngastrointestinal tract should be initiated.\n\n**Physical Examination:** Physical examination reveals an alert patient.\n\n- Oral mucosa: Moist and rosy, no plaques typical of thrush, no\n plaques typical of herpes.\n\n- Hear: Heart sounds pure, rhythmic, normofrequency.\n\n- Lungs: Laterally attenuated breath sound with wheezing.\n\n- Abdomen: Abdomen soft, regular bowel sounds over all 4 quadrants, no\n defensive tension, no resistances, diffuse pressure pain over the\n upper abdomen. No renal tap pain, no spinal tap pain. Spleen\n palpable under the costal arch.\n\n- Extremities: No edema, freely movable\n\n- Neurology: GCS 15, pupils directly and indirectly reactive to light,\n no flapping tremor. No meningism.\n\n**Therapy and Progression:** Mr. Wells presented an age-appropriate\ngeneral status and cardiopulmonary stability. Anamnestically, there was\nno evidence of an acute infection. Skin or scleral icterus and pruritus\nwere denied. No B symptoms. No stool changes, no dysuria. There would be\nregular alcohol consumption of about 3-4 beers a day, as well as\nnicotine abuse (120 PY). The general performance in COPD Gold grade III\nwas strongly limited, with a walking distance reduced to 100m due to\ndyspnea. He had a home oxygen demand with 4L/min O2 during the day, up\nto 6L/min under load. At night, 2L/min O2. The last colonoscopy was\nperformed 4 years ago, with no anamnestic abnormalities. No known\nallergies. Family history is positive for colorectal cancer (mother).\n\nClinical examination revealed the typical auscultation findings of\nadvanced COPD with attenuated breath sounds bilateral, with\nhyperinflation and clear wheezing. Otherwise, there were no significant\nfindings. Laboratory chemistry did not reveal any higher-grade\nabnormalities. On the day of admission, after detailed clarification,\nthe patient was able to undergo the complication-free sonographically\nguided puncture of the liver cavity in SIV. Thereby, two punch cylinders\nwere preserved for histopathological processing. Histologically, the\nfindings presented as infiltrates of a macrotrabecular and\npseudoglandular growing, well-differentiated hepatocellular carcinoma\n(G1). The postinterventional course was unremarkable. In particular, no\nclinical or laboratory signs were found for bleeding.\n\nCT staging revealed a size constant known in the short term.\nHypervascularized hepatic space demands in both lobes of the liver\nwithout further malignancy suspect thoracoabdominal tumor detection and\nwithout metastasis aspects. MR also revealed the large, partly exophytic\ngrowing, partly centrally hemorrhaged HCC lesions in S3/4 and S7/8 to\nthe illustration. In addition, complete enforcement of the left lobe of\nthe liver was evident with smaller satellites and macroinvasion of the\nleft portal vein branch. There was a low cholestasis of the left biliary\nsystem. Gastroscopy and colonoscopy were also performed. Here, a reflux\nesophagitis, sigmoid diverticulosis, multiple colonic diverticula, and a\n4mm polyp were removed from the sigmoid colon to prevent bleeding; a\nhemoclip was applied. Histologically, no adenoma was found. An\nappointment to discuss the findings in our HCC outpatient clinic has\nbeen arranged. We recommend further therapy preparation and the\nperformance of an echocardiography.\n\nWe were able to discharge Mr. Wells on 7/28/19.\n\n**Addition:**\n\n**Ultrasound on 07/26/2019 10:15 AM:**\n\n- Indication: Targeted liver puncture for suspected metastatic liver\n malignancy\n\n- Organ puncture: Quick: 114%, PTT: 28 s, and platelets: 475 G/L. A\n valid declaration of consent is available. According to the patient,\n he does not receive antiplatelet drugs.\n\n- In segment IV, an approximately 8.3 x 6 cm echo-depleted mass with\n central cystic fusion is accessible in the dorsal position of a\n sonographically guided puncture at 6.5 cm puncture depth. After\n extensive skin disinfection, local anesthesia with 10 mL Mecaine 1%\n and puncture incision with a scalpel. Repeated puncture with 18 G\n Magnum needles is performed. Two approximately 1 cm fragile whitish\n cylinders obtained for histologic examination. Band-aid dressing.\n\n- **Assessment:** Hepatic space demand\n\n**MRI of the liver plain + contrast agent from 07/26/2019 1:15 PM:**\n\n**Technique**: Coronary and axial T2 weighted sequences, axial\ndiffusion-weighted EPI sequence with ADC map (b: 0, 50, 300 and 600\ns/mmÇ), axial dynamic T1 weighted sequences with Dixon fat suppression\nand (liver-specific) contrast agent (Dotagraf/Primovist); slice\nthickness: 4 mm. Premedication with 2 mL Buscopan.\n\n**Liver**: Centrally hemorrhagic masses observed in liver segments 4, 7,\nand 8 demonstrate T2 hyperintensity, marked diffusion restriction,\narterial phase enhancement, and venous phase washout. These\ncharacteristics are congruent with histopathological diagnosis of\nhepatocellular carcinoma. The largest lesion in segment 4 exhibits\npronounced exophytic growth but no evidence of organ invasion. Notably,\nbranches of the mammary arteries penetrate directly into the tumor.\nDiffusion-weighted imaging further reveals disseminated foci throughout\nthe entire left hepatic lobe. Disruption of the peripheral left portal\nvein branch indicative of macrovascular invasion, accompanied by\nperipheral cholestasis in the left biliary system.\n\n**Biliary Tract:** Bile ducts are emphasized on both left and right\nsides, with no evidence of mechanical obstruction in drainage. The\ncommon hepatic duct remains non-dilated.\n\n**Pancreas and Spleen:** Both organs exhibit no abnormalities.\n\n**Kidneys:** Normal signal characteristics observed.\n\n**Bone Marrow:** Signal behavior is within normal limits.\n\nAssessment: Radiological features highly suggestive of hepatocellular\ncarcinoma in liver segments 4, 7, and 8, with evidence of macrovascular\ninvasion and peripheral cholestasis in the left biliary system. No signs\nof organ invasion or biliary obstruction. Pancreas, spleen, kidneys, and\nbone marrow appear unremarkable.\n\n**Assessment:**\n\nLarge liver lesions, some exophytic and some centrally hemorrhagic, are\nobserved in segments 3/4 and 7/8.\n\nIn addition, the left lobe of the liver is completely involved with\nsmaller satellite lesions and macroinvasion of the left portal branch.\nMild cholestasis of the left biliary system is noted.\n\nDilated bile ducts are also found on the right side with no apparent\nmechanical obstruction to outflow.\n\n**CT Chest/Abdomen/Pelvis with contrast agent from 07/27/2019 2:00 PM:**\n\n**Clinical Indication:** Evaluation of an unclear liver lesion\n(approximately 9 cm) in a patient with severe COPD. No prior\nliver-related medical history.\n\n**Question:** Are there any suspicious lesions in the liver?\n\n**Pre-recordings:** Previous external CT abdomen dated 09/13/2021.\n\n**Findings:**\n\n**Technique:** CT imaging involved a multi-line spiral CT through the\nchest, abdomen, and pelvis in the venous contrast phase. Oral contrast\nagent with Gastrolux 1:33 in water was administered. Thin-layer\nreconstructions and coronary and sagittal secondary reconstructions were\nperformed.\n\n**Chest:** No axillary or mediastinal lymphadenopathy is observed. There\nis marked coronary sclerosis, as well as calcification of the aortic and\nmitral valves. Nonspecific nodules smaller than 2 mm are noted in the\nposterolateral lower lobe on the right side and lateral middle lobe. No\npneumonic infiltrates are observed. There is reduced aeration with\npresumed additional scarring changes at the base of the lung\nbilaterally, along with centrilobular emphysema.\n\n**Abdomen:** Known exophytic liver lesions are confirmed, with\ninvolvement in segment III extending to the subhepatic region (0.1 cm\nextension) and a 6 cm lesion in segment VIII. Further spotty\nhypervascularized lesions are observed throughout the left lobe of the\nliver. No pathological dilatation of intra- or extrahepatic bile ducts\nis seen, and there is no evidence of portal vein thrombosis. There are\nno pathologically enlarged lymph nodes at the hepatic portal,\nretroperitoneal, or inguinal regions. No ascites or pneumoperitoneum is\nnoted. There is no pancreatic duct congestion, and the spleen is not\nenlarged. Additionally, there is a Bosniak 1 left renal cyst measuring\n3.6 cm. Pronounced sigmoid diverticulosis is observed, with no evidence\nof other masses in the gastrointestinal tract. Skeletal imaging reveals\nno malignancy-specific osteodestructions but shows ventral pontifying\nspondylophytes of the thoracic spine with no fractures.\n\n**Assessment:**\n\nShort-term size-constant known hypervascularized hepatic space lesions\nare present in both lobes of the liver.\n\nNo other malignancy-susceptible thoracoabdominal tumor evidence is\nfound, and there are no metastasis-specific lymph nodes.\n\n**Gastroscopy from 07/28/2019**\n\n**Findings:**\n\n**Esophagus:** Unobstructed intubation of the esophageal orifice under\nvisualization. Mucosa appears inconspicuous, with the Z-line at 37 cm\nand measuring less than 5 mm. Small mucosal lesions are observed but do\nnot straddle mucosal folds.\n\n**Stomach:** The gastric lumen is completely distended under air\ninsufflation. There are streaky changes in the antrum, while the fundus\nand cardia appear regular on inversion. The pylorus is inconspicuous and\npassable.\n\n**Duodenum:** Good development of the bulbus duodeni is noted, with good\ninsight into the pars descendens duodeni. The mucosa appears overall\ninconspicuous.\n\n**Assessment:** Findings suggest reflux esophagitis (Los Angeles\nClassification Grade A) and antrum gastritis.\n\n**Colonoscopy from 07/28/2019**\n\n**Findings:**\n\n**Colon:** Some residual fluid contamination is noted in the sigmoid\n(Boston Bowel Preparation Scale \\[BBPS\\] 8). There is pronounced sigmoid\ndiverticulosis, along with multiple colonic diverticula. A 4mm polyp in\nthe lower sigma (Paris IIa, NICE 1) is observed and ablated with a cold\nsnare, with hemoclip application for bleeding prophylaxis. Other mucosal\nfindings appear inconspicuous, with normal vascular markings. There is\nno indication of inflammatory or malignant processes.\n\n**Maximum Insight:** Terminal ileum.\n\n**Anus:** Inspection of the anal region reveals no pathological\nfindings. Palpation is inconspicuous, and the mucosa is smooth and\ndisplaceable, with no resistance and no blood on the glove.\n\n**Assessment:** Polypectomy was performed for sigmoid diverticulosis and\na colonic diverticulum, with histology revealing minimally hyperplastic\ncolorectal mucosa and no evidence of malignancy.\n\n**Pathology from 08/27/2019**\n\n**Clinical Information/Question:**\n\n**Macroscopy:** Unclear liver tumor: numerous tissue samples up to a\nmaximum of 0.7 cm in size. Complete embedding.\n\nProcessing: One tissue block processed and stained with Hematoxylin and\nEosin (H&E), Gomori\\'s trichrome, Iron stain, Diastase Periodic\nAcid-Schiff (D-PAS), and Van Gieson stain.\n\n**Microscopic Findings:**\n\n- Liver architecture is presented in fragmented liver core biopsies\n with observable lobular structures and two included portal fields.\n\n- Hepatic trabeculae are notably wider than the typical 2-3 cell\n width, featuring the formation of druse-like luminal structures.\n\n- Sinusoidal dilatation is markedly observed.\n\n- Hepatocytes show mildly enlarged nuclei with minimal cytologic\n atypia and isolated mitotic figures.\n\n- Gomori staining reveals a notable, partial loss of the fine\n reticulin fiber network.\n\n- Adjacent areas show fibrosed liver parenchyma containing hemosiderin\n pigmentation.\n\n- No significant evidence of parenchymal fatty degeneration is\n observed.\n\n**Assessment**: Histologic features indicative of marked sinusoidal\ndilatation, trabecular widening, and partial loss of reticulin network,\nalongside minimally atypical hepatocytes and fibrosed parenchyma with\nhemosiderin pigment. No significant hepatic fat degeneration noted.\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe would like to report on Paul Wells, born on 04/02/1953, who was under\nour outpatient treatment on 08/24/2019.\n\n**Diagnoses:**\n\n- Multifocal HCC (Hepatocellular Carcinoma) involving segments IV,\n VII/VIII, with portal vein invasion, classified as BCLC C, diagnosed\n in July 2019.\n\n- Extensive HCC lesions, some exophytic and others centrally\n hemorrhagic, in segments S3/4 and S7/8, complete involvement of the\n left liver lobe with smaller satellite lesions, and macrovascular\n invasion of the left portal vein.\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- COPD with a current severity level of Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency requiring home oxygen therapy.\n\n- Postnasal Drip Syndrome.\n\n- History of nicotine use (120 pack-years).\n\n- Hypertension (high blood pressure).\n\n**Medical History:** Mr. Wells presented with persistent right upper\nabdominal pain and was initially treated at St. Luke\\'s Medical Center.\nCT scans revealed multiple intrahepatic lesions in the right liver lobe\n(SIV, SVII/VIII). Short-term follow-up CT staging revealed a known,\nsize-stable, hypervascularized hepatic lesion in both lobes of the\nliver, with no evidence of other thoracoabdominal malignancies or\nsuspicious lymph nodes. MRI also confirmed the presence of large HCC\nlesions, some exophytic and others centrally hemorrhagic, in segments\nS3/4 and S7/8, along with complete infiltration of the left liver lobe\nwith smaller satellite lesions and macroinvasion of the left portal\nvein. There was mild cholestasis in the left biliary system.\n\n**Current Recommendations: **\n\n- Liver function remains good based on laboratory tests.\n\n- Mr. Wells has been extensively informed about systemic therapy\n options with Atezolizumab/Bevacizumab and the possibility of\n alternative therapy with a tyrosine kinase inhibitor.\n\n- The decision has been made to initiate standard first-line therapy\n with Atezolizumab/Bevacizumab. Detailed information regarding\n potential side effects has been provided, with particular emphasis\n on the need for immediate medical evaluation in case of signs of\n gastrointestinal bleeding (blood in stool, black tarry stool, or\n vomiting blood) or worsening pulmonary symptoms.\n\n- The patient has been strongly advised to abstain from alcohol\n completely.\n\n- A follow-up evaluation through liver MRI and CT has been scheduled\n for January 4, 2020, at our HCC (Hepatocellular Carcinoma) clinic.\n The exact appointment time will be communicated to the patient\n separately.\n\n- We are available for any questions or concerns.\n\n- In case of persistent or worsening symptoms, we recommend an\n immediate follow-up appointment.\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe would like to provide an update regarding Mr. Paul Wells, born on\n04/02/1953, who was under our inpatient care from 08/13/2020 to\n08/14/2020.\n\n**Medical History:**\n\nWe assume familiarity with Mr. Wells\\'s comprehensive medical history as\ndescribed in the previous referral letter. At the time of admission, he\nreported significantly reduced physical performance due to his known\nsevere COPD. Following the consensus of the Liver Board, we admitted Mr.\nWells for a SIRT simulation.\n\n**Current Presentation:** Mr. Wells is a 66-year-old patient with normal\nconsciousness and reduced general condition. He is largely compensated\non 3 liters of oxygen per minute. His abdomen is soft with regular\nperistalsis. A palpable tumor mass in the right upper abdomen is noted.\n\n**DSA Coeliac-Mesenteric on 08/13/2020:**\n\n- Uncomplicated SIRT simulation.\n\n- Catheter position 1: Right hepatic artery.\n\n- Catheter position 2: Left hepatic artery.\n\n- Catheter position 3: Liver segment arteries 4a/4b.\n\n- Uncomplicated and technically successful embolization of parasitic\n tumor supply from the inferior and superior epigastric arteries.\n\n**Perfusion Scintigraphy of the Liver and Lungs, including SPECT/CT on\n08/13/2020:**\n\n- The liver/lung shunt volume is 9.4%.\n\n- There is intense radioactivity accumulation in multiple lesions in\n both the right and left liver lobes.\n\n**Therapy and Progression:** On 08/13/2020, we performed a DSA\ncoeliac-mesenteric angiography on Mr. Wells, administering a total of\napproximately 159 MBq Tc99m-MAA into the liver\\'s arterial circulation\n(simulation). This procedure revealed that a significant portion of\nradioactivity would reach the lung parenchyma during therapy, posing a\nrisk of worsening his already compromised lung function. In view of\nthese comorbidities, SIRT was not considered a viable treatment option.\nTherefore, an interdisciplinary decision was made during the conference\nto recommend systemic therapy. With an uneventful course, we discharged\nMr. Wells in stable general condition on 08/14/2020.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are reporting on Paul Wells, born on 04/02/1953, who presented to our\ninterdisciplinary clinic for Hepato- and Cholangiocellular Tumors on\n10/24/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- Histology from 07/27/2019: A well-differentiated hepatocellular\n carcinoma (G1) with a macrotrabecular and pseudoglandular growth\n pattern.\n\n- Decision from the Liver Tumor Board on 08/18/2019: Recommending\n systemic therapy.\n\n- Initiation of Atezolizumab/Bevacizumab on 08/24/2019.\n\n- Liver fibrosis: Elevated alcohol consumption (3-4 beers/day).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n**Other Diagnoses:**\n\n- Suspected Polyneuropathy or Restless Legs Syndrome\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema\n\n- Respiratory partial insufficiency with home oxygen\n\n- Postnasal-Drip Syndrome\n\n- History of nicotine abuse (120 py)\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- History of severe pneumonia (Medical Center St. Luke's) in 10/2019\n\n- Pneumogenic sepsis with detection of Streptococcus pneumoniae\n\n- Arterial hypertension\n\n- Atrial fibrillation\n\n- Treatment with Apixaban\n\n- Reflux esophagitis Grade A (Esophagogastroduodenoscopy in 08/2019).\n\n**Current Presentation**: Mr. Wells presented to discuss follow-up after\nsystemic therapy with Atezolizumab/Bevacizumab due to his impaired\ngeneral condition.\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nThe therapy had to be paused after a single administration due to a\nsubstantial increase in transaminases (GPT 164 U/L, GOT 151 U/L),\nsuspected to be associated with immunotherapy-induced hepatitis. With\nonly minimal improvement in transaminases, Prednisolone therapy was\ninitiated on and tapered successfully after significant transaminase\nregression. However, before the next planned administration, the patient\nexperienced severe pneumonic sepsis, requiring hospitalization on\n10/2019. Following discharge, there was a recurrent infection requiring\ninpatient antibiotic therapy.\n\nStaging examinations in 01/2020 showed a very good tumor response.\nSubsequently, Atezolizumab/Bevacizumab was re-administered on 01/23/2020\nand 02/14/2020. However, in the following days, the patient experienced\nsignificant side effects, including oral burning, appetite and weight\nloss, low blood pressure, and worsening pulmonary status. Steroid\ntreatment improved the pulmonary situation, but due to poor tolerance,\ntherapy was paused after 02/14/2020.\n\nCurrently, Mr. Wells reports a satisfactory general condition, although\nhis pulmonary function remains limited but stable.\n\n**Summary:** Laboratory results from external testing on 01/02/2020\nindicate excellent liver function, with transaminases within normal\nrange. The latest CT examination shows continued tumor regression.\nHowever, MRI quality is limited due to the patient\\'s inability to hold\ntheir breath adequately. Given the excellent tumor response and previous\nsignificant side effects, it was decided to continue the treatment pause\nuntil the next tumor staging.\n\n**Current Recommendations:** A follow-up imaging appointment has been\nscheduled for four months from now. We kindly request you send the\nlatest CT images (Chest/Abdomen/Pelvis, including dynamic liver CT) and\ncurrent blood values to our HCC clinic. Due to limited assessability,\nanother MRI is not advisable.\n\nWe remain at your disposal for any further inquiries. In case of\npersistent or worsened symptoms, we recommend prompt reevaluation.\n\n**Medication upon discharge:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------------------- ------------ -------------------------\n Ipratropium/Fenoterol (Combivent) As needed As needed\n Beclomethasone/Formoterol (Fostair) 6+200 mcg 2-0-2\n Tiotropium (Spiriva) 2.5 mcg 2-0-0\n Prednisolone (Prelone) 5 mg 2-0-0 (or as necessary)\n Pantoprazole (Protonix) 40 mg 1-0-0\n Fenoterol 0.1 mg As needed\n Apixaban (Eliquis) 5 mg On hold\n Olmesartan (Benicar) 20 mg 1-0-0\n\nLab results upon Discharge:\n\n **Parameter** **Results** **Reference Range**\n ----------------------------- ------------- ---------------------\n Sodium (Na) 144 mEq/L 134-145 mEq/L\n Potassium (K) 3.7 mEq/L 3.4-5.2 mEq/L\n Calcium (Ca) 2.37 mEq/L 2.15-2.65 mEq/L\n Chloride (Cl) 106 mEq/L 95-112 mEq/L\n Inorganic Phosphate (PO4) 0.93 mEq/L 0.8-1.5 mEq/L\n Transferrin Saturation 20 % 16-45 %\n Magnesium 0.78 mEq/L 0.75-1.06 mEq/L\n Creatinine 1.88 mg/dL \\<1.2 mg/dL\n GFR 36 mL/min \\<90 mL/min\n BUN 60 mg/dL 14-46 mg/dL\n Uric Acid 4.6 mg/dL 3.0-6.9 mg/dL\n Total Bilirubin 0.5 mg/dL \\<1 mg/dL\n Albumin 4.0 g/dL 3.6-5.0 g/dL\n Total Protein 6.8 g/dL 6.5-8.7 g/dL\n CRP 0.19 mg/dL \\<0.5 mg/dL\n Transferrin 269 mg/dL 200-360 mg/dL\n Ferritin 110 mcg/L 30-300 mcg/L\n ALT 339 U/L \\<45 U/L\n AST 424 U/L \\<50 U/L\n GGT 904 U/L \\<55 U/L\n Lipase 61 U/L \\<70 U/L\n Thyroid-Stimulating Hormone 0.54 mIU/L 0.27-4.20 mIU/L\n Hemoglobin 14.5 g/dL 14.0-17.5 g/dL\n Hematocrit 43 % 40-52 %\n Red Blood Cells 4.60 M/µL 4.6-6.2 M/µL\n White Blood Cells 8.78 K/µL 4.5-11.0 K/µL\n Platelets 205 K/µL 150-400 K/µL\n MCV 94 fL 81-100 fL\n MCH 31.5 pg 27-34 pg\n MCHC 33.5 g/dL 32.4-35.0 g/dL\n MPV 11 fL 7-12 fL\n RDW 14.8 % 11.9-14.5 %\n Neutrophils 3.72 K/µL 1.8-7.7 K/µL\n Lymphocytes 2.37 K/µL 1.4-3.7 K/µL\n Monocytes 0.93 K/µL 0.2-1.0 K/µL\n Eosinophils 1.67 K/µL \\<0.7 K/µL\n Basophils 0.09 K/µL 0.01-0.10 K/µL\n Erythroblasts Negative \\<0.01 K/µL\n Antithrombin Activity 85 % 80-120 %\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe are reporting an update of the medical condition of Mr. Paul Wells\nborn on 04/02/1953, who presented for a follow up in our outpatient\nclinic on 11/20/2020.\n\n**Diagnoses:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation.\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased alcohol consumption (3-4 beers/day).\n\n**Other diagnoses:**\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with detection of Streptococcus pneumonia\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** Mr. Wells initially presented with right upper\nabdominal pain, which led to the discovery of multiple intrahepatic\nmasses in liver segments IV, VII/VIII. Subsequent investigations\nconfirmed the diagnosis of HCC. He also suffers from chronic obstructive\npulmonary disease (COPD), emphysema, and respiratory insufficiency\nrequiring home oxygen therapy. Previous investigations and treatments\nwere documented in detail in our previous medical records.\n\n**Physical Examination:**\n\n- General Appearance: Alert, cooperative, and oriented.\n\n- Vital Signs: Stable blood pressure, heart rate, respiratory rate,\n and temperature. Oxygen Saturation (SpO2): Within the normal range.\n\n- Respiratory System: Normal chest symmetry, no accessory muscle use.\n Clear breath sounds, no wheezing or crackles. Regular respiratory\n rate.\n\n- Cardiovascular System: Regular heart rate and rhythm, no murmurs.\n Strong radial and pedal pulses bilaterally. No lower extremity\n edema.\n\n- Gastrointestinal System: Soft, nontender abdomen. Bowel sounds\n present in all quadrants. Spleen palpable under the costal arch.\n\n- Neurological Examination: Alert and oriented. Cranial nerves, motor,\n sensory, reflexes, coordination and gait normal. No focal\n neurological deficits.\n\n- Skin and Mucous Membranes: Intact skin, no rashes or lesions. Moist\n oral mucosa without lesions.\n\n- Extremities: No edema. Full range of motion in all joints. Normal\n capillary refill.\n\n- Lymphatic System:\n\n- No palpable lymphadenopathy.\n\n**MRI Liver (plain + contrast agent) on 11/20/2020 09:01 AM.**\n\n- Imaging revealed stable findings in the liver. The previously\n identified HCC lesions in segments IV, VII/VIII, including their\n size and characteristics, remained largely unchanged. There was no\n evidence of new lesions or metastases. Detailed MRI imaging provided\n valuable insight into the nature of the lesions, their vascularity,\n and possible effects on adjacent structures.\n\n**CT Chest/Abdomen/Pelvis with contrast agent on 11/20/2020 12:45 PM.**\n\n- Thoracoabdominal CT scan showed the same results as the previous\n examination. Known space-occupying lesions in the liver remained\n stable, and there was no evidence of malignancy or metastasis\n elsewhere in the body. The examination also included a thorough\n evaluation of the thoracic and pelvic regions to rule out possible\n metastasis.\n\n**Gastroscopy on 11/20/2020 13:45 PM.**\n\n- Gastroscopy follow-up confirmed the previous diagnosis of reflux\n esophagitis (Los Angeles classification grade A) and antral\n gastritis. These findings were consistent with previous\n investigations. It is important to note that while these findings\n are unrelated to HCC, they contribute to Mr. Wells\\' overall medical\n profile and require ongoing treatment.\n\n**Colonoscopy on 11/20/2020 15:15 PM.**\n\n- Colonoscopy showed that the sigmoid colon polyp, which had been\n removed during the previous examination, had not recurred. No new\n abnormalities or malignancies were detected in the gastrointestinal\n tract. This examination provides assurance that there is no\n concurrent colorectal malignancy complicating Mr. Wells\\' medical\n condition.\n\n**Pulmonary Function Testing:**\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency were\nevaluated in detail. Pulmonary function tests confirmed his current\nseverity score of Gold III, indicating advanced COPD. Despite the\nchronic nature of his disease, there has been no significant\ndeterioration since the last assessment.\n\n**Oxygen Therapy:**\n\nAs previously documented, Mr. Wells requires home oxygen therapy. His\noxygen requirements have been constant, with no significant increase in\noxygen requirements during daily activities or at rest. This stability\nin his oxygen demand is encouraging and indicates effective management\nof his respiratory disease.\n\n**Overall Assessment:** Based on the results of recent follow-up, Mr.\nPaul Wells\\' hepatocellular carcinoma (HCC) has not progressed\nsignificantly. The previously noted HCC lesions have remained stable in\nterms of size and characteristics. In addition, there is no evidence of\nmalignancy elsewhere in his thoracoabdominal region.\n\nMr. Wells\\' COPD, emphysema, and respiratory insufficiency, which is\nbeing treated with home oxygen therapy, have also not changed\nsignificantly during this follow-up period. His cardiopulmonary\ncondition remains well controlled, with no acute deterioration.\n\nPsychosocially, Mr. Wells continues to demonstrate resilience and\nactively participates in his care. His strong support system continues\nto contribute to his overall well-being.\n\nAdditional monitoring and follow-up appointments have been scheduled to\nensure continued management of Mr. Wells\\' health. In addition,\ndiscussions continue regarding potential treatment options and\ninterventions to provide him with the best possible care.\n\n**Current Recommendations:** In light of the stability observed in Mr.\nWells\\' HCC and overall medical condition, we recommend the following\nsteps for his continued care:\n\n1. Regular Follow-up: Maintain a schedule of regular follow-up\n appointments to monitor the status of the HCC, cardiopulmonary\n function, and other associated conditions.\n\n2. Lifestyle-Modification\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Paul Wells born on 04/02/1953 who received\ninpatient treatment from 02/04/2021 to 02/12/2021.\n\n**Diagnosis**: Community-Acquired Pneumonia (CAP)\n\n**Previous Diagnoses and Treatment:**\n\n- Multifocal HCC Segment with portal vein invasion, BCLC C, first\n diagnosed 07/19\n\n- Large, partly exophytic, partly centrally hemorrhagic HCC lesions in\n S3/4 and S7/8, complete infiltration of the left lateral lobe with\n smaller satellites, macrovascular invasion of the left portal vein.\n\n- Histology on 07/27/2019: Macrotrabecular and pseudoglandular growth\n of well-differentiated hepatocellular carcinoma (G1).\n\n- SIRT simulation attempt on 08/13/2019: No feasible SIRT.\n\n- Liver Tumor Board decision on 08/18/2019: Systemic therapy.\n\n- Atezolizumab/Bevacizumab since 10/26/2021, with a pause starting on\n 09/17/2019, due to transaminase elevation (up to 4x ULN).\n\n- CT in 01/2020: Very good tumor response.\n\n- Re-administration of Atezolizumab/Bevacizumab on 01/25/2022 and\n 02/16/2022, followed by a treatment pause due to limited tolerance.\n\n- CT from 02/2020 to 08/2020: Continuously regressing tumor findings.\n\n- Liver fibrosis: Increased C2 consumption (3-4 beers/day).\n\n- Suspected PNP DD RLS (Restless Legs Syndrome).\n\n<!-- -->\n\n- COPD, current severity Gold III.\n\n- Pulmonary emphysema.\n\n- Respiratory partial insufficiency with home oxygen.\n\n- Postnasal-Drip Syndrome.\n\n- History of nicotine abuse (120 py).\n\n- Transient worsening of lung function with steroid requirement after\n Atezolizumab/Bevacizumab administrations\n\n- Pneumogenic sepsis with Streptococcus pneumoniae detection.\n\n- History of unclear infection vs. pneumonia in 10/2019-01/2020.\n\n- Arterial hypertension.\n\n- Atrial fibrillation\n\n- Treatment with Apixaban.\n\n- Reflux esophagitis LA Grade A (Esophagogastroduodenoscopy in\n 08/2019).\n\n**Medical History:** For detailed medical history, please refer to the\nprevious medical reports. In summary, Mr. Wells presented in 07/2019\nwith persistent right upper abdominal pain. A CT scan showed multiple\nintrahepatic lesions in the right liver lobe (SIV, SVII/VIII). MR\nimaging also revealed large, partly exophytic, partly centrally\nhemorrhagic HCC lesions in S3/4 and S7/8. There was complete\ninfiltration of the left liver lobe with smaller satellites and\nmacroinvasion of the left portal vein branch. Histology confirmed a\nwell-differentiated hepatocellular carcinoma (G1). There is no known\nunderlying liver disease, but peritumoral liver fibrosis was observed\nhistologically. Mr. Wells reported increased alcohol consumption of 3-4\nbeers per day.\n\nDue to comorbidities and a large tumor with a relatively high liver-lung\nshunt, SIRT simulation was initially attempted but found to be an\nunsuitable treatment option. Therefore, our interdisciplinary liver\ntumor board recommended systemic therapy. After comprehensive\ncounseling, treatment with Atezolizumab/Bevacizumab commenced on\n08/24/2019.\n\nCurrently, Mr. Wells complains about progressively worsening respiratory\nsymptoms, which included shortness of breath, productive cough with\nyellow-green sputum, pleuritic chest pain, fever, and chills, spanning a\nperiod of five days.\n\n**Physical Examination:**\n\nTemperature: 38.6°C, Blood Pressure: 140/80 mm Hg, Heart Rate: 110 beats\nper minute Respiratory Rate: 30 breaths per minute, Oxygen Saturation\n(SpO2): 88% on room air\n\nBreath Sounds: Auscultation revealed diminished breath sounds and coarse\ncrackles, notably in the right lower lobe.\n\nThe patient further reported pleuritic chest pain localized to the right\nlower chest.\n\n**Therapy and Progression:**\n\nDuring his hospitalization, Mr. Wells was in stable cardiopulmonary\ncondition. We initiated an empiric antibiotic therapy with intravenous\nCeftriaxone and Azithromycin to treat community-acquired pneumonia\n(CAP). Oxygen supplementation was provided to maintain adequate oxygen\nsaturation levels, and pain management strategies were implemented to\nalleviate pleuritic chest pain. Additionally, pulmonary hygiene measures\nand chest physiotherapy were applied to facilitate sputum clearance.\nFrequent respiratory treatments with bronchodilators were administered\nto mitigate airway obstruction, and continuous monitoring of vital\nsigns, oxygen saturation, and respiratory status was carried out.\nThroughout his hospital stay, Mr. Wells exhibited gradual clinical\nimprovement, marked by several positive developments. These included the\nresolution of fever, improved oxygen saturation levels, and a follow-up\nchest X-ray demonstrating the resolution of the right lower lobe\nconsolidation. Furthermore, antibiotic therapy was adjusted based on\nsputum culture results, which identified Streptococcus pneumoniae as the\ncausative pathogen. Mr. Wells continued to receive supportive care and\nrespiratory interventions.\n\nWe were thus able to discharge Mr. Wells in a good general condition.\n", "title": "text_5" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n\n\n### text_2\n**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n\n\n### text_3\n**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n\n\n### text_6\n**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n\n\n### text_7\n**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n\n\n### text_8\n**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n\n\n### text_9\n**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n\n\n### text_10\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n\n\n### text_11\n**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n\n\n### text_12\n**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n\n\n\n\nHere is the query:\nWhich medication was prescribed to Mrs. Anderson for her mental health concerns?\n\nChoose the correct answer from the following options:\nA. Diazepam\nB. Paracetamol\nC. Mirtazapine\nD. Novalgin\nE. Cisplatin\n\n\nYour response:\n", "role": "user" }, { "content": "Mirtazapine", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDiagnoses: extensor tendon rupture D3 right foot\n\nAnamnesis: The patient comes with a cut wound in the area of the MTP of\nthe D3 of the right foot to our surgical outpatient clinic. A large\nshard of a broken vase had fallen on her toe with great force.\n\nFindings: Right foot, D3:\n\nApproximately 1cm long laceration in the area of the MTP. Tenderness to\npressure. Flexion\n\nunrestricted, extension not possible.\n\nX-ray: X-ray of the D3 of the right foot from 09/01/2010:\n\nNo evidence of bony lesion, regular joint position.\n\nTherapy: inspection, clinical examination, radiographic control, primary\ntendon suture and fitting of a dorsal splint.\n\nTetanus booster.\n\nMedication: Mono-Embolex 3000IE s.c. (Certoparin).\n\nProcedure: We recommend the patient to wear a dorsal splint until the\nsuture removal in 12-14 days. Afterwards further treatment with a vacuum\northosis for another 4 weeks.\n\nWe ask for presentation in our accident surgery consultation on\nSeptember 14^th^, 2010.\n\nIn case of persistence or progression of complaints, we ask for an\nimmediate\n\nour surgical clinic. If you have any questions, please do not hesitate\nto contact us.\n\nBest regards\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, born on\n06/07/1975, who was in our outpatient treatment on 07/08/2014.\n\nDiagnoses: Fracture tuberculum majus humeri\n\nLuxation of the shoulder joint\n\nAnamnesis: Fell on the left arm while falling down a hill during a hike.\nNo fall on the head.\n\nTetanus vaccination coverage is present according to the patient.\n\nFindings: multiple abrasions: Left forearm, left pelvis and left tibia.\nDislocation of the shoulder. Motor function of forearm and hand not\nlimited. Peripheral circulation, motor function, and sensitivity intact.\n\nX-ray: Shoulder left in two planes from 07/08/2014.\n\nAnteroinferior shoulder dislocation with dislocated tuberculum majus\nfracture and possible subcapital fracture line.\n\nX-ray: Shoulder in 2 planes after reduction\n\nReduction of the shoulder joint. Still more than 3 mm dislocated\ntuberculum majus\n\n**Therapy**:\n\nReduction with **Midazolam** and **Fentanyl**.\n\n**Medication**:\n\n**Lovenox 40mg s.c.** daily\n\n**Ibuprofen 400mg** 1-1-1\n\nPain management as needed.\n\n**Procedure**:\n\nDue to sedation, the patient was not able to be educated for surgery.\nSurgery is planned for either tomorrow or today using a proximal humerus\ninternal locking system (PHILOS) or screw osteosynthesis. The patient is\nto remain fasting.\n\n**Other Notes**:\n\nInpatient admission.\n\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nWe report to you about our common patient, Mrs. Jill Anderson, who was\nin our outpatient treatment on 02/01/2015.\n\nDiagnoses: Ankle sprain on the right side.\n\nCase history: patient presents to the surgical emergency department with\nright ankle sprain after tripping on the stairs. The fall occurred\nyesterday evening. Immediately thereafter cooled and\n\nimmobilized.\n\nFindings: Right foot: Swelling and pressure pain over the fibulotalar\nanterior ligament. No pressure pain over syndesmosis, outer ankle+fibula\nhead, Inner ankle, Achilles tendon, tarsus, or with midfoot compression.\nLimited mobility due to pain. Toe mobility free, no pain over base of\nfifth toe.\n\nX-ray: X-ray of the right ankle in two planes dated 02/01/2015.\n\nNo evidence of fresh fracture\n\nProcedure: The following procedure was discussed with the patient:\n\n-Cooling, resting, elevation and immobilization in the splint for a\ntotal of 6 weeks.\n\n-Pain medication: Ibuprofen 400mg 1-1-1-1 under stomach protection with\nNexium 20mg 1-0-0\n\nIn case of persistence of symptoms, magnetic resonance imaging is\nrecommended.\n\nPresentation with the findings to a resident orthopedist.\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Anderson, Jill, born 06/07/1975, who was in our\ninpatient treatment from 09/28/2021 to 10/03/2021\n\nDiagnosis:\n\nSuspected pancreatic carcinoma\n\nOther diseases and previous operations:\n\nStatus post thyroidectomy 2008\n\nFracture tuberculum majus humeri 2014\n\nCurrent complaints:\n\nThe patient presented as an elective admission for ERCP and EUS puncture\nfor pancreatic head space involvement. She reported stool irregularities\nwith steatorrhea and acholic stool beginning in July 2021. Weight loss\nof approximately 3kg. No bleeding stigmata. Micturition complaints are\ndenied. Urine color: dark yellow. The patient first noticed scleral and\ncutaneous icterus in August 2021. No other hepatic skin signs. Patient\nreported mild pain 1/10 in right upper quadrant.\n\nCT of the chest and abdomen on 09/28/2021 showed a mass in the\npancreatic head with contact with the SMV (approximately 90 degrees) and\nsuspicion of lymph node metastasis dorsal adherent to the SMA.\nPronounced intra or extrahepatic cholestasis. Congested pancreatic duct.\nAlso showed suspicious locoregional lymph nodes, especially in the\ninteraortocaval space. No evidence of distant metastases.\n\nAlcohol\n\nAverage consumption: 0.20L/day (wine)\n\nSmoking status: Some days\n\nConsumption: 0.20 packs/day\n\nSmoking Years: 30.00; Pack Years: 6.00\n\nLaboratory tests:\n\nBlood group & Rhesus factor\n\nRh factor +\n\nAB0 blood group: B\n\nFamily history\n\nPatient's mother died of breast cancer\n\nOccupational history: Consultant\n\nPhysical examination:\n\nFully oriented, neurologically unaffected. Normal general condition and\nnutritional status\n\nHeart: rhythmic, normofrequency, no heart murmurs.\n\nLungs: vesicular breath sounds bilaterally.\n\nAbdomen: soft, vivid bowel sounds over all four quadrants. Negative\nMurphy\\'s sign.\n\nLiver and spleen not enlarged palpable.\n\nLymph nodes: unremarkable\n\nScleral and cutaneous icterus. Mild skin itching. No other hepatic skin\nsigns.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born born 06/07/1975, who was in our\ninpatient treatment from 10/09/2021 to 10/30/2021.\n\n**Diagnosis:**\n\nHigh-grade suspicious for locally advanced pancreatic cancer.\n\n**-CT of chest/abdomen/pelvis**: Mass in the head of the pancreas with\ninvolvement of the SMV (approx. 90 degrees) and suspicious for lymph\nnode metastasis adjacent to the SMA. Prominent intra- or extrahepatic\nbile duct dilation. Dilated pancreatic duct. Suspicious regional lymph\nnodes, notably in the interaortocaval region. No evidence of distant\nmetastasis.\n\n**-Endoscopic ultrasound-guided FNA (Fine Needle Aspiration)** on\n09/29/21.\n\n**-ERCP (Endoscopic Retrograde Cholangiopancreatography)** and metal\nstent placement, 10 mm x 60 mm, on 09/29/21.\n\n-Tumor board discussion on 09/30/21: Port placement recommended,\nneoadjuvant chemotherapy with FOLFIRINOX proposed.\n\nMedical history:\n\nMrs. Anderson was admitted to the hospital on 09/29/21 for ERCP and\nendoscopic ultrasound-guided biopsy due to an unclear mass in the head\nof the pancreas. She reported changes in bowel habits with fatty stools\nand pale stools starting in July 2021, and has lost approximately 3 kg\nsince then. She denied any signs of bleeding. She had no urinary\nsymptoms but did note that her urine had been darker than usual. In\nAugust 2021, she first noticed yellowing of the eyes and skin.\n\nThe CT scan of the chest and abdomen performed on 09/28/21 revealed a\nmass in the pancreatic head in contact with the SMV (approx. 90 degrees)\nand suspected lymph node metastasis close to the SMA. Additionally,\nthere was significant intra- or extrahepatic bile duct dilation and a\ndilated pancreatic duct. Suspicious regional lymph nodes were also\nnoted, particularly in the area between the aorta and vena cava. No\ndistant metastases were found.\n\nShe was admitted to our gastroenterology ward for further evaluation of\nthe pancreatic mass. Upon admission, she reported only mild pain in the\nright upper abdomen (pain scale 2/10).\n\nFamily history:\n\nHer mother passed away from breast cancer.\n\nPhysical examination on admission:\n\nAppearance: Alert and oriented, neurologically intact.\n\nHeart: Regular rhythm, normal rate, no murmurs.\n\nLungs: Clear breath sounds in both lungs.\n\nAbdomen: Soft, active bowel sounds in all quadrants. No tenderness.\nLiver and spleen not palpable.\n\nLymph nodes: Not enlarged.\n\nSkin: Jaundice present in the eyes and skin, slight itching. No other\nliver-related skin changes.\n\nRadiology\n\n**Findings:**\n\n**CT Chest/Abdomen/Pelvis with contrast on 09/28/21:**\n\nTechnique: After uneventful IV contrast injection, multi-slice spiral CT\nwas performed through the upper abdomen during arterial and parenchymal\nphases and through the chest, abdomen, and pelvis during venous phase.\nOral contrast was also administered. Thin-section, coronal, and sagittal\nreconstructions were done.\n\nThorax: The soft tissues of the neck appear symmetric. Heart and\nmediastinum in midline position. No enlarged lymph nodes in mediastinum\nor axilla. A calcified granuloma is seen in the right lower lung lobe;\nno suspicious nodules or signs of inflammation. No fluid or air in the\npleural space.\n\nAbdomen: A low-density mass is seen in the pancreatic head, measuring\nabout 37 x 26 mm. The mass is in contact with the superior mesenteric\nartery (\\<180°) and could represent lymph node metastasis. It is also in\ncontact with the superior mesenteric vein (\\<180°) and the venous\nconfluence. There are some larger but not abnormally large lymph nodes\nbetween the aorta and vena cava, as well as other suspicious regional\nlymph nodes. Significant dilation of both intra- and extrahepatic bile\nducts is noted. The pancreatic duct is dilated to about 5 mm. The liver\nappears normal without any suspicious lesions and shows signs of fatty\ninfiltration. The hepatic and portal veins appear normal. Spleen appears\nnormal; its vein is not involved. The left adrenal gland is slightly\nenlarged while the right is normal. Kidneys show uniform contrast\nuptake. No urinary retention. The contrast passes normally through the\nsmall intestine after oral administration. Uterus and its appendages\nappear normal. No free air or fluid inside the abdomen.\n\nBones: No signs of destructive lesions. Mild degenerative changes are\nseen in the lower lumbar spine.\n\nAssessment:\n\n-Mass in the pancreatic head with contact to the SMV (approximately 90\ndegrees) and suspected lymph node metastasis near the SMA. There is\nsignificant dilation of the intra- or extrahepatic bile ducts and the\npancreatic duct.\n\n-Suspicious regional lymph nodes, especially between the aorta and vena\ncava.\n\n-No distant metastases.\n\n**Ultrasound/Endoscopy:**\n\nEndoscopic Ultrasound (EUS) on 09/29/21:\n\nProcedure: Biopsy with a 22G needle was performed on an approximately 3\ncm x 3 cm mass in the pancreatic head. No obvious bleeding was seen\npost-procedure. Histopathological examination is pending.\n\nAssessment: Biopsy of pancreatic head, awaiting histology results.\n\n**ERCP on 09/29/21:**\n\nProcedure: Fluoroscopy time: 17.7 minutes.\n\nIndication: ERCP/Stenting.\n\nThe papilla was initially difficult to visualize due to a long mucosal\nimpression/swelling (possible tumor). Initially, only the pancreatic\nduct was visualized with contrast. Afterward, the bile duct was probed\nand dark bile was extracted for microbial testing. The contrast image\nrevealed a significant distal bile duct narrowing of about 2.8 cm length\nwith extrahepatic bile duct dilation. After an endoscopic papillotomy\n(EPT) of 5 mm, a plastic stent with an inner diameter of 8.5 mm was\nplaced through the narrow passage, and the bile duct was emptied.\n\nAssessment: Successful ERCP with stenting of bile duct. Clear signs of\ntumor growth/narrowing in the distal bile duct. Awaiting microbial\nresults and histopathology results from the extracted bile.\n\nTreatment:\n\nBased on the initial findings, Mrs. Anderson was started on pain\nmanagement with acetaminophen and was scheduled for an ERCP and\nendoscopic ultrasound-guided biopsy. The ERCP and stenting of the bile\nduct were successful, and she is currently awaiting histopathological\nexamination results from the biopsy and microbial testing results from\nthe bile.\n\nGastrointestinal Tumor Board of 09/30/2021.\n\nMeeting Occasion:\n\nPancreatic head carcinoma under evaluation.\n\nCT:\n\nDefined mass in the pancreatic head with contact to the SMV (approx. 90\ndegrees) and under evaluation for lymph node metastasis dorsally\nadherent to the SMA. Pronounced intra- or extrahepatic bile duct\ndilation. Dilated pancreatic duct.\n\n-Suspected locoregional lymph nodes especially between aorta and vena\ncava.\n\n-No evidence of distant metastases.\n\nMR liver (external):\n\n-No liver metastases.\n\nPrevious therapy:\n\n-ERCP/Stenting.\n\nQuestion:\n\n-Neoadjuvant chemo with FOLFIRINOX?\n\nConsensus decision:\n\n-CT: Pancreatic head tumor with contact to SMA \\<180° and SMV, contact\nto abdominal aorta, bile duct dilation.\n\nMR: No liver metastases.\n\nPancreatic histology: -pending-.\n\nConsensus:\n\n-Surgical port placement,\n\n-wait for final histology,\n\n-intended neoadjuvant chemotherapy with FOLFIRINOX,\n\n-Follow-up after 4 cycles.\n\nPathology findings as of 09/30/2021\n\nInternal Pathology Report:\n\nClinical information/question:\n\nFNA biopsy for pancreatic head carcinoma.\n\nMacroscopic Description:\n\nFNA: Fixed. Multiple fibrous tissue particles up to 2.2 cm in size.\nEntirely embedded.\n\nProcessing: One block, H&E staining, PAS staining, serial sections.\n\nMicroscopic Description:\n\nHistologically, multiple particles of columnar epithelium are present,\nsome with notable cribriform architecture. The nuclei within are\nirregularly enlarged without discernible polarity. In the attached\nfibrin/blood, individual cells with enlarged, irregular nuclei are also\nobserved. No clear stromal relationship is identified.\n\nCritical Findings Report:\n\nFNA: Segments of atypical glandular cell clusters, at least pancreatic\nintraepithelial neoplasia with low-grade dysplasia. Corresponding\ninvasive growth can neither be confirmed nor ruled out with the current\nsample.\n\nFor quality assurance, the case was reviewed by a pathology specialist.\n\nExpected follow-up:\n\nMrs. Anderson is expected to follow up with her gastroenterologist and\nthe multidisciplinary team for her biopsy results, and the potential\ntreatment plan will be discussed after the results are available.\nDepending on the biopsy results, she may need further imaging, surgery,\nradiation, chemotherapy, or targeted therapies. Continuous monitoring of\nher jaundice, abdominal pain, and bile duct function will be critical.\n\nBased on this information, Mrs. Anderson has a mass in the pancreatic\nhead with suspected metastatic regional lymph nodes. The management and\nprognosis for Mrs. Anderson will largely depend on the results of the\nhistopathological examination and staging of the tumor. If it is\npancreatic cancer, early diagnosis and treatment are crucial for a\nbetter outcome. The multidisciplinary team will discuss the best course\nof action for her treatment after the results are obtained.\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are updating you on Mrs. Jill Anderson, who was under our outpatient\ncare on October 4th, 2021.\n\n**Outpatient Treatment:**\n\n**Diagnoses:**\n\nRecommendation for neoadjuvant chemotherapy with FOLFIRINOX for advanced\npancreatic cancer (Dated 10/21)\n\nExocrine pancreatic dysfunction since around 07/21.\n\nPrior occurrences on 02/21 and 2020.\n\n**CT Scan of the chest, abdomen, and pelvis** on September 28, 2021:\n\n**Thorax:** Symmetrical imaging of neck soft tissues. Cardiomediastinum\nis centralized. There is no sign of mediastinal, hilar, or axillary\nlymphadenopathy. Calcified granuloma noted in the right lower lobe, and\nno concerning rounded objects or inflammatory infiltrates. No fluid in\nthe pleural cavity or pneumothorax.\n\n**Abdomen:** Hypodense mass in the head of the pancreas measuring\napproximately 34 x 28 mm. A secondary finding touching the superior\nmesenteric artery (\\< 180°). Possible lymph node metastasis. Contact\nwith the superior mesenteric vein (\\<180°) and venous confluence.\nNoticeable, yet not pathologically enlarged lymph nodes in the\ninteraortocaval space and other regional suspicious lymph nodes.\nSignificant intra- and extrahepatic bile duct blockage. The pancreatic\nduct is dilated up to around 5 mm. The liver is consistent with no signs\nof suspicious lesions and shows fatty infiltration. Liver and portal\nveins are well perfused. The spleen appears normal with its vein not\ninfiltrated. The left adrenal gland appears enlarged, while the right is\nslim. Kidney tissue displays even contrast. No urinary retention\nobserved. Post oral contrast, the contrast agent passed regularly\nthrough the small intestine. Both the uterus and adnexa appear normal.\nNo free air or fluid present in the abdomen.\n\n**Skeleton:** No osteodestructive lesions. Mild degenerative changes\nwith arthrosis of the facet joints in the lower back.\n\n**Assessment:**\n\n-Mass in the head of the pancreas touching the superior mesenteric vein\n(approx 90 degrees) and possible lymph node metastasis adhering dorsally\nto the superior mesenteric artery. Significant bile duct blockage.\nDilated pancreatic duct.\n\n-Suspicious regional lymph nodes, especially interaortocaval.\n\n-No distant metastases found.\n\n**GI Tumor Board** on September 30, 2021:\n\n**CT:** Tumor in the pancreatic head with contacts noted.\n\n**MR:** No liver metastases.\n\n**Pancreatic histology:** Pending.\n\n**Consensus:**\n\nAwait final pathology.\n\nNeoadjuvant-intended chemotherapy with FOLFIRINOX.\n\nReview after 4 cycles.\n\n**Summary:**\n\nMrs. Anderson was referred to us by her primary care physician following\nthe discovery of a tumor in the head of the pancreas through an\nultrasound. She has been experiencing unexplained diarrhea for\napproximately 3 months, sometimes with an oily appearance. She exhibited\njaundice noticeable for about a week without any itching, and an MRI was\nconducted.\n\nGiven the suspicion of a pancreatic head cancer, we proceeded with CT\nstaging. This identified an advanced pancreatic cancer with specific\ncontacts. MRI did not reveal liver metastases. The imaging did show bile\nduct blockage consistent with her jaundice symptom.\n\nShe was admitted for an endosonographic biopsy of the pancreatic tumor\nand ERCP/stenting. The biopsy identified dysplastic cells. No invasion\nwas observed due to the absence of a stromal component. A metal stent\nwas successfully inserted.\n\nAfter reviewing the findings in our tumor board, we recommended\nneoadjuvant chemotherapy with FOLFIRINOX. We scheduled her for a port\nimplant, and a DPD test is currently underway. Chemotherapy will begin\non October 14, with the first review scheduled after 4 cycles.\n\nPlease reach out if you have any questions. If her symptoms persist or\nworsen, we advise an immediate revisit. For any emergencies outside\nregular office hours, she can seek medical attention at our emergency\ncare unit.\n\nBest regards,\n\n", "title": "text_5" }, { "content": "**Dear colleague, **\n\nWe are writing to update you on Ms. Jill Anderson, who visited our day\ncare center on December 22, 2021, for a partial inpatient treatment.\n\nDiagnosis:\n\n-Locally advanced pancreatic cancer recommended for neoadjuvant\nchemotherapy with FOLFIRINOX.\n\n-Exocrine pancreatic insufficiency since around July 2021.\n\n-Previous incidents in February 2021 and 2020.\n\nPast treatments:\n\n-Diagnosis of locally advanced pancreatic head cancer in September 2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant were intended.\n\nCT Scan:\n\nGI Tumor Board Review:\n\nSummary:\n\nMrs. Anderson had a CT follow-up while on FOLFIRINOX treatment. In case\nher symptoms persist or worsen, we advise an immediate consultation. If\noutside regular business hours, she can seek emergency care at our\nemergency medical unit.\n\nBest regards,\n\n", "title": "text_6" }, { "content": "**Dear colleague, **\n\nUpdating you about Mrs. Jill Anderson, who visited our surgical clinic\non December 25, 2021.\n\nDiagnosis:\n\nPotentially resectable pancreatic head cancer.\n\nCT Scan:\n\n-Progressive tumor growth with significant contact to the celiac trunk\nand the superior mesenteric artery. Direct contact with the aorta\nbeneath.\n\n-Progressive, suspicious lymph nodes around the aorta, but no clear\ndistant metastases.\n\n-External MR for liver showed no liver metastases.\n\nMedical History:\n\n-ERCP/Stenting for bile duct blockage in 09/2021.\n\n-4 cycles of FOLFIRINOX neoadjuvant from November to December 15, 2021.\n\n-Encountered complications resulting in prolonged hospital stay.\n\n-Received 3 Covid-19 vaccinations, last one in May 2021 and recovered\nfrom the virus on August 14, 2021.\n\n-Exocrine pancreatic insufficiency.\n\nPhysical stats: 65 kg (143 lbs), 176 cm (5\\'9\\\").\n\nCT consensus:\n\n-Primary tumor has reduced in size with decreased contact with the\naorta. New tumor extension towards the celiac trunk. No distant\nmetastases found.\n\n-MR showed no liver metastases.\n\n-Tumor marker Ca19-9 levels: 525 U/mL (previously 575 U/mL in September\nand 380 U/mL in November).\n\nRecommendation:\n\nExploratory surgery and potential pancreatic head resection.\n\nProcedure:\n\nWe discussed with the patient about undergoing an exploration with a\npossible Whipple\\'s procedure. The patient is scheduled to meet the\ndoctor today for lab work (Hemoglobin and white blood cell count). A\nprescription for pantoprazole was provided.\n\nPrehabilitation Recommendations:\n\n-Individualized strength training and aerobic exercises.\n\n-Lung function improvement exercises using Triflow, three times a day.\n\n-Consider psycho-oncological support through primary care.\n\n-Nutritional guidance, potential high-protein and calorie-dense diet,\nsupplemental nutrition through a port, and intake of creon and\npantoprazole.\n\nThe patient is scheduled for outpatient preoperative preparation on\nJanuary 13, 2022, at 10:00 AM. The surgical procedure is planned for\nJanuary 15th. Eliquis needs to be stopped 48 hours before the surgery.\n\nWarm regards,\n\n**Surgery Report:**\n\nDiagnosis: Locally advanced pancreatic head cancer post 4 cycles of\nFOLFIRINOX.\n\nProcedure:\n\nExploratory laparotomy, adhesion removal, pancreatic head and vascular\nvisualization, biopsy of distal mesenteric root area, surgery halted due\nto positive frozen section results, gallbladder removal, catheter\nplacement, and 2 drains.\n\nReport:\n\nMrs. Anderson has a pancreatic head cancer and had received 4 cycles of\nFOLFIRINOX neoadjuvant therapy. The surgery involved a detailed\nabdominal exploration which did not reveal any liver metastases or\nperitoneal cancer spread. However, a hard nodule was found away from the\nhead of the pancreas in the peripheral mesenteric root, from which a\nbiopsy was taken. Results showed adenocarcinoma infiltrates, leading to\nthe surgery\\'s termination. An additional gallbladder removal was\nperformed due to its congested appearance. The surgical procedure\nconcluded with no complications.\n\n**Histopathological Report:**\n\nFurther immunohistochemical tests were performed which indicate the\npresence of a pancreatobiliary primary cancer. Other findings from the\ngallbladder showed signs of chronic cholecystitis.\n\nGI Tumor Board Review on January 9th, 2022:\n\nDiscussion focused on Mrs. Anderson's locally advanced pancreatic head\ncancer, her exploratory laparotomy, and the halted surgery due to\npositive frozen section results. The CT scan indicated the progression\nof her tumor, but no distant metastases or liver metastases were found.\nThe question posed to the board concerns the best subsequent procedure\nto follow.\n\n", "title": "text_7" }, { "content": "**Dear colleague, **\n\nWe are providing an update on Mrs. Jill Anderson, who was in our\noutpatient care on 11/05/2022:\n\n**Outpatient treatment**:\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n01/17/22 Surgery: Exploratory laparotomy, adhesiolysis, visualization of\nthe pancreatic head and vascular structures, biopsy near the distal\nmesenteric root. Surgery was stopped due to positive frozen section\nresults; gallbladder removal.\n\n09/21 ERCP/Stenting: Metal stent insertion.\n\nDiarrhea likely from exocrine pancreatic insufficiency since around\n07/21.\n\nPrior diagnosis: Locally advanced pancreatic head carcinoma as of 09/21.\n\nClinical presentation: Chronic diarrhea due to exocrine pancreatic\ninsufficiency.\n\nCT: Pancreatic head carcinoma, borderline resectable.\n\nMRI of liver: No liver metastases.\n\nTM Ca19-9: 587 U/mL.\n\nERCP/Stenting: Metal stent in the bile duct.\n\nEUS biopsy: PanIN with low-grade dysplasia.\n\nGI tumor board: Proposed neoadjuvant chemotherapy.\n\nFrom 10/21 to 12/21: 4 cycles of FOLFIRINOX (neoadjuvant).\n\nHospitalized for: Anemia, dehydration, and COVID.\n\n12/21 CT: Mixed response, primary tumor site, lymph node metastasis.\n\nGI tumor board: Recommendation for exploratory surgery/resection.\n\n01/12/2021: Surgery: Evidence of adenocarcinoma near distal mesenteric\nroot. Surgery was discontinued.\n\nGI tumor board: Chemotherapy change recommendation.\n\n02/22 CT: Progression at the primary tumor site with increased contact\nto the SMA; lymph node metastasis.\n\nFrom 02/22 to 06/22: 4 cycles of gemcitabine/nab-paclitaxel.\n\n05/22 TM Ca19-9: 224 U/mL.\n\n1. Concomitant PRRT therapy:\n\n 02/22: 7.9 GBq Lutetium-177 FAP-3940.\n\n 04/22: 8.5 GBq Lutetium-177 FAP-3940.\n\n 06/22: 8.4 GBq Lutetium-177 FAP-3940.\n\n07/22: CT: Progression of primary tumor with encasement of AMS;\nsuspected liver metastases.\n\nTM: Ca19-9: 422 U/mL.\n\nRecommendation: Switch to the NAPOLI regimen and perform diagnostic\npanel sequencing.\n\n**Summary**:\n\nMrs. Anderson visited with her sister and friend to discuss recent CT\nresults. With advanced pancreatic cancer and a prior surgery in 01/22,\nshe has been on gemcitabine/nab-paclitaxel and concurrent PRRT with\nlutetium-177 FAP since 02/22. The latest CT indicates tumor progression\nand potential liver metastases. We have recommended a change in\nchemotherapy and continuation of PRRT. A follow-up CT in 3 months is\nadvised. Please contact us with any inquiries. If symptoms persist or\nworsen, urgent consultation is advised. After hours, she can visit the\nemergency room at our clinic.\n\n**Operation report**:\n\nDiagnosis: Infection of the right chest port.\n\nProcedure: Removal of the port system and microbiological culture.\n\nAnesthesia: Local.\n\n**Procedure Details**:\n\nSuspected infection of the right chest port. Elevated lab parameters\nindicated a possible infection, prompting port removal. The patient was\ninformed and consented.\n\nAfter local anesthesia, the previous incision site was reopened.\nYellowish discharge was observed. A sample was sent for microbiology.\nThe port was accessed, detached, and removed along with the associated\ncatheter. The vein was ligated. Infected tissue was excised and sent for\npathology. The site was cleaned with an antiseptic solution and sutured\nclosed. Sterile dressing applied.\n\nPost-operative care followed standard protocols.\n\nWarm regards,\n\n", "title": "text_8" }, { "content": "**Dear colleague, **\n\nWe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on12/01/2022.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma (Date of onset 09/22).\n\n-low progressive lung lesions, possibly metastases\n\n**CT pancreas, thorax, abdomen, pelvis dated 12/02/2022. **\n\n**Findings:**\n\nChest:\n\nNodular goiter with low-density nodules in the left thyroid tissue. Port\nplacement in the right chest with the catheter tip located in the\nsuperior vena cava. There are no suspicious pulmonary nodules. There is\nalso no increase in mediastinal or axillary lymph nodes. The dense\nbreast tissue on the right remains unchanged from the previous study.\n\nAbdomen:\n\nFatty liver with uneven contrast in the liver tissue, possibly due to\nuneven blood flow. As far as can be seen, no new liver lesions are\npresent. There is a small low-density area in the spleen, possibly a\nsplenic cyst. Two distinct low-density areas are noted in the right\nkidney\\'s tissue, likely cysts. Pancreatic tumor decreasing in site.\nLocal lymph nodes and nodules in the mesentery, with sizes up to about\n9mm; some are near the intestines, also decreasing in size. There are\noutpouchings (diverticula) in the left-sided colon. Hardening of the\nabdominal vessels. An elongation of the right iliac artery is noted.\n\nSpine:\n\nThere are degenerative changes, including a forward slip of the fifth\nlumbar vertebra over the first sacral vertebra (grade 1-2\nspondylolisthesis). There is also an indentation at the top of the tenth\nthoracic vertebra.\n\nImpression:\n\nIn the context of post-treatment chemotherapy following the surgical\nremoval of a pancreatic tumor, we note:\n\n-Advanced pancreatic cancer, decreasing in size.\n\n-Lymph nodes smaller than before.\n\n-No other signs of metastatic spread.\n\n**Summary:**\n\nMrs. Andersen completed neoadjuvant chemotherapy. Pancreatic head\nresection can now be performed. For this we agreed on an appointment\nnext week. If you have any questions, please do not hesitate to contact\nus. In case of persistence or worsening of the symptoms, we recommend an\nimmediate reappearance. Outside of regular office hours, this is also\npossible in emergencies at our emergency unit.\n\nYours sincerely\n\n", "title": "text_9" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, born 06/07/1975 who presented to our\noutpatient clinic on 3/05/2023.\n\nDiagnosis:\n\nProgressive tumor disease under gemcitabine/nab-paclitaxel for\npancreatic head carcinoma after resection in 12/2022.\n\nCT staging on 03/05/2023:\n\nNo local recurrence.\n\nIntrapulmonary nodules of progressive size on both sides, suspicious for\npulmonary metastases.\n\nQuestion:\n\nBiopsy confirmation of suspicious lung foci?\n\nConsensus decision:\n\nVATS of a suspicious lung lesion (vs. CT-guided puncture).\n\n", "title": "text_10" }, { "content": "**Dear colleague, **\n\nWe report on your outpatient treatment on 04/01/2023.\n\nDiagnoses:\n\nFollow-up after completion of adjuvant chemotherapy with Gemcitabine\nmono\n\nto 03/23 (initial gemcitabine / 5-FU)\n\n\\- progressive lung lesions, possibly metastases -\\> recommendation for\nCT guided puncture\n\n\\- status post Whipple surgery for pancreatic cancer\n\nCT staging: unexplained pulmonary lesions, possibly metastatic\n\n**CT Chest/Abd./Pelvis with contrast dated 04/02/2023: **\n\nImaging method: Following complication-free bolus i.v. administration of\n100 mL Ultravist 370, multi-detector spiral CT scan of the chest,\nabdomen, and pelvis during arterial, late arterial, and venous phases of\ncontrast. Additionally, oral contrast was administered. Thin-slice\nreconstructions, as well as coronal and sagittal secondary\nreconstructions, were done.\n\nChest: Normal lung aeration, fully expanded to the chest wall. No\npneumothorax detected. Known metastatic lung nodules show increased size\nin this study. For instance, the nodule in the apical segment of the\nright lower lobe now measures 17 x 15 mm, previously around 8 x 10 mm.\nSimilarly, a solid nodule in the right posterior basal segment of the\nlower lobe is now 12 mm (previously 8 mm) with adjacent atelectasis. No\nsigns of pneumonia. No pleural effusions. Homogeneous thyroid tissue\nwith a nodule on the left side. Solitary lymph nodes seen in the left\naxillary region and previously smaller (now 9 mm, was 4mm) but with a\nretained fatty hilum, suggesting an inflammatory origin. No other\nevidence of abnormally enlarged or conspicuously shaped mediastinal or\nhilar lymph nodes. A port catheter is inserted from the right, with its\ntip in the superior vena cava; no signs of port tip thrombosis. Mild\ncoronary artery sclerosis.\n\nAbdomen/Pelvis: Fatty liver changes visible with some areas of irregular\nblood flow. No signs of lesions suspicious for cancer in the liver. A\nsmall area of decreased density in segment II of the liver, seen\npreviously, hasn\\'t grown in size. Portal and hepatic veins are patent.\nHistory of pancreatic head resection with pancreatogastrostomy. The\nremaining pancreas shows some dilated fluid-filled areas, consistent\nwith a prior scan from 06/26/20. No signs of cancer recurrence. Local\nlymph nodes appear unchanged with no evidence of growth. More lymph\nnodes than usual are seen in the mesentery and behind the peritoneum. No\nsigns of obstructions in the intestines. Mild abdominal artery\nsclerosis, but no significant narrowing of major vessels. Both kidneys\nappear normal with contrast, with some areas of dilated renal pelvis and\ncortical cysts in both kidneys. Both adrenal glands are small. The rest\nof the urinary system looks normal.\n\nSkeleton: Known degenerative changes in the spine with calcification,\nand a compression of the 10th thoracic vertebra, but no evidence of any\nfractures. There are notable herniations between vertebral discs in the\nlumbar spine and spondylolysis with spondylolisthesis at the L5/S1 level\n(Meyerding grade I-II). No osteolytic or suspicious lesions found in the\nskeleton.\n\nConclusion:\n\nOncologic follow-up post adjuvant chemotherapy and pancreatic cancer\nresection:\n\n-Lung nodules are increasing in size and number.\n\n-No signs of local recurrence or regional lymph node spread.\n\n-No new distant metastases detected\n\n**Summary:**\n\nMrs. Anderson visited our outpatient department to discuss her CT scan\nresults, part of her ongoing pancreatic cancer follow-up. For a detailed\nmedical history, please refer to our previous notes. In brief, Mrs.\nAnderson had advanced pancreatic head cancer for which she underwent a\npancreatic head resection after neoadjuvant therapy. She underwent three\ncycles of adjuvant chemotherapy with gemcitabine/5-FU. The CT scan did\nnot show any local issues, and there was no evidence of local recurrence\nor liver metastases. The previously known lung lesions have slightly\nincreased in size. We have considered a CT-guided biopsy. A follow-up\nappointment has been set for 04/22/23. We are available for any\nquestions. If symptoms persist or worsen, we advise an immediate\nrevisit. Outside of regular hours, emergency care is available at our\nclinic's department.\n\nDear Mrs. Anderson,\n\n**Encounter Summary (05/01/2023):**\n\n**Diagnosis:**\n\n-Progressive lung metastasis during ongoing treatment break for\npancreatic adenocarcinoma\n\n-CT scan 04/14-23: Uncertain progressive lung lesions -- differential\ndiagnoses include metastases and inflammation.\n\nHistory of clot at the tip of the port.\n\n**Previous Treatment:**\n\n09/21: Diagnosed with pancreatic head cancer.\n\n12/22: Surgery - pancreatic head removal-\n\n3 months adjuvant chemo with gemcitabine/5-FU (outpatient).\n\n**Summary:**\n\nRecent CT results showed mainly progressive lung metastasis. Weight is\n59 kg, slightly decreased over the past months, with ongoing diarrhea\n(about 3 times daily). We have suggested adjusting the pancreatic enzyme\ndose and if no improvement, trying loperamide. The CT indicated slight\nsize progression of individual lung metastases but no abdominal tumor\nprogression.\n\nAfter discussing the potential for restarting treatment, considering her\ndiagnosis history and previous therapies, we believe there is a low\nlikelihood of a positive response to treatment, especially given\npotential side effects. Given the minor tumor progression over the last\nfour months, we recommend continuing the treatment break. Mrs. Anderson\nwants to discuss this with her partner. If she decides to continue the\nbreak, we recommend another CT in 2-3 months.\n\n**Upcoming Appointment:** Wednesday, 3/15/2023 at 11 a.m. (Arrive by\n9:30 a.m. for the hospital\\'s imaging center).\n\n", "title": "text_11" }, { "content": "**Dear colleague, **\n\nwe report on Mrs. Jill Anderson, who was in our inpatient treatment from\n07/20/2023 to 09/12/2023.\n\n**Diagnosis**\n\nSeropneumothorax secondary to punction of a malignant pleural effusion\nwith progressive pulmonary metastasis of a pancreatic head carcinoma.\n\nPrevious therapy and course\n\n-Status post Whipple surgery on 12/22\n\n-3 months adjuvant CTx with gemcitabin/5-FU (out).\n\n-\\> discontinuation due to intolerance\n\n1/23-3/23: 3 cycles gemcitabine mono\n\n06/23 CT: progressive pulmonary lesions bipulmonary metastases.\n\n06/23-07/23: 2 cycles gemcitabine / nab-paclitaxel\n\n07/23 CT: progressive pulmonary metastases bilaterally, otherwise idem\n\nAllergy: penicillin\n\n**Medical History**\n\nMrs. Anderson came to our ER due to worsening shortness of breath. She\nhas a history of metastatic pancreatic cancer in her lungs. With\nsignificant disease progression evident in the July 2023 CT scan and\nworsening symptoms, she was advised to begin chemotherapy with 5-FU and\ncisplatin (reduced dose) due to severe polyneuropathy in her lower\nlimbs. She has experienced worsening shortness of breath since July.\nThree weeks ago, she developed a cough and consulted her primary care\nphysician, who prescribed cefuroxime for a suspected pneumonia. The\ncough improved, but the shortness of breath worsened, leading her to\ncome to our ER with suspected pleural effusion. She denies fever and\nsystemic symptoms. Urinalysis was unremarkable, and stool is\nwell-regulated with Creon. She denies nausea and vomiting. For further\nevaluation and treatment, she was admitted to our gastroenterology unit.\n\n**Physical Examination at Admission**\n\n48-year-old female, 176 cm, 59 kg. Alert and stable.\n\nSkin: Warm, dry, no rashes.\n\nLungs: Diminished breath sounds on the right, normal on the left.\n\nCardiac: Regular rate and rhythm, no murmurs.\n\nAbdomen: Soft, non-tender.\n\nExtremities: Normal circulation, no edema.\n\nNeuro: Alert, oriented x3. Neurological exam normal.\n\n**Radiologic Findings**\n\n07/20/2023 Chest X-ray: Evidence of right-sided pneumothorax with\npleural fluid, multiple lung metastases, port-a-cath in place with tip\nat superior vena cava. Cardiomegaly observed.\n\n08/02/2023 Chest X-ray: Pneumothorax on the right has increased. Fluid\nstill present.\n\n08/06/2023 Chest X-ray after chest tube insertion: Improved lung\nexpansion, reduced fluid and pneumothorax.\n\n08/17/2023 Chest X-ray: Chest tube on the right removed. Evidence of\nright pleural effusion. No new pneumothorax.\n\n07/12/2023 CT Chest/Abdomen/Pelvis with contrast: Progression of\npancreatic cancer with enlarged mediastinal and hilar lymph nodes\nsuggestive of metastasis. Increase in right pleural effusion. Right\nadrenal mass noted, possibly adenoma.\n\n**Consultations/Interventions**\n\n06/07/2023 Surgery: Insertion of a 20Ch chest tube on the right side,\ndraining 500 mL of fluid immediately.\n\n09/01/2023 Palliative Care: Discussed the progression of her disease,\ncurrent symptoms, and future care plans. Patient is waiting for the next\nCT results but is leaning towards home care.\n\nPatient advised about painkiller recall (burning in the upper abdomen,\ncentral, radiating to the right; doctor\\'s contact provided). Pain meds\ndistributed.\n\nPatient reports increasing shortness of breath; according to on-call\nphysician, a consult for pleural condition is scheduled.\n\nPatient denies pain and shortness of breath; overall, she is much\nimproved. Oxygen arranged by ward for home use.\n\n-Home intake of pancreatic enzymes effective: 25,000 IU during main\nmeals and 10,000 IU for snacks.\n\n-Patient notes constipation with excess pancreatic enzyme, insufficient\nenzyme results in diarrhea/steatorrhea.\n\n-Patient consumes Ensure Plus (400 kcal) once daily.\n\nAssessment:\n\n-Severe protein and calorie malnutrition with insufficient oral intake\n\n-Current oral caloric intake: 700 kcal + 400 kcal drink supplement\n\n-In the hospital, pancreatic enzyme intake is challenging because the\npatient struggles to assess food fat content.\n\nRecommendations:\n\nLab tests for malnutrition: Vitamin D, Vitamin B12, zinc, folic acid\n\nTwice daily Ensure Plus or alternative product. Please record, possibly\norder from pharmacy. After discharge, prescribe via primary care doctor.\n\n-Pancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks. Include in\nthe medical chart.\n\n-Detailed discussion of pancreatic enzyme replacement (consumption of\nenzymes with fatty meals, dosage based on fat content).\n\n-Dietary guidelines for cancer patients (balanced nutrient-rich diet,\nfrequent small high-calorie, and protein-rich meals to maintain weight).\n\nPsycho-oncology consult from 9/10/2023\n\nCurrent status/medical history:\n\nThe patient is noticeably stressed due to her physical limitations in\nthe current scenario, leading to supply concerns. She is under added\nstrain because her insurance recently denied a care level. She dwells on\nthis and suffers from sleep disturbances. She also experiences pain but\nis hesitant about \\\"imposing\\\" and requesting painkillers. The\npalliative care service was consulted for both pain management and\nexploration of potential additional outpatient support.\n\nMental assessment:\n\nAlert, fully oriented. Engages openly and amicably. Thought processes\nare orderly. Tends to ruminate. Worried about her care. No signs of\ndelusion or ego disorders. No anhedonia. Decreased drive and energy.\nAppetite and sleep are significantly disrupted. No signs of suicidal\ntendencies.\n\nCoping with illness:\n\nPatient\\'s approach to illness appears passive. There is a notable\nmental strain due to worries about living alone and managing daily life\nindependently.\n\nDiagnosis: Adjustment disorder\n\nInterventions:\n\nA diagnostic and supportive discussion was held. We recommended\nmirtazapine 7.5 mg at night, increasing to 15 mg after a week if\ntolerated well. She was also encouraged to take pain medication with\nTylenol proactively or at fixed intervals if needed. A follow-up visit\nat our outpatient clinic was scheduled for psycho-oncological care.\n\n**Encounter Summary (07/24/2023):**\n\n**Diagnosis:** Lung metastatic pancreatic cancer, seropneumothorax.\n\n**Procedure:** Left-sided chest tube placement.\n\n**Report: **\n\n**INDICATION:**\n\nMrs. Anderson showed signs of a rapidly expanding seropneumothorax\nfollowing a procedure to drain a pleural effusion. Given the increase in\nsize and Mrs. Anderson\\'s new requirement for supplemental oxygen, we\ndecided to place an emergency chest tube. After informing and obtaining\nconsent from Mrs. Anderson, the procedure was performed.\n\n**PROCEDURE DETAILS:**\n\nAfter pain management and patient positioning, a local anesthetic was\napplied. An incision was made and the chest tube was inserted, which\nimmediately drained about 500 mL of fluid. The tube was then secured,\nand the procedure was concluded. For the postoperative protocol, please\nrefer to the attached documentation.\n\n**Pathology report (07/26/2023): **\n\nSample: Liquid material, 50 mL, yellow and cloudy.\n\nProcessing: Papanicolaou, Hemacolor, and HE staining.\n\nMicroscopic Findings:\n\nProtein deposits, red blood cells, lymphocytes, many granulocytes,\neosinophils, histiocyte cell forms, mesothelium, and a lot of active\nmesothelium. Granulocyte count is raised. There is a notable increase in\nactivated mesothelium. Additionally, atypical cells were found in\nclusters with vacuolated cytoplasm and darkly stained nuclei.\n\nInitial findings:\n\nPresence of a malignant cell population in the samples, suggestive of\nadenocarcinoma cells. A cell block was prepared from the residual liquid\nfor further categorization.\n\nFollow-up findings from 8/04/2023:\n\nProcessing: Immunohistochemistry (BerEP4, CK7, CK20, CK19.9, CEA).\n\nMicroscopic Findings:\n\nAs mentioned, a cell block was created from the leftover liquid. HE\nstaining showed blood and clusters of plasma-rich cells, with contained\neosinophilia, mild to moderate vacuolization. Cell nuclei are darkly\nstained, some are marginal. PAS test was negative. Immunohistochemical\nreaction with antibodies against BerEP4, CK7, CK20, CK19.9, CEA were all\npositive.\n\nFinal Findings:\n\nAfter reviewing the leftover liquid in a cell block, the findings are:\n\nPleural puncture sample with evidence of atypical cells, both\ncytopathologically and immunohistochemically, is consistent with cells\nfrom a primary pancreatic-biliary cancer.\n\nDiagnostic classification: Positive.\n\n**Treatment and Progress:**\n\nThe patient was hospitalized with the mentioned medical history. Lab\nresults were inconclusive. During the physical exam, a notably weak\nrespiratory sound was noted on the right side; oxygen saturation was 97%\nunder 3L of O2. X-rays revealed a significant right-sided pleural\neffusion, which was drained. After the procedure, the patient\\'s\nshortness of breath improved, with SpO2 at 95% under 2L of O2. However,\nan x-ray follow-up displayed a seropneumothorax, which became more\nevident over time, leading to the placement of a chest tube by the\nthoracic surgery department. The pneumothorax decreased with suction and\nremained stable without suction, allowing for tube removal. After the\npathological analysis of the fluid, atypical cells consistent with\npancreatic cancer were identified. A dietary consultation occurred; the\npatient declined the recommended IV nutrition via port; proper\npancreatic enzyme intake was thoroughly explained. Given the cancer\\'s\nprogression and the patient\\'s deteriorating condition,\npsycho-oncological care was initiated, and Mirtazapine 7.5 mg at night\nwas prescribed. An ultrasound follow-up at the bedside showed the\npleural effusion was slowly progressing (around 100-200mL/day), but no\ndraining was needed as vital signs were clinically stable. Our\npalliative care colleagues arranged home care, including home oxygen\nsupply. The patient was discharged to her home on 9/28/2023 in stable\ncondition and without symptoms.\n\n**Discharge Medications:**\n\nMirtazapine 7.5 mg at night\n\nParacetamol as required\n\nTylenol as required\n\nPancreatic enzymes: 25,000 IU main meals, 10,000 IU snacks.\n\nFollow-up:\n\nA follow-up visit was scheduled at our outpatient clinic for\npsycho-oncological care. The patient is advised to get in touch\nimmediately if there are any concerns or if the pleural effusion\nreturns.\n", "title": "text_12" } ]

[ { "content": "\nPlease answer the following query based on the provided context:\n\nHere is the context:\n### text_0\n**Dear colleague, **\n\nWe are reporting on Mr. Ben Harder, born on 08/02/1940, who was admitted\nto our hospital from 12/17/2015 to 12/27/2015.\n\n**Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Status post excision on the nose with suspicion of basal cell\n carcinoma\n\n- Status post laparoscopic cholecystectomy\n\n- Retropubic radical prostatectomy without nerve preservation and with\n bilateral pelvic lymphadenectomy was performed on 12/17/2015.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------- ---------------------------------------------------\n Valsartan (Diovan) 160 mg 1-0-1\n Aspirin 100 mg 1-0-1\n Simvastatin (Zocor) 15 mg 0-0-1\n Doxazosin (Cardura) 1 mg 0-0-1\n Enoxaparin (Lovenox) 0.6 mL s.c. Administer subcutaneously for a total of 4 weeks.\n Acetaminophen (Tylenol) 500 mg 1-1-1 (for 4 days)\n\n**Histopathology:**\n\n1. 2 adenocarcinoma metastases in 2 out of 4 lymph nodes, left external\n iliac region.\n\n2. 3 adenocarcinoma metastases in 3 out of 6 lymph nodes, right pelvic\n region.\n\n3. 7 adenocarcinoma metastases in 7 out of 7 lymph nodes, right lumbar\n para-aortic region.\n\n4. Acinar adenocarcinoma of the prostate is observed bilaterally, with\n a Gleason score of 4 (70%) + 5 (25%) = 9 and a tertiary Gleason\n grade of 3 (5%) according to the modified Gleason grading of the\n ISUP 2005. The tumor is multifocal and encompasses the entire\n prostate with a maximum extrapolated tumor extension of 60 mm. There\n is extracapsular tumor growth, with focal involvement at the dorsal\n right base. Vascular invasion is not noted, but perineural invasion\n is extensive. Both seminal vesicles are heavily infiltrated, and the\n resection margin of the left seminal vesicle is involved. Before\n tissue embedding, the margins of the specimen show focal\n infiltration by the tumor, in the right anterior region near the\n base (section 7) with a total contact area of 2 mm wide, and the\n primary Gleason grade at the positive margin is 4. In addition to\n the carcinoma, other prostatic tissue shows features of myoglandular\n hyperplasia and high-grade prostatic intraepithelial neoplasia\n (HGPIN). The prostatic urethra is free of tumors or dysplasia.\n\n5. **Tumor classification:** pT3bpN1(12/17), R1L0V0, Gleason: 4 + 5 = 9\n\n**Medical History:** Mr. Harder was admitted for open prostatectomy due\nto biopsy-confirmed prostate carcinoma.\n\nInitial PSA value: 5.42 ng/ml. Gleason score of biopsy: 4+5=9 in 11 out\nof 12 biopsy samples. Clinical tumor stage: cT2c PSMA PET-CT + MRI from\n12/23/2015: Left capsular penetration without rectal infiltration.\nSeminal vesicles are infiltrated on both sides. Evidence of multiple\nlymph nodes; intrapelvic locoregional and two lymph nodes on the right\nparailiacal and lumbar interaortocaval region.\n\nTRUS: 88 cc Digital Rectal Examination: Abnormal findings on the left\nside\n\n**Physical Examination:** The patient is in good general condition, has\na lean nutritional status, and reports feeling well. The abdomen is\nsoft, with no tenderness, masses, resistance, or guarding, and the\nexternal genitalia are unremarkable.\n\n**Ultrasound upon admission:** Both kidneys are not dilated and show no\nspace-occupying lesions. The bladder is minimally filled and appears\nunremarkable to the extent assessable.\n\n**Pretherapeutic Tumor Conference:** The findings were discussed\ninterdisciplinary, and the possible treatment options were explained.\nThe patient opted for radical prostatectomy.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complications. The postoperative course was uneventful. Blood\ntransfusions were not required. Unfortunately, a cystogram on revealed\nextravasation, requiring the indwelling catheter to be retained. The\nwound drain was lifted once with serum-identical creatinine values and\nretained with persistent output (approximately 400 ml daily). Both\nkidneys were not dilated, and there were no signs of lymphocele or\nhematoma in the pelvic region on ultrasound. A follow-up rehabilitation\ntreatment has been organized through our social services. We discharged\nthe patient with absorbable intracutaneous sutures for further\noutpatient care.\n\n**Current Recommendations:** The patient was discharged with a permanent\ncatheter and will present on 01/03/2016 for cystogram and possibly\ncatheter removal. If catheter removal is indicated, we recommend\nconsidering a trial of voiding with subsequent admission if the\ncystogram is normal. The wound drain was also retained, and we request\ndocumentation of output. If output regresses and remains persistently \\<\n30-40 ml, and there is no ultrasound evidence of lymphocele, it could be\nremoved on an outpatient basis or during the follow-up appointment.\n\nWe recommend the first PSA check 6 -- 8 weeks postoperatively, followed\nby quarterly intervals. If the PSA level does not reach the zero range\nor rises again from the zero range, the patient can be offered\nradiotherapy of the prostatic bed and lymphatic drainage pathways in\ncombination with a 2-year hormonal ablative therapy as an individual\ntherapeutic trial. Alternatively, primary hormonal ablative therapy is\nan option. If the PSA level reaches the zero range, the patient may be\noffered adjuvant hormonal ablative therapy for 2 years, possibly\ncombined with radiotherapy. Additional findings will be discussed in our\npost-therapeutic conference. In case of changes in the recommended\nprocedure mentioned above, we will inform you again.\n\n**Course of the lab results:**\n\n **Parameter** **12/18/15** **12/19/15** **12/20/15** **12/23/15** **Reference Range**\n --------------------------- --------------- ---------------- --------------- -------------- ---------------------\n Sodium 135 mEq/L 138 mEq/L 136-145 mEq/L\n Potassium 5.1 mEq/L 4.4 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffe method) 0.93 mg/dL 1.05 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 83 65 \n Hemoglobin 11.4 g/dL 12.4 g/dL 12.5-17.2 g/dL\n Hematocrit 0.323 L/L 0.361 L/L 0.370-0.490 L/L\n Red Blood Cells 3.8 x10\\^12/L 4.3 x10\\^12/L 4.2 x10\\^12/L 4.0-5.7 x10\\^12/L\n White Blood Cells 9.57 x10\\^9/L 11.51 x10\\^9/L 9.65 x10\\^9/L 3.90-10.50 x10\\^9/L\n Platelets 216 x10\\^9/L 239 x10\\^9/L 285 x10\\^9/L 150-370 x10\\^9/L\n MCV 88.1 fL 86.0 fL 88.3 fL 80.0-101.0 fL\n MCH 30.2 pg 30.1 pg 29.5 pg 27.0-34.0 pg\n MCHC 34.5 g/dL 35.3 g/dL 33.8 g/dL 31.5-36.0 g/dL\n MPV 10.2 fL 10.4 fL 10.3 fL 7.0-12.0 fL\n RDW-CV 12.1% 12.2% 12.8% 11.6-14.4%\n\n\n\n### text_1\n**Dear colleague, **\n\nWe report to you about Mr. Ben Harder, born on 08/02/1940 who received\ninpatient treatment from 01/13/2016 to 01/19/2016.\n\n**Diagnosis:** Urinary Tract Infection in Patient with indwelling\ncatheter\n\n**Other Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n- Arterial hypertension\n\n- History of excision on the nose with suspicion of basal cell\n carcinoma\n\n- History of laparoscopic cholecystectomy\n\n**Medication upon Admission: **\n\n **Medication (Brand)** **Dosage** **Frequency**\n ------------------------------ ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan (Atacand) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multivitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Selenium 999 mcg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Thiamine 200 mg 1x/Week\n Pyridoxine 25 mg 2-3x/Week\n\n**Current presentation:** Mr. Harder returned to our clinic on\n01/13/2016, complaining of new-onset symptoms including increased\nurgency and frequency of urination, discomfort, lower abdominal pain,\nand fever. Given his recent surgery and indwelling catheter, concerns\nwere raised about a possible urinary tract infection.\n\n**Clinical Examination:** On physical examination, Mr. Harder appeared\nunwell. He had a temperature of 38.8°C, elevated heart rate\n(tachycardia), and mild lower abdominal tenderness on palpation. The\nindwelling urinary catheter was in situ, and no signs of catheter\ndislodgment or leakage were observed.\n\n**Ultrasound of the Abdomen upon admission:** Bilateral, no urinary\ntransport obstruction, approximately 4x2 cm-sized fluid collection noted\nin the right inguinal area, suggestive of possible lymphocele.\n\n**CT Scan Abdomen/Pelvic from 01/13/2016:** The liver displays a smooth\ncontour, with homogeneous parenchymal contrast enhancement, and no\nevidence of focal intrahepatic lesions. There is no indication of\nintrahepatic or extrahepatic cholestasis. History of previous\ncholecystectomy with an accentuated common hepatic duct. Spleen,\npancreas, and adrenal glands appear unremarkable. Both orthotopically\nlocated kidneys exhibit simultaneous and equal contrast enhancement. No\nintrarenal structural abnormalities or signs of urinary obstruction are\nobserved. The colonic frame and small intestine show adequate perfusion,\nwithout focal wall thickening. The stomach is distended. The urinary\nbladder contains a catheter. Two intraluminal air pockets are seen.\nKnown circumferential, uniform bladder wall thickening from previous\nexaminations. No free intrabdominal air is detected. No evidence of\nascites. Bilateral iliac and inguinal operative clips from prior\nlymphadenectomy. Right iliac region shows a serous fluid collection\nmeasuring approximately 3 x 2 cm. Para-aortic lymph nodes, up to 14 mm\nin size, are consistent with findings from previous evaluations. No\nsuspicious malignancy-related bone destruction is noted. A drainage tube\nhas been placed through the right lower abdominal wall, with its tip\nlocated in the left pelvic area.\n\n**Assessment:** No evidence of abscess formation. A lymphocele measuring\napproximately 3 x 2 cm is noted in the right iliac region, without signs\nof acute inflammation.\n\n**Microbiological Examination**\n\n**Material**: Catheter Urine Examination Request: Identification of\nPathogens and Resistance Results: Organism 1: Growth of 100,000 CFU/mL\nEnterococcus faecalis Possible ICD-10 Coding Suggestion: Enterococci as\nPathogen.\n\n- Acute Cystitis\n\n- Pyelonephritis\n\n- Urinary Tract Infection related to Catheter/Implant\n\n- Urinary Tract Infection, Unspecified Location\n\n**Antibiogram**\n\n- Gentamicin HL: S\n\n- Levofloxacin: R 1\n\n- Teicoplanin: S \\<=0.5\n\n- Ampicillin: S \\<=2\n\n- Piperacillin: S\n\n- Ampicillin/Sulbactam: S \\<=2\n\n- Piperacillin/Tazobactam: S\n\n- Imipenem: S \\<=1\n\n- Cefuroxim: R \\>=64\n\n- Gentamicin: R\n\n- Cotrimoxazole: R \\<=10\n\n- Ciprofloxacin: R \\<=0.5\n\n- Vancomycin: S 2\n\n- Linezolid: S 2\n\n- Tigecyclin: S \\<=0.12\n\n**Therapy and Progression:** After CT morphological exclusion of an\nabscess formation or retention, the wound drainage was removed under\nantibiotic coverage. Initially, empirical antibiotic therapy with\nCefuroxim was administered, followed by targeted treatment with oral\nUnacid based on resistance testing. The drainage insertion site healed\nprimarily. The bladder catheter was removed, after which urination was\nfree of residual urine. The patient has primary continence. We\ndischarged the patient to further outpatient treatment, with the patient\nreporting subjective well-being.\n\nMr. Harder showed gradual clinical improvement after initiating\nantibiotic therapy. His fever subsided, and lower abdominal tenderness\ndiminished. The IV fluids were discontinued, and he remained on oral\nantibiotics.\n\n**Urine Culture Results:** The urine culture results returned positive\nfor Escherichia coli (E. coli), a common uropathogen. The sensitivity\nprofile indicated susceptibility to ciprofloxacin.\n\n**Follow-Up:** Mr. Harder was closely monitored for the duration of his\nantibiotic course. He was advised to complete the full course of\nantibiotics and maintain adequate hydration. The urinary catheter was\nremoved on the fifth day of hospitalization after demonstrating improved\nurine output and resolution of symptoms. No further complications\nrelated to the catheter removal were observed.\n\n**Current Recommendations:**\n\n1. Please refer to the previous discharge letter for the procedure\n regarding prostate cancer.\n\n2. He was educated on the signs and symptoms of UTIs and instructed to\n seek prompt medical attention if symptoms recurred.\n\n**\\\n**\n\n\n\n### text_2\n**Dear colleague, **\n\nThank you for assigning Mr. Ben Harder, born on 08/02/1940 to the PET/CT\ncombination scanner examination on 12/11/2022.\n\n**Diagnoses:**\n\n- Initial diagnosis of prostate cancer in December 2015, confirmed by\n prostate biopsy.\n\n- Tumor detected in 11 out of 12 biopsy samples\n\n- Maximum Gleason score of 9\n\n- Preoperative PSA level: 5.42 ng/ml\n\n- In the initial PET/CT examination (preoperative) on 12/23/2015\n evidence of prostate cancer extending beyond the capsule in both\n prostatic lobes was found.\n\n- Infiltration of the left seminal vesicles and beginning infiltration\n of the right seminal vesicles\n\n- Multiple retroperitoneal lymph node metastases and bilateral pelvic\n lymph nodes.\n\n- Radical prostatectomy\n\n- Current PSA level: 1.23 ng/ml\n\n- Radiation therapy planned at our facility\n\n**Technique**: To expedite renal-urinary activity elimination, the\npatient was adequately hydrated. The examination was conducted using the\nPET/CT combination scanner BIOGRAPH 64 with CT parameters set at 120 kV\nand 1 mm slice thickness. PET emission data were acquired with 5 bed\npositions on a radiation therapy-compatible table for whole-body\nexamination in the caudocranial direction with transverse slices at 3.0\nmm intervals over the same axial range as the CT scan. Iterative\nreconstruction was performed. A whole-body scan was conducted 90 minutes\nafter the administration of 278 MBq Ga-68-PSMA (prostate-specific\nmembrane antigen). Transmissions-corrected and non-corrected PET scans,\nCT scans, fusion images, and the determination of the SUV value\n(standard uptake value, a measure of activity uptake per volume) were\nused for evaluation.\n\n**PET Findings:** The 3D whole-body images documented in 3 planes using\nPET and PET/CT technology showed the following changes compared to the\nprior examination on 12/23/2015:\n\n- Post-radical prostatectomy, there is diffuse activity accumulation\n in the region dorsal to the bladder, on the left side.\n\n- Regarding the known retroperitoneal lymph node metastases, the\n following changes were observed: New retrocrural nodule on the\n right. SUV 6.6, diameter: 6 mm.\n\n- Known interaortocaval lymph node, dorsally at the level of L3/4,\n showed increased metabolic activity from SUV 4.7 to 11.5. Slightly\n increased in size, measuring 7 to 8 mm. Additionally, two new\n metabolically active nodules cranially, up to the level of L2/3.\n\n- Slightly increased metabolic activity in the known right iliaca\n communis lymph node, located between the fifth lumbar vertebra and\n the psoas muscle, from 4.0 to 4.6, with the same size of 5 mm.\n\n- Progressive enlargement of the known confluent lymph nodes on the\n right parailiacal externa proximal side, now having a combined size\n of 10 x 26 mm (width x height), previously individual nodules of 10\n and 12 mm. SUV 18.2, previously max 11.5.\n\n- New paraaortic lymph nodes on the left, mostly small, SUV 11.2.\n\n- Newly added lymph nodes in both biiliac communal areas. Maximum size\n on the left is 15 mm, SUV 17.2.\n\n- New retrocrural lymph node on the right, measuring 6 mm, SUV 6.6.\n\n- Known lymph node on the right perirectal, slightly progressive from\n 8 to 10 mm. SUV 6.9, previously 6.4.\n\n- Known lymph node on the left iliaca externa not currently\n verifiable, possibly postoperative scarring.\n\n- Newly added focus in the bone at the level of the spinous\n process/dorsal arch of the fifth lumbar vertebra. In CT, a 7 mm\n focal sclerosis is noted. Normal activity accumulation in the soft\n tissues of the neck, axillae, and chest. Physiological accumulation\n in the parenchymal upper abdominal organs. Kidneys and urinary tract\n appear functionally normal. Whole-body CT following bolus-like\n peripheral venous machine injection of 100 ml of Optiray 350: No\n suspicious lymph nodes in the cervical, axillary, or mediastinal\n regions. Normal-sized thyroid gland. No pleuropulmonary infiltrates\n or round lesions. Scarred changes in the left lower lobe.\n Normal-sized liver without focal lesions. Spleen, pancreas, adrenal\n glands, and kidneys appear regular. No urinary obstruction..\n\n**Results**: In the postoperative PET/CT compared to the preoperative\nexamination on, there is now malignancy-typical PSMA receptor binding in\nthe former prostate lodge, indicating a local recurrence. Progression of\nretroperitoneal lymph node metastases, with further extension cranially,\nextending to the interaortocaval region up to the level of L2/3. Newly\nadded metastases on the left paraaortic and biiliac communal areas.\nProgression of known right iliaca externa lymph node metastases. The\nleft iliaca externa nodule is not verifiable, likely removed. New small\nretrocrural nodule on the right. New osteosclerotic metastasis in the\ndorsal arch of LWK 5. Minimal activity accumulation in the 8th rib on\nthe right lateral aspect. A developing metastasis cannot be conclusively\nruled out here. We kindly request information on the patient\\'s further\nclinical course (submission of medical reports, etc.).\n\n**Lab results**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Glucose (Plasma) 91 mg/dL 55-100 mg/dL\n Alkaline Phosphatase 93 U/L \\< 130 U/L\n Total Cholesterol 152 mg/dL \\< 200 mg/dL\n LDL-Cholesterol 89 mg/dL \\< 130 mg/dL\n HDL-Cholesterol 50 mg/dL 40-60 mg/dL\n Non-HDL Cholesterol 101.8 mg/dL \\< 200 mg/dL\n Triglycerides 64 mg/dL \\< 150 mg/dL\n White Blood Cells 4.1 K/uL 4.5-11 K/uL\n Red Blood Cells 4.68 M/uL 4.0-5.5 M/uL\n Hemoglobin 13.6 g/dL 12.5-17.2 g/dL\n Hematocrit 39.5% 37.0-49.0%\n MCH 29.1 pg 27.0-34.0 pg\n MCHC 34.4 g/dL 31.5-36.0 g/dL\n MCV 84.4 fL 80.0-101.0 fL\n RDW 13.0% 11.6-14.4%\n Platelets 238 K/uL 150-370 K/uL\n\n**\\\n**\n\n\n\n### text_3\n**Dear colleague, **\n\nWe are writing to provide an update on Mr. Ben Harder, born on\n08/02/1940, who received inpatient treatment at our facility from\n06/23/2023 to 06/26/2023.\n\n**Diagnosis:**\n\nProstate Cancer pT3b pN1 R1 L0 V0 Gleason Score: 4 + 5 = 9 (Initial\ndiagnosis in December 2015)\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015. Currently, lymph node and bone metastasis\n\n**Other Diagnoses:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015.\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n (thora 11 and 12) with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT in 06/2023 scan indicated new extensive metastasis in\n the sacrum and diffuse lung metastases, accompanied by a PSA level\n of 1.35 ng/ml.\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n**Medications on Admission:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Candesartan (Atacand) 16 mg 1-0-1-0\n Aspirin 100 mg 1-0-0-0\n Chlorthalidone (Thalitone) 25 mg 1-0-0-0\n\n**Physical Examination:** The patient was in good general condition and\nhad normal orientation to all qualities. There were no edemas, dyspnea,\nfever, or cough.\n\n**Medical History:** Mr. Hader presents himself for the 1st cycle of RLT\nwith Ac-225-PSMA/Lu-177-I&T-PSMA for lymph node and bone metastatic\nprostate cancer on an inpatient basis. In the presence of progressive\nimaging findings under guideline-compliant therapy, the indication for\nRLT tandem therapy was confirmed according to the tumor conference on.\nUpon admission, the patient reports feeling well, denies any B-symptoms.\nThere is no fever or nausea, and the weight is currently stable. There\nhas been a tendency to fall for some time. The rest of the medical\nhistory is assumed to be known.\n\n**Neurological Consultation on 06/25/2023: **\n\nClinically neurological examination revealed a polyneuropathy syndrome\nof the lower extremities, predominantly on the right side, as well as a\nknown right-sided foot drop. In summary, we consider the falls to be\nmultifactorial due to foot weakness as well as polyneuropathy syndrome\nwith impaired proprioception as the cause of the balance disorder.\nRecommended further procedure: In the presence of a known PNP syndrome\nthat has occurred during chemotherapy, consider outpatient neurological\nevaluation and objectification by means of Electromyography and\npolyneuropathy laboratory tests.\n\n**Salivary Gland Scintigraphy on 06/26/2023**\n\n**Assessment**: Normal function of the submandibular and parotid glands\nbilaterally.\n\nPost-therapeutic imaging with Lu-177-PSMA imaging using\nSPECT/low-dose-CT\n\n**Assessment:** Consistent with the PET-CT, there is no tracer uptake in\nthe area of the prostate. Intensive accumulation of the therapeutic\nagent in the area of lymph node metastases, especially mediastinal.\nCorresponding to the PET/CT, there are clear focal tracer accumulations\nin the left upper lobe of the lung in the area of nodular or diffuse\ntissue condensations, possibly metastases or, secondarily,\npost-inflammatory. Intensive tracer uptake in the area of known bone\nmetastases from the previous examination. No newly appearing\ntracer-enhancing lesions. In addition, physiological accumulation in the\norgan systems involved in tracer metabolism and excretion. NB: Small\npleural effusions on both sides. Known pronounced peribronchial cuffs in\nthe upper lobes on both sides, possibly scarred, or indicative of\npulmonary venous congestion. Known atrophic kidney on the right.\n\n**Current Recommendations:**\n\n- Blood count checks and determination of kidney and liver parameters\n 1, 2, 4, and 8 weeks after therapy\n\n- Outpatient neurologic assessment for the evaluation of\n polyneuropathy\n\n- PSA determination 6-8 weeks after therapy\n\n- Appointment for a 2nd cycle of radioligand therapy\n (Ac-225-/Lu-177-PSMA)\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Neutrophils (%) 72.2 % 42.0-77.0 %\n Lymphocytes (%) 8.6 % 20.0-44.0 %\n Monocytes (%) 11.6 % 2.0-9.5 %\n Basophils (%) 1.4 % 0.0-1.8 %\n Eosinophils (%) 6.0 % 0.5-5.5 %\n Immature Granulocytes (%) 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 2.31 mEq/L 2.20-2.55 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n C-reactive Protein 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 µg/L \\< 4.40 µg/L\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 µg/L 1.32-8.92 µg/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 0.285 L/L 0.370-0.490 L/L\n RBC 3.3 /pL 4.0-5.6 /pL\n WBC 4.98 /nL 3.90-10.50 /nL\n Platelets 281 /nL 150-370 /nL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Neutrophils (Absolute) 3.59 /nL 1.50-7.70 /nL\n Immature Granulocytes (Absolute) 0.010 /nL \\< 0.050 /nL\n Lymphocytes (Absolute) 0.43 /nL 1.10-4.50 /nL\n Monocytes (Absolute) 0.58 /nL 0.10-0.90 /nL\n Eosinophils (Absolute) 0.30 /nL 0.02-0.50 /nL\n Basophils (Absolute) 0.07 /nL 0.00-0.20 /nL\n Reticulocytes 31.3 /nL 25.0-105.0 /nL\n Reticulocyte (%) 0.94 % 0.50-2.00 %\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.\n\n\n\n### text_4\n**Dear colleague, **\n\nWe would like to report on our mutual patient, Mr. Ben Harder, born on\n08/02/1940, who presented himself to our outpatient clinic on 1/8/2023.\n\n**Diagnoses:**\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9 (initial\n diagnosis in 11/2015)\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally on\n 11/16/2015\n\n- Currently, there are lymph node and bone metastases\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Initial PSA level was 4.8 ng/ml\n\n- History of Docetaxel therapy\n\n- History of Cabazitaxel therapy\n\n- History of 4 cycles of Lutetium-Radioligand therapy\n\n- Subsequently, radiation therapy was initiated for the lymph node\n metastasis but discontinued after 11 sessions due to dyspnea and G3\n esophagitis.\n\n- Arterial hypertension\n\n- Chronic renal insufficiency\n\n- Type 2 diabetes mellitus\n\n**Treatment and Progression:** The patient presents for a second opinion\non his prostate cancer, which has metastasized to the bones and lymph\nnodes and has become castration-resistant. He recently received\nLutetium-Radioligand therapy. Genetic sequencing from the tissue biopsy\ndid not reveal any significant gene mutations. The patient wishes to\nundergo further evaluation for the diagnosis of relevant genetic\nmutations. A previously punctured subdiaphragmatic lymph node metastasis\nhas not yet undergone genetic testing, which may be justified based on\nthe available data and publications in specific cases. A chemotherapy\nsession with Cabazitaxel is planned for the end of January in the\ntreating urological practice. In cases of DNA repair gene alterations, a\nplatinum combination could also be considered. Further possible\ndiagnostic and therapeutic steps were discussed with the patient. An\napplication for a repeat genetic sequencing will be submitted by our\ncolleagues from the genetics department.\n\n**Current Recommendations:**\n\n- Application for genetic sequencing for the punctured lymph node\n metastasis through the genetics department and DNA-med\n\n- Subsequent re-genetic sequencing of the subdiaphragmatic lymph node\n metastasis for relevant mutations\n\n- After receiving the results, a follow-up appointment can be\n scheduled in our uro-oncology outpatient clinic.\n\n.\n\n**\\\n**\n\n\n\n### text_5\n**Dear colleague, **\n\nWe are reporting to you regarding the inpatient stay of our patient Mr.\nBen Harder, born on 08/02/1940. He was under our care from 09/16/2023 to\n09/23/2023.\n\n**Diagnosis**: Prostate Cancer pT3b pN1 R1 L0 V0\n\n- Gleason Score: 4 + 5 = 9\n\n- Postoperative status following retropubic radical prostatectomy\n without nerve preservation and with pelvic lymphadenectomy.\n\n- Currently presenting with lymph node and bone metastases, mCRPC\n (metastatic castration-resistant prostate cancer)\n\n- Initial PSA level: 4.8 ng/ml\n\n**Previous Treatment and Course:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects in 01/2023.\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT scan indicated new extensive metastasis in the sacrum\n and diffuse lung metastases, accompanied by a PSA level of 1.35\n ng/ml.\n\n- Current PET-CT not available. Recommendations for further treatment\n options are as follows, based on externally described\n image-morphological progression in the recent CT:\n\n 1. Actinium-225-PSMA Therapy (Lu-177 Tandem Therapy), provided that\n all vital metastases are PSMA-positive (mandatory exclusion of\n post-renal urinary flow obstruction)\n\n 2. Alternatively, consider initiating therapy with Abiraterone +\n Prednisolone or a Cabazitaxel re-challenge (if there was a\n favorable response to the last 2 cycles of Cabazitaxel\n\n 3. Evaluation of pre-screening for CAR-T cell studies in oncology\n at CBF (contact will be made)\n\n**Other Diagnoses:**\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n- Type 2 Diabetes Mellitus\n\n**Current Presentation:** Mr. Ben Harder is presenting for his 2nd cycle\nof Radioligand Therapy (RLT) with Ac-225-PSMA/Lu-177-I&T-PSMA for lymph\nnode and bone metastatic prostate cancer. In light of progressive\nimage-morphological findings despite guideline-compliant treatment, the\nindication for RLT tandem therapy was determined in the tumor\nconference.\n\n**Medical History:** Mr. Harder reports that after the last treatment\ncycle, he experienced pronounced fatigue symptoms. He particularly\nstruggled with climbing stairs and walking longer distances. However, he\nmanaged to fully recover from these symptoms through targeted training.\nAdditionally, he developed pain in the area of the right ribcage\nfollowing the last treatment cycle. The pain occurs intermittently and\nis accompanied by increased salivation and nausea, sometimes leading to\nvomiting. Mr. Ben Harder also reports newly developed swallowing\ndifficulties. He feels that food gets stuck in his throat after\nswallowing.\n\n**Therapy and Progression:**\n\nIn the case of Mr. Ben Harder, due to metastatic prostate cancer with\nradiographic progression despite previous guideline-recommended therapy,\naccording to the recommendations, there was an indication for the 2nd\nradioligand therapy with Ac-225-PSMA/Lu-177-I&T-PSMA. The\npost-therapeutic imaging showed targeted accumulation of the therapeutic\nagent within the tumor. The therapy was administered due to elevated\nrenal retention parameters with reduced activity of Lu-177-PSMA. The\ncourse of therapy and the entire hospital stay were uncomplicated, so we\ncan now transition the patient to your outpatient care. We recommend\nclose laboratory monitoring (blood count, liver and kidney parameters)\nat 1, 2, 4, and 8 weeks, as well as a PSA determination 6-8 weeks after\ntherapy.\n\nIn the case of significant fatigue symptoms after the 1st cycle of\ntandem RLT, if there are blood count changes indicating a decrease in\nhemoglobin levels and recurrent fatigue symptoms, the administration of\nerythropoietin or the indication for blood product transfusion should be\nconsidered. Depending on the PSA value 6 weeks post-therapy and the\nfindings of the PSMA-PET/CT, the further course of action will be\ndetermined in the interdisciplinary Tumor Conference.\n\nIf the patient desires, they can seek a second opinion on further\ntherapeutic procedures in the specialized clinic of the Uro-Oncology\ncolleagues. In case of pronounced rib pain, if requested by the patient,\nthe possibility of undergoing radiation therapy can be evaluated. To do\nso, Mr. Harder can schedule an appointment at the Radio-Oncology clinic.\nPsycho-oncological counseling has been offered to the patient.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan Cilexetil (Atacan) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multi-Vitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Sodium Selenite 999 µg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B Complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Vitamin B1 200 mg 1x/Week\n Vitamin B6 25 mg 2-3x/Week\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------------- ---------------------\n Neutrophils % 80.3 % 42.0-77.0 %\n Lymphocytes % 6.7 % 20.0-44.0 %\n Monocytes % 8.9 % 2.0-9.5 %\n Basophils % 1.3 % 0.0-1.8 %\n Eosinophils % 2.4 % 0.5-5.5 %\n Immature Granulocytes % 0.4 % 0.0-1.0 %\n I:T Ratio 0.005 \n HFLC Absolute 0.0 /µL \n Sodium 140 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Calcium 9.36 mg/dL 8.8-10.2 mg/dL\n Chloride 102 mEq/L 98-107 mEq/L\n Creatinine 1.25 P+ mg/dL 0.70-1.20 mg/dL\n Estimated GFR 52 mL/min/1.73m\\^2 \n BUN (Urea) 44 mg/dL 17-48 mg/dL\n Uric Acid 3.8 mg/dL 3.6-8.2 mg/dL\n CRP 1.3 mg/L \\< 5.0 mg/L\n PSA 2.98 ng/mL \\< 4.4 ng/mL\n ALT (GPT) 22 U/L \\< 41 U/L\n AST (GOT) 49 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 19 U/L 8-61 U/L\n LDH 404 P+ U/L 135-250 U/L\n Testosterone \\<0.03 P- ng/mL 1.32-8.92 ng/mL\n TSH 1.14 mIU/L 0.27-4.20 mIU/L\n Complete Blood Count \n Differential Count \n Hemoglobin 10.6 g/dL 12.5-17.2 g/dL\n Hematocrit 30.5 % 37.0-49.0 %\n RBC 3.4 M/µL 4.0-5.6 M/µL\n WBC 5.49 K/µL 3.90-10.50 K/µL\n Platelets 279 K/µL 150-370 K/µL\n MCV 88.7 fL 80.0-101.0 fL\n MCH 30.8 pg 27.0-34.0 pg\n MCHC 34.8 g/dL 31.5-36.0 g/dL\n MPV 10.1 fL 7.0-12.0 fL\n RDW-CV 14.1 % 11.5-15.0 %\n Absolute Neutrophils 4.41 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.020 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.37 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.49 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.13 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 37.8 K/µL 25.0-105.0 K/µL\n Reticulocyte Percentage 1.10 % 0.50-2.00 %\n Reticulocyte Production Index 0.4 \n Ret-Hb 35.0 pg 28.5-34.5 pg\n Prothrombin Time 117 % \\> 78 %\n INR 0.94 \\< 1.25\n aPTT 30.2 sec 25.0-38.0 sec\n\n\n\n\nHere is the query:\nWhat was the significant change in Mr. Harder's PSA levels between July 2019 and November 2019?\n\nChoose the correct answer from the following options:\nA. From undetectable to >0.03 ng/ml\nB. From 0.48 ng/ml to 1.35 ng/ml\nC. From 5.42 ng/ml to 1.23 ng/ml\nD. From 1.23 ng/ml to 0.01 ng/ml\nE. No change, remained undetectable\n\n\nYour response:\n", "role": "user" }, { "content": "From undetectable to >0.03 ng/ml", "role": "assistant" } ]

[ { "content": "**Dear colleague, **\n\nWe are reporting on Mr. Ben Harder, born on 08/02/1940, who was admitted\nto our hospital from 12/17/2015 to 12/27/2015.\n\n**Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n**Other Diagnoses:**\n\n- Arterial hypertension\n\n- Status post excision on the nose with suspicion of basal cell\n carcinoma\n\n- Status post laparoscopic cholecystectomy\n\n- Retropubic radical prostatectomy without nerve preservation and with\n bilateral pelvic lymphadenectomy was performed on 12/17/2015.\n\n**Medication upon Admission:**\n\n **Medication** **Dosage** **Frequency**\n ------------------------- ------------- ---------------------------------------------------\n Valsartan (Diovan) 160 mg 1-0-1\n Aspirin 100 mg 1-0-1\n Simvastatin (Zocor) 15 mg 0-0-1\n Doxazosin (Cardura) 1 mg 0-0-1\n Enoxaparin (Lovenox) 0.6 mL s.c. Administer subcutaneously for a total of 4 weeks.\n Acetaminophen (Tylenol) 500 mg 1-1-1 (for 4 days)\n\n**Histopathology:**\n\n1. 2 adenocarcinoma metastases in 2 out of 4 lymph nodes, left external\n iliac region.\n\n2. 3 adenocarcinoma metastases in 3 out of 6 lymph nodes, right pelvic\n region.\n\n3. 7 adenocarcinoma metastases in 7 out of 7 lymph nodes, right lumbar\n para-aortic region.\n\n4. Acinar adenocarcinoma of the prostate is observed bilaterally, with\n a Gleason score of 4 (70%) + 5 (25%) = 9 and a tertiary Gleason\n grade of 3 (5%) according to the modified Gleason grading of the\n ISUP 2005. The tumor is multifocal and encompasses the entire\n prostate with a maximum extrapolated tumor extension of 60 mm. There\n is extracapsular tumor growth, with focal involvement at the dorsal\n right base. Vascular invasion is not noted, but perineural invasion\n is extensive. Both seminal vesicles are heavily infiltrated, and the\n resection margin of the left seminal vesicle is involved. Before\n tissue embedding, the margins of the specimen show focal\n infiltration by the tumor, in the right anterior region near the\n base (section 7) with a total contact area of 2 mm wide, and the\n primary Gleason grade at the positive margin is 4. In addition to\n the carcinoma, other prostatic tissue shows features of myoglandular\n hyperplasia and high-grade prostatic intraepithelial neoplasia\n (HGPIN). The prostatic urethra is free of tumors or dysplasia.\n\n5. **Tumor classification:** pT3bpN1(12/17), R1L0V0, Gleason: 4 + 5 = 9\n\n**Medical History:** Mr. Harder was admitted for open prostatectomy due\nto biopsy-confirmed prostate carcinoma.\n\nInitial PSA value: 5.42 ng/ml. Gleason score of biopsy: 4+5=9 in 11 out\nof 12 biopsy samples. Clinical tumor stage: cT2c PSMA PET-CT + MRI from\n12/23/2015: Left capsular penetration without rectal infiltration.\nSeminal vesicles are infiltrated on both sides. Evidence of multiple\nlymph nodes; intrapelvic locoregional and two lymph nodes on the right\nparailiacal and lumbar interaortocaval region.\n\nTRUS: 88 cc Digital Rectal Examination: Abnormal findings on the left\nside\n\n**Physical Examination:** The patient is in good general condition, has\na lean nutritional status, and reports feeling well. The abdomen is\nsoft, with no tenderness, masses, resistance, or guarding, and the\nexternal genitalia are unremarkable.\n\n**Ultrasound upon admission:** Both kidneys are not dilated and show no\nspace-occupying lesions. The bladder is minimally filled and appears\nunremarkable to the extent assessable.\n\n**Pretherapeutic Tumor Conference:** The findings were discussed\ninterdisciplinary, and the possible treatment options were explained.\nThe patient opted for radical prostatectomy.\n\n**Therapy and Progression:** The above-mentioned procedure was performed\nwithout complications. The postoperative course was uneventful. Blood\ntransfusions were not required. Unfortunately, a cystogram on revealed\nextravasation, requiring the indwelling catheter to be retained. The\nwound drain was lifted once with serum-identical creatinine values and\nretained with persistent output (approximately 400 ml daily). Both\nkidneys were not dilated, and there were no signs of lymphocele or\nhematoma in the pelvic region on ultrasound. A follow-up rehabilitation\ntreatment has been organized through our social services. We discharged\nthe patient with absorbable intracutaneous sutures for further\noutpatient care.\n\n**Current Recommendations:** The patient was discharged with a permanent\ncatheter and will present on 01/03/2016 for cystogram and possibly\ncatheter removal. If catheter removal is indicated, we recommend\nconsidering a trial of voiding with subsequent admission if the\ncystogram is normal. The wound drain was also retained, and we request\ndocumentation of output. If output regresses and remains persistently \\<\n30-40 ml, and there is no ultrasound evidence of lymphocele, it could be\nremoved on an outpatient basis or during the follow-up appointment.\n\nWe recommend the first PSA check 6 -- 8 weeks postoperatively, followed\nby quarterly intervals. If the PSA level does not reach the zero range\nor rises again from the zero range, the patient can be offered\nradiotherapy of the prostatic bed and lymphatic drainage pathways in\ncombination with a 2-year hormonal ablative therapy as an individual\ntherapeutic trial. Alternatively, primary hormonal ablative therapy is\nan option. If the PSA level reaches the zero range, the patient may be\noffered adjuvant hormonal ablative therapy for 2 years, possibly\ncombined with radiotherapy. Additional findings will be discussed in our\npost-therapeutic conference. In case of changes in the recommended\nprocedure mentioned above, we will inform you again.\n\n**Course of the lab results:**\n\n **Parameter** **12/18/15** **12/19/15** **12/20/15** **12/23/15** **Reference Range**\n --------------------------- --------------- ---------------- --------------- -------------- ---------------------\n Sodium 135 mEq/L 138 mEq/L 136-145 mEq/L\n Potassium 5.1 mEq/L 4.4 mEq/L 3.4-4.5 mEq/L\n Creatinine (Jaffe method) 0.93 mg/dL 1.05 mg/dL 0.70-1.20 mg/dL\n Estimated GFR (eGFR) 83 65 \n Hemoglobin 11.4 g/dL 12.4 g/dL 12.5-17.2 g/dL\n Hematocrit 0.323 L/L 0.361 L/L 0.370-0.490 L/L\n Red Blood Cells 3.8 x10\\^12/L 4.3 x10\\^12/L 4.2 x10\\^12/L 4.0-5.7 x10\\^12/L\n White Blood Cells 9.57 x10\\^9/L 11.51 x10\\^9/L 9.65 x10\\^9/L 3.90-10.50 x10\\^9/L\n Platelets 216 x10\\^9/L 239 x10\\^9/L 285 x10\\^9/L 150-370 x10\\^9/L\n MCV 88.1 fL 86.0 fL 88.3 fL 80.0-101.0 fL\n MCH 30.2 pg 30.1 pg 29.5 pg 27.0-34.0 pg\n MCHC 34.5 g/dL 35.3 g/dL 33.8 g/dL 31.5-36.0 g/dL\n MPV 10.2 fL 10.4 fL 10.3 fL 7.0-12.0 fL\n RDW-CV 12.1% 12.2% 12.8% 11.6-14.4%\n\n", "title": "text_0" }, { "content": "**Dear colleague, **\n\nWe report to you about Mr. Ben Harder, born on 08/02/1940 who received\ninpatient treatment from 01/13/2016 to 01/19/2016.\n\n**Diagnosis:** Urinary Tract Infection in Patient with indwelling\ncatheter\n\n**Other Diagnoses:**\n\n- Prostate carcinoma pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Urine extravasation\n\n- Persistent lymphatic leakage\n\n- Arterial hypertension\n\n- History of excision on the nose with suspicion of basal cell\n carcinoma\n\n- History of laparoscopic cholecystectomy\n\n**Medication upon Admission: **\n\n **Medication (Brand)** **Dosage** **Frequency**\n ------------------------------ ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan (Atacand) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multivitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Selenium 999 mcg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Thiamine 200 mg 1x/Week\n Pyridoxine 25 mg 2-3x/Week\n\n**Current presentation:** Mr. Harder returned to our clinic on\n01/13/2016, complaining of new-onset symptoms including increased\nurgency and frequency of urination, discomfort, lower abdominal pain,\nand fever. Given his recent surgery and indwelling catheter, concerns\nwere raised about a possible urinary tract infection.\n\n**Clinical Examination:** On physical examination, Mr. Harder appeared\nunwell. He had a temperature of 38.8°C, elevated heart rate\n(tachycardia), and mild lower abdominal tenderness on palpation. The\nindwelling urinary catheter was in situ, and no signs of catheter\ndislodgment or leakage were observed.\n\n**Ultrasound of the Abdomen upon admission:** Bilateral, no urinary\ntransport obstruction, approximately 4x2 cm-sized fluid collection noted\nin the right inguinal area, suggestive of possible lymphocele.\n\n**CT Scan Abdomen/Pelvic from 01/13/2016:** The liver displays a smooth\ncontour, with homogeneous parenchymal contrast enhancement, and no\nevidence of focal intrahepatic lesions. There is no indication of\nintrahepatic or extrahepatic cholestasis. History of previous\ncholecystectomy with an accentuated common hepatic duct. Spleen,\npancreas, and adrenal glands appear unremarkable. Both orthotopically\nlocated kidneys exhibit simultaneous and equal contrast enhancement. No\nintrarenal structural abnormalities or signs of urinary obstruction are\nobserved. The colonic frame and small intestine show adequate perfusion,\nwithout focal wall thickening. The stomach is distended. The urinary\nbladder contains a catheter. Two intraluminal air pockets are seen.\nKnown circumferential, uniform bladder wall thickening from previous\nexaminations. No free intrabdominal air is detected. No evidence of\nascites. Bilateral iliac and inguinal operative clips from prior\nlymphadenectomy. Right iliac region shows a serous fluid collection\nmeasuring approximately 3 x 2 cm. Para-aortic lymph nodes, up to 14 mm\nin size, are consistent with findings from previous evaluations. No\nsuspicious malignancy-related bone destruction is noted. A drainage tube\nhas been placed through the right lower abdominal wall, with its tip\nlocated in the left pelvic area.\n\n**Assessment:** No evidence of abscess formation. A lymphocele measuring\napproximately 3 x 2 cm is noted in the right iliac region, without signs\nof acute inflammation.\n\n**Microbiological Examination**\n\n**Material**: Catheter Urine Examination Request: Identification of\nPathogens and Resistance Results: Organism 1: Growth of 100,000 CFU/mL\nEnterococcus faecalis Possible ICD-10 Coding Suggestion: Enterococci as\nPathogen.\n\n- Acute Cystitis\n\n- Pyelonephritis\n\n- Urinary Tract Infection related to Catheter/Implant\n\n- Urinary Tract Infection, Unspecified Location\n\n**Antibiogram**\n\n- Gentamicin HL: S\n\n- Levofloxacin: R 1\n\n- Teicoplanin: S \\<=0.5\n\n- Ampicillin: S \\<=2\n\n- Piperacillin: S\n\n- Ampicillin/Sulbactam: S \\<=2\n\n- Piperacillin/Tazobactam: S\n\n- Imipenem: S \\<=1\n\n- Cefuroxim: R \\>=64\n\n- Gentamicin: R\n\n- Cotrimoxazole: R \\<=10\n\n- Ciprofloxacin: R \\<=0.5\n\n- Vancomycin: S 2\n\n- Linezolid: S 2\n\n- Tigecyclin: S \\<=0.12\n\n**Therapy and Progression:** After CT morphological exclusion of an\nabscess formation or retention, the wound drainage was removed under\nantibiotic coverage. Initially, empirical antibiotic therapy with\nCefuroxim was administered, followed by targeted treatment with oral\nUnacid based on resistance testing. The drainage insertion site healed\nprimarily. The bladder catheter was removed, after which urination was\nfree of residual urine. The patient has primary continence. We\ndischarged the patient to further outpatient treatment, with the patient\nreporting subjective well-being.\n\nMr. Harder showed gradual clinical improvement after initiating\nantibiotic therapy. His fever subsided, and lower abdominal tenderness\ndiminished. The IV fluids were discontinued, and he remained on oral\nantibiotics.\n\n**Urine Culture Results:** The urine culture results returned positive\nfor Escherichia coli (E. coli), a common uropathogen. The sensitivity\nprofile indicated susceptibility to ciprofloxacin.\n\n**Follow-Up:** Mr. Harder was closely monitored for the duration of his\nantibiotic course. He was advised to complete the full course of\nantibiotics and maintain adequate hydration. The urinary catheter was\nremoved on the fifth day of hospitalization after demonstrating improved\nurine output and resolution of symptoms. No further complications\nrelated to the catheter removal were observed.\n\n**Current Recommendations:**\n\n1. Please refer to the previous discharge letter for the procedure\n regarding prostate cancer.\n\n2. He was educated on the signs and symptoms of UTIs and instructed to\n seek prompt medical attention if symptoms recurred.\n\n**\\\n**\n\n", "title": "text_1" }, { "content": "**Dear colleague, **\n\nThank you for assigning Mr. Ben Harder, born on 08/02/1940 to the PET/CT\ncombination scanner examination on 12/11/2022.\n\n**Diagnoses:**\n\n- Initial diagnosis of prostate cancer in December 2015, confirmed by\n prostate biopsy.\n\n- Tumor detected in 11 out of 12 biopsy samples\n\n- Maximum Gleason score of 9\n\n- Preoperative PSA level: 5.42 ng/ml\n\n- In the initial PET/CT examination (preoperative) on 12/23/2015\n evidence of prostate cancer extending beyond the capsule in both\n prostatic lobes was found.\n\n- Infiltration of the left seminal vesicles and beginning infiltration\n of the right seminal vesicles\n\n- Multiple retroperitoneal lymph node metastases and bilateral pelvic\n lymph nodes.\n\n- Radical prostatectomy\n\n- Current PSA level: 1.23 ng/ml\n\n- Radiation therapy planned at our facility\n\n**Technique**: To expedite renal-urinary activity elimination, the\npatient was adequately hydrated. The examination was conducted using the\nPET/CT combination scanner BIOGRAPH 64 with CT parameters set at 120 kV\nand 1 mm slice thickness. PET emission data were acquired with 5 bed\npositions on a radiation therapy-compatible table for whole-body\nexamination in the caudocranial direction with transverse slices at 3.0\nmm intervals over the same axial range as the CT scan. Iterative\nreconstruction was performed. A whole-body scan was conducted 90 minutes\nafter the administration of 278 MBq Ga-68-PSMA (prostate-specific\nmembrane antigen). Transmissions-corrected and non-corrected PET scans,\nCT scans, fusion images, and the determination of the SUV value\n(standard uptake value, a measure of activity uptake per volume) were\nused for evaluation.\n\n**PET Findings:** The 3D whole-body images documented in 3 planes using\nPET and PET/CT technology showed the following changes compared to the\nprior examination on 12/23/2015:\n\n- Post-radical prostatectomy, there is diffuse activity accumulation\n in the region dorsal to the bladder, on the left side.\n\n- Regarding the known retroperitoneal lymph node metastases, the\n following changes were observed: New retrocrural nodule on the\n right. SUV 6.6, diameter: 6 mm.\n\n- Known interaortocaval lymph node, dorsally at the level of L3/4,\n showed increased metabolic activity from SUV 4.7 to 11.5. Slightly\n increased in size, measuring 7 to 8 mm. Additionally, two new\n metabolically active nodules cranially, up to the level of L2/3.\n\n- Slightly increased metabolic activity in the known right iliaca\n communis lymph node, located between the fifth lumbar vertebra and\n the psoas muscle, from 4.0 to 4.6, with the same size of 5 mm.\n\n- Progressive enlargement of the known confluent lymph nodes on the\n right parailiacal externa proximal side, now having a combined size\n of 10 x 26 mm (width x height), previously individual nodules of 10\n and 12 mm. SUV 18.2, previously max 11.5.\n\n- New paraaortic lymph nodes on the left, mostly small, SUV 11.2.\n\n- Newly added lymph nodes in both biiliac communal areas. Maximum size\n on the left is 15 mm, SUV 17.2.\n\n- New retrocrural lymph node on the right, measuring 6 mm, SUV 6.6.\n\n- Known lymph node on the right perirectal, slightly progressive from\n 8 to 10 mm. SUV 6.9, previously 6.4.\n\n- Known lymph node on the left iliaca externa not currently\n verifiable, possibly postoperative scarring.\n\n- Newly added focus in the bone at the level of the spinous\n process/dorsal arch of the fifth lumbar vertebra. In CT, a 7 mm\n focal sclerosis is noted. Normal activity accumulation in the soft\n tissues of the neck, axillae, and chest. Physiological accumulation\n in the parenchymal upper abdominal organs. Kidneys and urinary tract\n appear functionally normal. Whole-body CT following bolus-like\n peripheral venous machine injection of 100 ml of Optiray 350: No\n suspicious lymph nodes in the cervical, axillary, or mediastinal\n regions. Normal-sized thyroid gland. No pleuropulmonary infiltrates\n or round lesions. Scarred changes in the left lower lobe.\n Normal-sized liver without focal lesions. Spleen, pancreas, adrenal\n glands, and kidneys appear regular. No urinary obstruction..\n\n**Results**: In the postoperative PET/CT compared to the preoperative\nexamination on, there is now malignancy-typical PSMA receptor binding in\nthe former prostate lodge, indicating a local recurrence. Progression of\nretroperitoneal lymph node metastases, with further extension cranially,\nextending to the interaortocaval region up to the level of L2/3. Newly\nadded metastases on the left paraaortic and biiliac communal areas.\nProgression of known right iliaca externa lymph node metastases. The\nleft iliaca externa nodule is not verifiable, likely removed. New small\nretrocrural nodule on the right. New osteosclerotic metastasis in the\ndorsal arch of LWK 5. Minimal activity accumulation in the 8th rib on\nthe right lateral aspect. A developing metastasis cannot be conclusively\nruled out here. We kindly request information on the patient\\'s further\nclinical course (submission of medical reports, etc.).\n\n**Lab results**\n\n **Parameter** **Results** **Reference Range**\n ---------------------- ------------- ---------------------\n Glucose (Plasma) 91 mg/dL 55-100 mg/dL\n Alkaline Phosphatase 93 U/L \\< 130 U/L\n Total Cholesterol 152 mg/dL \\< 200 mg/dL\n LDL-Cholesterol 89 mg/dL \\< 130 mg/dL\n HDL-Cholesterol 50 mg/dL 40-60 mg/dL\n Non-HDL Cholesterol 101.8 mg/dL \\< 200 mg/dL\n Triglycerides 64 mg/dL \\< 150 mg/dL\n White Blood Cells 4.1 K/uL 4.5-11 K/uL\n Red Blood Cells 4.68 M/uL 4.0-5.5 M/uL\n Hemoglobin 13.6 g/dL 12.5-17.2 g/dL\n Hematocrit 39.5% 37.0-49.0%\n MCH 29.1 pg 27.0-34.0 pg\n MCHC 34.4 g/dL 31.5-36.0 g/dL\n MCV 84.4 fL 80.0-101.0 fL\n RDW 13.0% 11.6-14.4%\n Platelets 238 K/uL 150-370 K/uL\n\n**\\\n**\n\n", "title": "text_2" }, { "content": "**Dear colleague, **\n\nWe are writing to provide an update on Mr. Ben Harder, born on\n08/02/1940, who received inpatient treatment at our facility from\n06/23/2023 to 06/26/2023.\n\n**Diagnosis:**\n\nProstate Cancer pT3b pN1 R1 L0 V0 Gleason Score: 4 + 5 = 9 (Initial\ndiagnosis in December 2015)\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015. Currently, lymph node and bone metastasis\n\n**Other Diagnoses:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n November 16, 2015.\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n (thora 11 and 12) with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT in 06/2023 scan indicated new extensive metastasis in\n the sacrum and diffuse lung metastases, accompanied by a PSA level\n of 1.35 ng/ml.\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n**Medications on Admission:**\n\n **Medication ** **Dosage** **Frequency**\n ---------------------------- ------------ ---------------\n Candesartan (Atacand) 16 mg 1-0-1-0\n Aspirin 100 mg 1-0-0-0\n Chlorthalidone (Thalitone) 25 mg 1-0-0-0\n\n**Physical Examination:** The patient was in good general condition and\nhad normal orientation to all qualities. There were no edemas, dyspnea,\nfever, or cough.\n\n**Medical History:** Mr. Hader presents himself for the 1st cycle of RLT\nwith Ac-225-PSMA/Lu-177-I&T-PSMA for lymph node and bone metastatic\nprostate cancer on an inpatient basis. In the presence of progressive\nimaging findings under guideline-compliant therapy, the indication for\nRLT tandem therapy was confirmed according to the tumor conference on.\nUpon admission, the patient reports feeling well, denies any B-symptoms.\nThere is no fever or nausea, and the weight is currently stable. There\nhas been a tendency to fall for some time. The rest of the medical\nhistory is assumed to be known.\n\n**Neurological Consultation on 06/25/2023: **\n\nClinically neurological examination revealed a polyneuropathy syndrome\nof the lower extremities, predominantly on the right side, as well as a\nknown right-sided foot drop. In summary, we consider the falls to be\nmultifactorial due to foot weakness as well as polyneuropathy syndrome\nwith impaired proprioception as the cause of the balance disorder.\nRecommended further procedure: In the presence of a known PNP syndrome\nthat has occurred during chemotherapy, consider outpatient neurological\nevaluation and objectification by means of Electromyography and\npolyneuropathy laboratory tests.\n\n**Salivary Gland Scintigraphy on 06/26/2023**\n\n**Assessment**: Normal function of the submandibular and parotid glands\nbilaterally.\n\nPost-therapeutic imaging with Lu-177-PSMA imaging using\nSPECT/low-dose-CT\n\n**Assessment:** Consistent with the PET-CT, there is no tracer uptake in\nthe area of the prostate. Intensive accumulation of the therapeutic\nagent in the area of lymph node metastases, especially mediastinal.\nCorresponding to the PET/CT, there are clear focal tracer accumulations\nin the left upper lobe of the lung in the area of nodular or diffuse\ntissue condensations, possibly metastases or, secondarily,\npost-inflammatory. Intensive tracer uptake in the area of known bone\nmetastases from the previous examination. No newly appearing\ntracer-enhancing lesions. In addition, physiological accumulation in the\norgan systems involved in tracer metabolism and excretion. NB: Small\npleural effusions on both sides. Known pronounced peribronchial cuffs in\nthe upper lobes on both sides, possibly scarred, or indicative of\npulmonary venous congestion. Known atrophic kidney on the right.\n\n**Current Recommendations:**\n\n- Blood count checks and determination of kidney and liver parameters\n 1, 2, 4, and 8 weeks after therapy\n\n- Outpatient neurologic assessment for the evaluation of\n polyneuropathy\n\n- PSA determination 6-8 weeks after therapy\n\n- Appointment for a 2nd cycle of radioligand therapy\n (Ac-225-/Lu-177-PSMA)\n\n**Lab results upon Discharge**\n\n **Parameter** **Results** **Reference Range**\n ---------------------------------- ------------- ---------------------\n Neutrophils (%) 72.2 % 42.0-77.0 %\n Lymphocytes (%) 8.6 % 20.0-44.0 %\n Monocytes (%) 11.6 % 2.0-9.5 %\n Basophils (%) 1.4 % 0.0-1.8 %\n Eosinophils (%) 6.0 % 0.5-5.5 %\n Immature Granulocytes (%) 0.2 % 0.0-1.0 %\n Sodium 137 mEq/L 136-145 mEq/L\n Potassium 4.2 mEq/L 3.5-4.5 mEq/L\n Calcium 2.31 mEq/L 2.20-2.55 mEq/L\n Chloride 100 mEq/L 98-107 mEq/L\n Creatinine 1.27 mg/dL 0.70-1.20 mg/dL\n BUN 48 mg/dL 17-48 mg/dL\n Uric Acid 5.2 mg/dL 3.6-8.2 mg/dL\n C-reactive Protein 0.8 mg/L \\< 5.0 mg/L\n PSA 2.31 µg/L \\< 4.40 µg/L\n ALT 12 U/L \\< 41 U/L\n AST 38 U/L \\< 50 U/L\n Alkaline Phosphatase 115 U/L 40-130 U/L\n Gamma-GT 20 U/L 8-61 U/L\n LDH 335 U/L 135-250 U/L\n Testosterone \\<0.03 µg/L 1.32-8.92 µg/L\n TSH 1.42 mU/L 0.27-4.20 mU/L\n Hemoglobin 10.1 g/dL 12.5-17.2 g/dL\n Hematocrit 0.285 L/L 0.370-0.490 L/L\n RBC 3.3 /pL 4.0-5.6 /pL\n WBC 4.98 /nL 3.90-10.50 /nL\n Platelets 281 /nL 150-370 /nL\n MCV 85.6 fL 80.0-101.0 fL\n MCH 30.3 pg 27.0-34.0 pg\n MCHC 35.4 g/dL 31.5-36.0 g/dL\n MPV 9.2 fL 7.0-12.0 fL\n RDW 13.4 % 11.5-15.0 %\n Neutrophils (Absolute) 3.59 /nL 1.50-7.70 /nL\n Immature Granulocytes (Absolute) 0.010 /nL \\< 0.050 /nL\n Lymphocytes (Absolute) 0.43 /nL 1.10-4.50 /nL\n Monocytes (Absolute) 0.58 /nL 0.10-0.90 /nL\n Eosinophils (Absolute) 0.30 /nL 0.02-0.50 /nL\n Basophils (Absolute) 0.07 /nL 0.00-0.20 /nL\n Reticulocytes 31.3 /nL 25.0-105.0 /nL\n Reticulocyte (%) 0.94 % 0.50-2.00 %\n Reticulocyte Production Index 0.3 \\-\n Ret-Hb 33.9 pg 28.5-34.\n\n", "title": "text_3" }, { "content": "**Dear colleague, **\n\nWe would like to report on our mutual patient, Mr. Ben Harder, born on\n08/02/1940, who presented himself to our outpatient clinic on 1/8/2023.\n\n**Diagnoses:**\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9 (initial\n diagnosis in 11/2015)\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally on\n 11/16/2015\n\n- Currently, there are lymph node and bone metastases\n\n- History of retropubic radical prostatectomy without nerve\n preservation and with pelvic lymphadenectomy bilaterally\n\n- Prostate cancer pT3b pN1 R1 L0 V0, Gleason: 4 + 5 = 9\n\n- Initial PSA level was 4.8 ng/ml\n\n- History of Docetaxel therapy\n\n- History of Cabazitaxel therapy\n\n- History of 4 cycles of Lutetium-Radioligand therapy\n\n- Subsequently, radiation therapy was initiated for the lymph node\n metastasis but discontinued after 11 sessions due to dyspnea and G3\n esophagitis.\n\n- Arterial hypertension\n\n- Chronic renal insufficiency\n\n- Type 2 diabetes mellitus\n\n**Treatment and Progression:** The patient presents for a second opinion\non his prostate cancer, which has metastasized to the bones and lymph\nnodes and has become castration-resistant. He recently received\nLutetium-Radioligand therapy. Genetic sequencing from the tissue biopsy\ndid not reveal any significant gene mutations. The patient wishes to\nundergo further evaluation for the diagnosis of relevant genetic\nmutations. A previously punctured subdiaphragmatic lymph node metastasis\nhas not yet undergone genetic testing, which may be justified based on\nthe available data and publications in specific cases. A chemotherapy\nsession with Cabazitaxel is planned for the end of January in the\ntreating urological practice. In cases of DNA repair gene alterations, a\nplatinum combination could also be considered. Further possible\ndiagnostic and therapeutic steps were discussed with the patient. An\napplication for a repeat genetic sequencing will be submitted by our\ncolleagues from the genetics department.\n\n**Current Recommendations:**\n\n- Application for genetic sequencing for the punctured lymph node\n metastasis through the genetics department and DNA-med\n\n- Subsequent re-genetic sequencing of the subdiaphragmatic lymph node\n metastasis for relevant mutations\n\n- After receiving the results, a follow-up appointment can be\n scheduled in our uro-oncology outpatient clinic.\n\n.\n\n**\\\n**\n\n", "title": "text_4" }, { "content": "**Dear colleague, **\n\nWe are reporting to you regarding the inpatient stay of our patient Mr.\nBen Harder, born on 08/02/1940. He was under our care from 09/16/2023 to\n09/23/2023.\n\n**Diagnosis**: Prostate Cancer pT3b pN1 R1 L0 V0\n\n- Gleason Score: 4 + 5 = 9\n\n- Postoperative status following retropubic radical prostatectomy\n without nerve preservation and with pelvic lymphadenectomy.\n\n- Currently presenting with lymph node and bone metastases, mCRPC\n (metastatic castration-resistant prostate cancer)\n\n- Initial PSA level: 4.8 ng/ml\n\n**Previous Treatment and Course:**\n\n- History of Retropubic Radical Prostatectomy without nerve\n preservation and with bilateral pelvic lymph node dissection on\n\n- Prostate Cancer pT3b pN1 R1 L0 V0, Gleason Score: 4 + 5 = 9\n\n- Initial PSA (Prostate-Specific Antigen) level of 4.8 ng/ml\n\n- Subsequent treatments included Docetaxel, Cabazitaxel, and 4 cycles\n of Lutetium-Radioligand Therapy.\n\n- 12/2022, a subdiaphragmatic lymph node was punctured at Sea Clinic,\n followed by radiation therapy of the lymph node metastasis.\n Radiation was discontinued after 11 sessions due to dyspnea and\n Grade 3 esophagitis.\n\n- Notable PSA levels include 5.42 ng/ml in 10/2015, PSA undetectable\n in 07/2019 (PSA 0.01 ng/ml, Testosterone 0.00 ng/ml), PSA rising in\n 11/2019 (PSA \\> 0.03 ng/ml), PSA 0.16 ng/ml in 01/2020, PSA 0.06\n ng/ml in 02/ 2020 (with undetectable Testosterone and Ostease 31),\n and various other PSA values during the course of treatment.\n\n- Imaging studies confirmed bone metastasis in the ilium and sacrum in\n 03/2020. A CT scan of the pelvis revealed these metastases, as well\n as sclerosis of the sacrum and dorsal vertebral arches of L5.\n\n- Further treatments included Zometa, Trenantone, and radiotherapy.\n\n- An MRI of the lumbar spine in 02/2021 showed intraspinal soft tissue\n structures with compression of the dural sac, along with extensive\n predominantly sclerotic bone metastasis from L4 to S1.\n\n- Surgical intervention included a decompressive hemilaminectomy with\n microsurgical tumor resection from the epidural space in 02/2021,\n followed by postoperative radiation therapy to the lumbar spine in\n 04/2021.\n\n- Cabazitaxel therapy commenced in 07/2021, and a CT scan in 09/2021\n showed morphologically progressive bone metastasis in the lumbar\n spine.\n\n- The patient received Lutetium PSMA-Therapy cycles in 04/2022,\n 06/2022, 08/2022, and 10/2022. A PSMA-PET-CT scan in 11/2022\n indicated a very good partial remission in bone metastases but\n progressive mediastinal lymph node metastasis.\n\n- Radiotherapy was administered to the mediastinal lymph nodes but\n discontinued after 11 sessions due to side effects in 01/2023.\n\n- In 04/2023, the patient underwent a re-challenge with Cabazitaxel\n for one cycle but had to discontinue chemotherapy due to\n polyneuropathy and cramps.\n\n- A CT scan of the chest and abdomen in 04/2023 showed similar\n findings, including two new sclerosis sites in the thoracic spine\n with possible post-radiation changes.\n\n- PSA level in 05/2023 was 0.48 ng/ml.\n\n- Genetic sequencing revealed no therapeutic consequences.\n\n- A PSMA-PET-CT scan indicated new extensive metastasis in the sacrum\n and diffuse lung metastases, accompanied by a PSA level of 1.35\n ng/ml.\n\n- Current PET-CT not available. Recommendations for further treatment\n options are as follows, based on externally described\n image-morphological progression in the recent CT:\n\n 1. Actinium-225-PSMA Therapy (Lu-177 Tandem Therapy), provided that\n all vital metastases are PSMA-positive (mandatory exclusion of\n post-renal urinary flow obstruction)\n\n 2. Alternatively, consider initiating therapy with Abiraterone +\n Prednisolone or a Cabazitaxel re-challenge (if there was a\n favorable response to the last 2 cycles of Cabazitaxel\n\n 3. Evaluation of pre-screening for CAR-T cell studies in oncology\n at CBF (contact will be made)\n\n**Other Diagnoses:**\n\n- Arterial Hypertension\n\n- Chronic Kidney Insufficiency\n\n- Type 2 Diabetes Mellitus\n\n**Current Presentation:** Mr. Ben Harder is presenting for his 2nd cycle\nof Radioligand Therapy (RLT) with Ac-225-PSMA/Lu-177-I&T-PSMA for lymph\nnode and bone metastatic prostate cancer. In light of progressive\nimage-morphological findings despite guideline-compliant treatment, the\nindication for RLT tandem therapy was determined in the tumor\nconference.\n\n**Medical History:** Mr. Harder reports that after the last treatment\ncycle, he experienced pronounced fatigue symptoms. He particularly\nstruggled with climbing stairs and walking longer distances. However, he\nmanaged to fully recover from these symptoms through targeted training.\nAdditionally, he developed pain in the area of the right ribcage\nfollowing the last treatment cycle. The pain occurs intermittently and\nis accompanied by increased salivation and nausea, sometimes leading to\nvomiting. Mr. Ben Harder also reports newly developed swallowing\ndifficulties. He feels that food gets stuck in his throat after\nswallowing.\n\n**Therapy and Progression:**\n\nIn the case of Mr. Ben Harder, due to metastatic prostate cancer with\nradiographic progression despite previous guideline-recommended therapy,\naccording to the recommendations, there was an indication for the 2nd\nradioligand therapy with Ac-225-PSMA/Lu-177-I&T-PSMA. The\npost-therapeutic imaging showed targeted accumulation of the therapeutic\nagent within the tumor. The therapy was administered due to elevated\nrenal retention parameters with reduced activity of Lu-177-PSMA. The\ncourse of therapy and the entire hospital stay were uncomplicated, so we\ncan now transition the patient to your outpatient care. We recommend\nclose laboratory monitoring (blood count, liver and kidney parameters)\nat 1, 2, 4, and 8 weeks, as well as a PSA determination 6-8 weeks after\ntherapy.\n\nIn the case of significant fatigue symptoms after the 1st cycle of\ntandem RLT, if there are blood count changes indicating a decrease in\nhemoglobin levels and recurrent fatigue symptoms, the administration of\nerythropoietin or the indication for blood product transfusion should be\nconsidered. Depending on the PSA value 6 weeks post-therapy and the\nfindings of the PSMA-PET/CT, the further course of action will be\ndetermined in the interdisciplinary Tumor Conference.\n\nIf the patient desires, they can seek a second opinion on further\ntherapeutic procedures in the specialized clinic of the Uro-Oncology\ncolleagues. In case of pronounced rib pain, if requested by the patient,\nthe possibility of undergoing radiation therapy can be evaluated. To do\nso, Mr. Harder can schedule an appointment at the Radio-Oncology clinic.\nPsycho-oncological counseling has been offered to the patient.\n\n**Medication upon Discharge:**\n\n **Medication ** **Dosage** **Frequency**\n -------------------------------- ------------ ---------------\n Aspirin 100 mg 1-0-0-0\n Candesartan Cilexetil (Atacan) 16 mg 1-0-1-0\n Chlorthalidone (Hygroton) 25 mg 0.5-0-0-0\n Multi-Vitamin \\- 1-1-0-0\n Hawthorn Herb 450 mg 1-1-1-0\n Sodium Selenite 999 µg 0-0-1-0\n Zinc 157 mg 0-1-0-0\n Vitamin D3 (Cholecalciferol) 20 mg 0-1-0-0\n Vitamin B Complex 0.5 mg 1-0-0-0\n Vitamin E 200 IU 1-0-1-0\n Vitamin A \\- 0-2-0-0\n Lercanidipine 10 mg 0.5-0-0.5-0\n Vitamin B1 200 mg 1x/Week\n Vitamin B6 25 mg 2-3x/Week\n\n**Lab results upon Discharge:**\n\n **Parameter** **Results** **Reference Range**\n -------------------------------- -------------------- ---------------------\n Neutrophils % 80.3 % 42.0-77.0 %\n Lymphocytes % 6.7 % 20.0-44.0 %\n Monocytes % 8.9 % 2.0-9.5 %\n Basophils % 1.3 % 0.0-1.8 %\n Eosinophils % 2.4 % 0.5-5.5 %\n Immature Granulocytes % 0.4 % 0.0-1.0 %\n I:T Ratio 0.005 \n HFLC Absolute 0.0 /µL \n Sodium 140 mEq/L 136-145 mEq/L\n Potassium 3.9 mEq/L 3.5-4.5 mEq/L\n Calcium 9.36 mg/dL 8.8-10.2 mg/dL\n Chloride 102 mEq/L 98-107 mEq/L\n Creatinine 1.25 P+ mg/dL 0.70-1.20 mg/dL\n Estimated GFR 52 mL/min/1.73m\\^2 \n BUN (Urea) 44 mg/dL 17-48 mg/dL\n Uric Acid 3.8 mg/dL 3.6-8.2 mg/dL\n CRP 1.3 mg/L \\< 5.0 mg/L\n PSA 2.98 ng/mL \\< 4.4 ng/mL\n ALT (GPT) 22 U/L \\< 41 U/L\n AST (GOT) 49 U/L \\< 50 U/L\n Alkaline Phosphatase 114 U/L 40-130 U/L\n Gamma-GT 19 U/L 8-61 U/L\n LDH 404 P+ U/L 135-250 U/L\n Testosterone \\<0.03 P- ng/mL 1.32-8.92 ng/mL\n TSH 1.14 mIU/L 0.27-4.20 mIU/L\n Complete Blood Count \n Differential Count \n Hemoglobin 10.6 g/dL 12.5-17.2 g/dL\n Hematocrit 30.5 % 37.0-49.0 %\n RBC 3.4 M/µL 4.0-5.6 M/µL\n WBC 5.49 K/µL 3.90-10.50 K/µL\n Platelets 279 K/µL 150-370 K/µL\n MCV 88.7 fL 80.0-101.0 fL\n MCH 30.8 pg 27.0-34.0 pg\n MCHC 34.8 g/dL 31.5-36.0 g/dL\n MPV 10.1 fL 7.0-12.0 fL\n RDW-CV 14.1 % 11.5-15.0 %\n Absolute Neutrophils 4.41 K/µL 1.50-7.70 K/µL\n Absolute Immature Granulocytes 0.020 K/µL \\< 0.050 K/µL\n Absolute Lymphocytes 0.37 K/µL 1.10-4.50 K/µL\n Absolute Monocytes 0.49 K/µL 0.10-0.90 K/µL\n Absolute Eosinophils 0.13 K/µL 0.02-0.50 K/µL\n Absolute Basophils 0.07 K/µL 0.00-0.20 K/µL\n Reticulocytes 37.8 K/µL 25.0-105.0 K/µL\n Reticulocyte Percentage 1.10 % 0.50-2.00 %\n Reticulocyte Production Index 0.4 \n Ret-Hb 35.0 pg 28.5-34.5 pg\n Prothrombin Time 117 % \\> 78 %\n INR 0.94 \\< 1.25\n aPTT 30.2 sec 25.0-38.0 sec\n", "title": "text_5" } ]